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Angelo Franzini, Paolo Ferroli, Domenico Servello and Giovanni Broggi

✓ The authors describe a case of complete recovery from the so-called “thalamic hand” syndrome following chronic motor cortex stimulation in a 64-year-old man suffering from poststroke thalamic central pain. As of the 2-year follow-up examination, the patient's dystonia and pain are still controlled by electrical stimulation.

It is speculated that a common mechanism in which the thalamocortical circuit loops are rendered out of balance may sustain hand dystonia and central pain in this case of thalamic syndrome. To the authors' knowledge this is the first reported case of its kind.

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Paolo Ferroli, Elisa Ciceri, Alessandro Addis and Giovanni Broggi

The authors demonstrate the feasibility of a new procedure to create intracranial interrupted microvascular anastomosis. Self-closing nitinol surgical clips were used for a pericallosal artery–pericallosal artery side-to-side bypass in a 52-year-old man harboring an unruptured large aneurysm located on the right A2 segment. The outflow artery was found to arise from the dome of the aneurysm, which was considered unsuitable for stand-alone clip ligation or coil occlusion. After bypass patency was intraoperatively confirmed using near-infrared indocyanine green videoangiography, the aneurysm and feeding artery were embolized with coils and safely occluded. Both postoperative courses were uneventful. The patient was discharged neurologically intact on the 5th postembolization day. Postprocedure angiography demonstrated no ipsilateral aneurysm filling and excellent bilateral distal outflow from the left anterior cerebral artery.

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Paolo Ferroli, Dario Caldiroli, Matilde Leonardi and Morgan Broggi

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Vittoria Nazzi, Giuseppe Messina, Ivano Dones, Paolo Ferroli and Giovanni Broggi

✓The authors report on the case of a 32-year-old woman with an intramuscular arteriovenous hemangioma (AVH) of the left forearm with burning pain and paresthesias diffused to the radial nerve–related territories. The patient underwent coil embolization of the AVH and surgical removal of the remnant and regrown AVH. This case demonstrates the safety and efficacy of surgery when interventional radiology fails to achieve complete occlusion. En bloc removal of the lesion was performed through a left elbow cleft incision, and intraoperative electrophysiological monitoring and angiography with indocyanine green (ICG) were performed. The pathological diagnosis was intramuscular AVH. Postoperative follow-up examinations demonstrated the permanent disappearance of the subcutaneous mass and of the patient's sensory disturbances. Complete excision of the AVH was confirmed on postoperative magnetic resonance angiography, and no surgery-related complications or new neurological symptoms were detected.

Intramuscular AVHs are rare lesions that can be successfully treated with both coil endovascular embolization and surgery; the latter is indicated when endovascular procedures fail to occlude the AVH completely. Intraoperative angiography with ICG can be helpful in confirming the success of the procedure.

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Paolo Ferroli, Francesco Acerbi, Giovanni Tringali, Erminia Albanese, Morgan Broggi, Angelo Franzini and Giovanni Broggi

Object

The purpose of this paper is to evaluate whether venous indocyanine green (ICG) videoangiography has any potential for predicting the presence of a safe collateral circulation for veins that are at risk for intentional or unintentional damage during surgery.

Methods

The authors performed venous ICG videoangiography during 153 consecutive neurosurgical procedures. On those occasions in which a venous sacrifice occurred during surgery, whether that sacrifice was preplanned (intended) or unintended, venous ICG videoangiography was repeated so as to allow us to study the effect of venous sacrifice. A specific test to predict the presence of venous collateral circulation was also applied in 8 of these cases.

Results

Venous ICG videoangiography allowed for an intraoperative real-time flow assessment of the exposed veins with excellent image quality and resolution in all cases. The veins observed in this study were found to be extremely different with respect to flow dynamics and could be divided in 3 groups: 1) arterialized veins; 2) fast-draining veins with uniform filling and clear flow direction; and 3) slow-draining veins with nonuniform filling. Temporary clipping was found to be a simple and reversible way to test for the presence of potential anastomotic circulation.

Conclusions

Venous ICG videoangiography is able to reveal substantial variability in the venous flow dynamics. “Slow veins,” when they are tributaries of bridging veins, might hide a potential for anastomotic circulation that deserve further investigation.

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Angelo Franzini, Carlo Marras, Paolo Ferroli, Giovanna Zorzi, Orso Bugiani, Luigi Romito and Giovanni Broggi

✓ The authors report the results of long-term bilateral high-frequency pallidal stimulation in two patients affected by neuroleptic-induced dystonia.

The first patient, a 33-year-old man, experienced a dystonic posture of the trunk, with involvement of the neck and upper and lower limbs after 11 years of treatment with neuroleptic drugs. The second patient, a 30-year-old man, presented with a torsion dystonia, spasmodic torticollis, and involuntary movements of the upper limbs, which appeared after 4 years of neuroleptic treatment. Both of these dystonias worsened even after the neuroleptic treatment had been discontinued, and neither patient responded to clozapine or benzodiazepine therapy. The time lapse between the first appearance of dystonia and surgery was, respectively, 5 and 3 years. In each case bilateral stereotactic implantation of electrodes within the globus pallidus internus (GPI) was performed while the patient was in a state of general anesthesia. The electrodes were placed at the following anterior commissure—posterior commissure line—related coordinates: 20 mm lateral to the midline, 6 mm below the intercommissural plane, and 3 mm anterior to the midcommissural point. Electrical stimulation (130 Hz, 1 V, 90 µsec) was begun on the 1st postoperative day. In both patients, a genetic analysis positively ruled out a mutation in the DYT1 gene, and magnetic resonance imaging yielded normal findings in both cases.

Extrapyramidal symptoms and dystonia disappeared almost completely and dramatically in both patients just a few days after high-frequency bilateral pallidal stimulation commenced. Both patients regained autonomy and neuroleptic treatment was reinitiated. The follow-up period for both cases was 1 year. Long-term bilateral high-frequency stimulation of GPI resulted in a dramatic and long-lasting improvement of neuroleptic-induced tardive dystonia.

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Paolo Ferroli and Morgan Broggi