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Chien-Chen Chou, Cheng-Chia Lee, Chun-Fu Lin, Yi-Hsiu Chen, Syu-Jyun Peng, Fu-Jung Hsiao, Hsiang-Yu Yu, Chien Chen, Hsin-Hung Chen, and Yang-Hsin Shih

OBJECTIVE

The semiology of cingulate gyrus epilepsy is varied and may involve the paracentral area, the adjacent limbic system, and/or the orbitofrontal gyrus. Invasive electroencephalography (iEEG) recording is usually required for patients with deeply located epileptogenic foci. This paper reports on the authors’ experiences in the diagnosis and surgical treatment of patients with focal epilepsy originating in the cingulate gyrus.

METHODS

Eighteen patients (median age 24 years, range 5–53 years) with a mean seizure history of 23 years (range 2–32 years) were analyzed retrospectively. The results of presurgical evaluation, surgical strategy, and postoperative pathology are reported, as well as follow-up concerning functional morbidity and seizures (median follow-up 7 years, range 2–12 years).

RESULTS

Patients with cingulate gyrus epilepsy presented with a variety of semiologies and scalp EEG patterns. Prior to ictal onset, 11 (61%) of the patients presented with aura. Initial ictal symptoms included limb posturing in 12 (67%), vocalization in 5, and hypermotor movement in 4. In most patients (n = 16, 89%), ictal EEG presented as widespread patterns with bilateral hemispheric origin, as well as muscle artifacts obscuring the onset of EEG during the ictal period in 11 patients. Among the 18 patients who underwent resection, the pathology revealed mild malformation of cortical development in 2, focal cortical dysplasia (FCD) Ib in 4, FCD IIa in 4, FCD IIb in 4, astrocytoma in 1, ganglioglioma in 1, and gliosis in 2. The seizure outcome after surgery was satisfactory: Engel class IA in 12 patients, IIB in 3, IIIA in 1, IIIB in 1, and IVB in 1 at the 2-year follow-up.

CONCLUSIONS

In this study, the authors exploited the improved access to the cingulate epileptogenic network made possible by the use of 3D electrodes implanted using stereoelectroencephalography methodology. Under iEEG recording and intraoperative neuromonitoring, epilepsy surgery on lesions in the cingulate gyrus can result in good outcomes in terms of seizure recurrence and the incidence of postoperative permanent deficits.

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Chen-Ya Yang, Muh-Lii Liang, Hsin-Hung Chen, Jan-Wei Chiu, Kwong-Kum Liao, and Tsui-Fen Yang

OBJECTIVE

The aim of this study was to investigate the feasibility of using subdural strip electrodes, placed just rostral to the surgical field, to record sensory evoked potentials (SEPs) from the lumbosacral sensory nerves and define the most inferior functional portion of the conus medullaris during detethering surgery for spinal dysraphism and/or tethered cord syndrome (TCS).

METHODS

Six patients, 2 boys and 4 girls, aged 0.5 to 16 years, were enrolled in this study. One patient had lipomyelomeningocele-related, 4 had myelomeningocele-related, and 1 had diastematomyelia and lipomyelomeningocele-related TCS. In addition to the routine preparations that are needed for performing functional mapping and monitoring during surgery for spinal dysraphism and TCS, the patients had a 1 × 4 strip of electrodes placed rostral to the surgical field, where it was secured by a surgeon after opening the dura. With the patient under total intravenous anesthesia, the sensory nerves and conus medullaris were stimulated with a concentric bipolar electrode over the surgical field while SEPs were recorded with the strip electrodes to identify any possible sensory roots with remaining function and the most inferior functional portion of the conus medullaris.

RESULTS

The SEP amplitudes that were recorded with the subdural strip electrodes ranged from 4 to 400 μV, and the responses to sensory nerve stimulation were frequently much larger than were those to conus stimulation. Use of the SEP recordings for sensory mapping along with the routine mapping and monitoring techniques allowed detethering to be completed such that none of the patients sustained any new functional deficit after surgery.

CONCLUSIONS

Recording SEPs from the functional sensory nerves and conus medullaris through subdural strip electrodes proved to be a feasible and valuable tool during detethering surgery in young patients. This approach may help surgeons achieve maximal detethering while preserving important sensory functions, consequently retaining the patient’s quality of life.

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Chun-Hung Chang, Shin-Yuan Chen, Yi-Ling Hsiao, Sheng-Tzung Tsai, and Hsin-Chi Tsai

This 28-year-old Chinese man was referred for deep brain stimulation (DBS) evaluation for an 8-year history of refractory obsessive-compulsive disorder. After the patient had signed an informed consent, the authors implanted DBS leads. Hypomania with hypersexuality was noted on stimulation at Contact 2 and became aggravated with a higher voltage (≥ 3 V) during chronic bilateral DBS. After the voltage was decreased to 1 V, the patient's hypomanic symptoms subsided and his libido returned to baseline.

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Hsin-Hung Chen, Jay Riva-Cambrin, Douglas L. Brockmeyer, Marion L. Walker, and John R. W. Kestle

Object

In late 2008, the authors recognized a new type of ventriculoperitoneal shunt failure specific to the Bio-Glide Snap Shunt ventricular catheters. This prompted a retrospective review of the patient cohort and resulted in a recall by the FDA in the US.

Methods

After the index cases were identified, the FDA was notified by the hospital, leading to a recall of the product. Hospital operative logs were used to identify patients in whom the affected products were used. A letter describing the risk was sent to all patients offering a free screening CT scan to look for disconnection. A call center was established to respond to patient questions, and an informational video was made available on the hospital website. The authors reviewed the records of the index cases and other cases subsequently identified.

Results

Seven index cases and an additional 16 cases of disconnection were identified in the 466 patients in whom a BioGlide Snap Shunt ventricular catheter had been implanted. Mean time to disconnection was 2.7 years (range 4 days–5.8 years). Computed tomography slices in the plane of the catheter helped visualize disconnections. Retrieval was difficult, and in 5 patients the disconnected catheter was not removable. Three catheters were completely within the ventricle. At presentation, 4 children suffered from severe neurological deficits, including one who died as a result of the shunt malfunction.

Conclusions

BioGlide snap-design ventricular catheters are prone to disconnection. Continued vigilance and specific imaging are important. Catheter removal after disconnection may be difficult. Elective removal prior to disconnection in asymptomatic children has not been performed.

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Chun-Lung Chou, Hsin-Hung Chen, Huai-Che Yang, Yi-Wei Chen, Ching-Jen Chen, Yu-Wei Chen, Hsiu-Mei Wu, Wan-Yuo Guo, David Hung-Chi Pan, Wen-Yuh Chung, Tai-Tong Wong, and Cheng-Chia Lee

OBJECTIVE

Hypothalamic obesity is common among patients with craniopharyngioma. This study examined whether precise stereotactic radiosurgery reduces the risk of hypothalamic obesity in cases of craniopharyngioma with expected long-term survival.

METHODS

This cohort study included 40 patients who had undergone Gamma Knife radiosurgery (GKRS; n = 22) or fractionated radiotherapy (FRT; n = 18) for residual or recurrent craniopharyngioma. Neurological presentations, tumor volume changes, and BMI values were meticulously reviewed. The median clinical follow-up durations were 9.7 years in the GKRS group and 10.8 years in the FRT group.

RESULTS

The median ages at the time of GKRS and FRT were 9.0 years and 10.0 years, respectively. The median margin dose of GKRS was 12.0 Gy (range 10.0–16.0 Gy), whereas the median dose of FRT was 50.40 Gy (range 44.1–56.3 Gy). Prior to GKRS or FRT, the median BMI values were 20.5 kg/m2 in the GKRS cohort and 20.0 kg/m2 in the FRT cohort. The median BMIs after radiation therapy at final follow-up were 21.0 kg/m2 and 24.0 kg/m2 for the GKRS and FRT cohorts, respectively. In the FRT cohort, BMI curves rapidly increased beyond the 85th percentile of the upper limit of the general population. BMI curves in the GKRS cohort increased more gradually, and many of the patients merged into the normal growth curve after adolescence. However, the observed difference was not statistically significant (p = 0.409).

CONCLUSIONS

The study compared the two adjuvant radiation modalities most commonly used for recurrent and residual craniopharyngioma. The authors’ results revealed that precise radiosurgery dose planning can mediate the subsequent increase in BMI. There is every indication that meticulous GKRS treatment is an effective approach to treating craniopharyngioma while also reducing the risk of hypothalamic obesity.

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Syu-Jyun Peng, Chien-Chen Chou, Hsiang-Yu Yu, Chien Chen, Der-Jen Yen, Shang-Yeong Kwan, Sanford P. C. Hsu, Chun-Fu Lin, Hsin-Hung Chen, and Cheng-Chia Lee

OBJECTIVE

In this study, the authors investigated high-frequency oscillation (HFO) networks during seizures in order to determine how HFOs spread from the focal cerebral cortex and become synchronized across various areas of the brain.

METHODS

All data were obtained from stereoelectroencephalography (SEEG) signals in patients with drug-resistant temporal lobe epilepsy (TLE). The authors calculated intercontact cross-coefficients between all pairs of contacts to construct HFO networks in 20 seizures that occurred in 5 patients. They then calculated HFO network topology metrics (i.e., network density and component size) after normalizing seizure duration data by dividing each seizure into 10 intervals of equal length (labeled I1–I10).

RESULTS

From the perspective of the dynamic topologies of cortical and subcortical HFO networks, the authors observed a significant increase in network density during intervals I5–I10. A significant increase was also observed in overall energy during intervals I3–I8. The results of subnetwork analysis revealed that the number of components continuously decreased following the onset of seizures, and those results were statistically significant during intervals I3–I10. Furthermore, the majority of nodes were connected to a single dominant component during the propagation of seizures, and the percentage of nodes within the largest component grew significantly until seizure termination.

CONCLUSIONS

The consistent topological changes that the authors observed suggest that TLE is affected by common epileptogenic patterns. Indeed, the findings help to elucidate the epileptogenic network that characterizes TLE, which may be of interest to researchers and physicians working to improve treatment modalities for epilepsy, including resection, cortical stimulation, and neuromodulation treatments that are responsive to network topologies.

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Sheng-Tzung Tsai, Hsin-Chi Tsai, Chung-Chih Kuo, Hsiang-Yi Hung, Chien-Hui Lee, and Shin-Yuan Chen

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Chin-Chu Ko, Hsiao-Wen Tsai, Wen-Cheng Huang, Jau-Ching Wu, Yu-Chun Chen, Yang-Hsin Shih, Hung-Chieh Chen, Ching-Lan Wu, and Henrich Cheng

Object

Dynamic stabilization systems are used to stabilize degenerative lumbar spondylosis. Loosening of the pedicle screws in such nonfusion implants is predictable. This retrospective study evaluated the incidence of screw loosening and its effect on clinical outcomes.

Methods

Charts, radiographic films, and medical records of 71 consecutive patients who underwent decompression using Dynesys dynamic stabilization for 1- or 2-level lumbar spondylosis were reviewed. Radiographic films were evaluated and compared to detect screw loosening. A visual analog scale (VAS) for back pain and the Oswestry Disability Index (ODI) were used for measuring clinical outcome. Statistical analysis was conducted using the chisquare test and Student t-test.

Results

The 71 patients in the study sample had a mean age of 59.2 ± 11.65 years (range 23–80 years), with slight female predominance (39 women, 32 men). The mean follow-up duration was 16.6 months (range 8–29 months). There were loose screws in 14 of 71 patients (19.7%), for a rate of 4.6% per screw (17 of 368 screws). Most screw loosening occurred in patients ≥ 55 years old (13 of 14 patients) although age and sex had no effect on screw loosening (p = 0.233 and 0.109, respectively). Both the loose screw and solid screw groups experienced significant improvement after the surgery in VAS and ODI scores. On the VAS, scores improved from 5.9 ± 2.99 to 2.1 ± 2.14 in the loose screw group (p = 0.003), and from 5.7 ± 3.45 to 2.9 ± 2.68 in the solid screw group (p < 0.001). For the ODI scale, scores improved from 43.5 ± 16.78% to 28.0 ± 18.18% (p = 0.006) in the loose screw group, and from 52.1 ± 20.92% to 24.6 ± 19.78% (p < 0.001) in the solid screw group. There were no significant differences between the 2 groups (p = 0.334 for VAS, p = 0.567 for ODI).

Conclusions

The preliminary study of this pedicle-based dynamic stabilization device for 1- and 2-level lumbar spondylosis shows radiographic evidence of screw loosening in 19.7% of patients and 4.6% of screws. Nonetheless, the loosening of screws has no adverse effect on clinical improvement.