Ablative Neurosurgical Procedures Research Articles

Feasibility of targeting the cingulate gyrus using high-intensity focused ultrasound on a cadaveric specimen: illustrative case.

Cancer is commonly associated with pain. For patients with advanced cancer and intractable pain, ablative neurosurgical procedures can significantly improve pain and transition patients out of inpatient settings. These procedures are normally invasive, and this poses an important risk in this population. Cingulotomy has been reported to improve pain perception and contribute substantially to the quality of life of cancer patients with refractory pain. One fresh human cadaver specimen was used for the setup. The cingulate gyrus was targeted using intraoperative magnetic resonance images, and osseous aberrations were corrected after coregistration with the preoperative head computed tomography. After accounting for sinuses, membrane folds, and calcifications, a total of 737 elements were available for thermal ultrasound ablation. On high-power sonications, the total energy delivered reached a peak temperature of 57°C (15,050 J, 350 W, 45 seconds) in the right cingulate and 52°C (13,000 J, 405 W, 46 seconds) in the left cingulate. Despite the limitations of using a cadaver model (temperature, vascularization), cingulotomy appears to be feasible using high-intensity focused ultrasound. https://thejns.org/doi/10.3171/CASE2459.

Lesional psychiatric neurosurgery: meta-analysis of clinical outcomes using a transdiagnostic approach

BackgroundFour ablative neurosurgical procedures are used in the treatment of refractory psychiatric illness. The long-term effects of these procedures on psychiatric symptoms across disorders has never been synthesised and meta-analysed.MethodsA...

Technical and radiographic considerations for magnetic resonance imaging-guided focused ultrasound capsulotomy.

Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is an emerging treatment modality that enables incisionless ablative neurosurgical procedures. Bilateral MRgFUS capsulotomy has recently been demonstrated to be safe and effective in treating obsessive-compulsive disorder (OCD) and major depressive disorder (MDD). Preliminary evidence has suggested that bilateral MRgFUS capsulotomy can present increased difficulties in reaching lesional temperatures as compared to unilateral thalamotomy. The authors of this article aimed to study the parameters associated with successful MRgFUS capsulotomy lesioning and to present longitudinal radiographic findings following MRgFUS capsulotomy. Using data from 22 attempted MRgFUS capsulotomy treatments, the authors investigated the relationship between various sonication parameters and the maximal temperature achieved at the intracranial target. Lesion volume and morphology were analyzed longitudinally using structural and diffusion tensor imaging. A retreatment procedure was attempted in one patient, and their postoperative imaging is presented. Skull density ratio (SDR), skull thickness, and angle of incidence were significantly correlated with the maximal temperature achieved. MRgFUS capsulotomy lesions appeared similar to those following MRgFUS thalamotomy, with three concentric zones observed on MRI. Lesion volumes regressed substantially over time following MRgFUS. Fractional anisotropy analysis revealed a disruption in white matter integrity, followed by a gradual return to near-baseline levels concurrent with lesion regression. In the patient who underwent retreatment, successful bilateral lesioning was achieved, and there were no adverse clinical or radiographic events. With the current iteration of MRgFUS technology, skull-related parameters such as SDR, skull thickness, and angle of incidence should be considered when selecting patients suitable for MRgFUS capsulotomy. Lesions appear to follow morphological patterns similar to what is seen following MRgFUS thalamotomy. Retreatment appears to be safe, although additional cases will be necessary to further evaluate the associated safety profile.

Hypoactivity in the Paraterminal Gyrus Following Bilateral Anterior Capsulotomy.

Objective:Bilateral anterior capsulotomy (BAC) is one of the ablative neurosurgical procedures used to treat major depressive disorder or obsessive-compulsive disorder when all other therapies fail. Tristolysis, a reduction in sadness, is the most striking clinical effect of BAC and is seen in the first 1 to 2 weeks after surgery. This retrospective study measured regional cerebral blood flow (rCBF) following surgery to identify which cortical regions were impacted and could account for this clinical effect.Methods:All patients had their capsulotomies done in Vancouver by the same team. Pre- and postoperative single-photon emission computed tomography perfusion scans were analyzed for 10 patients with major depressive disorder and 3 with obsessive-compulsive disorder. rCBF was measured semiquantitatively by calculating the ratio between an identified region of interest and a whole brain reference area.Results:Decreased rCBF was found in the paraterminal gyri. Increased rCBF was found in the dorsolateral prefrontal cortices and in the left lateral temporal lobe.Conclusions:BAC causes hypoactivity in the paraterminal gyri and is the most likely explanation for its tristolytic effect, suggesting that the paraterminal gyrus is the limbic cortical locus for the emotion of sadness. Increased activity in the dorsolateral prefrontal cortices may be occurring via connectional diaschisis, and suppression by overactive paraterminal gyri during depression may account for some of the neurocognitive deficits observed during depressive episodes.

Neurosurgical ablative procedures for intractable cancer pain.

Cancer patients suffering from severe refractory pain may benefit from targeted ablative neurosurgical procedures aimed to disconnect pain pathways in the spinal cord or the brain. These patients often present with a plethora of medical problems requiring careful consideration before surgical interventions. The authors present their experience at an interdisciplinary clinic aimed to facilitate appropriate patient selection for neurosurgical procedures, and the outcome of these interventions. This study was a retrospective review of all patients who underwent neurosurgical interventions for cancer pain in the authors' hospital between March 2015 and April 2018. All patients had advanced metastatic cancer with limited life expectancy and suffered from intractable oncological pain. Sixty patients underwent surgery during the study period. Forty-three patients with localized pain underwent disconnection of the spinal pain pathways: 34 percutaneous-cervical and 5 open-thoracic cordotomies, 2 stereotactic mesencephalotomies, and 2 midline myelotomies. Thirty-nine of 42 patients (93%) who completed these procedures had excellent immediate postoperative pain relief. At 1 month the improvement was maintained in 30/36 patients (83%) available for follow-up. There was 1 case of hemiparesis.Twenty patients with diffuse pain underwent stereotactic cingulotomy. Nineteen of these patients reported substantial pain relief immediately after the operation. At 1 month good pain relief was maintained in 13/17 patients (76%) available for follow-up, and good pain relief was also found at 3 months in 7/11 patients (64%). There was no major morbidity or mortality. With careful patient selection and tailoring of the appropriate procedure to the patient's pain syndrome, the authors' experience indicates that neurosurgical procedures are safe and effective in alleviating suffering in patients with intractable cancer pain.

The therapeutic effects of ablative neurosurgical procedures on the spinal cord for intractable spinal spasticity.

This research is a retrospective study. To study the therapeutic effects of operative procedures, including dorsal longitudinal myelotomy (DLM) and dorsal root entry zone lesion (DREZL) on spasticity and associated aspects. Tertiary university hospital in Bangkok, Thailand. Eighteen patients with refractory spasticity of spinal origin who underwent the operations were recruited. Clinical parameters for evaluating severity of spasticity and ambulatory status were compared between before and after surgery, and between surgeries. A statistically significant reduction of spasticity as measured by the Modified Ashworth Scale (MAS), Adductor Tone Rating Scale (ATRS) and Penn Spasm Frequency Scale (PSFS) was found after surgeries and in the overall analysis (p < 0.05). Chronic pressure ulcers disappeared postoperatively in 11 cases. All of 7 bed-ridden subjects experienced improvement in their ambulatory status postoperatively. DLM was found to be more effective than DREZL in reduction of spasticity. Ablative neurosurgery on the spinal cord is still valuable in situations when intrathecal baclofen is unavailable. These operations are potentially effective in the treatment of intractable spasticity of spinal origin.

Clinical practice guidelines for Obsessive-Compulsive Disorder.

Obsessive-compulsive disorder (OCD) is a common psychiatric illness with lifetime prevalence of 1-3% [1]. It is the fourth-most common psychiatric illness and a leading cause of disability. OCD is associated with significant impairment in functioning, quality of life and disability. If untreated, OCD is a chronic illness with a waxing and waning of symptoms. A recent meta-analysis of long-term naturalistic prospective studies demonstrated that nearly a half of patients experience remission with much higher rates of remission in Indian patients compared to those in the west [2]. Early diagnosis and appropriate treatment may improve outcomes. Despite OCD being a common mental illness, most seek treatment after several years of suffering. Those who suffer from OCD tend to be secretive about their symptoms and suffer from shame and embarrassment. Less than a third of OCD sufferers receive appropriate pharmacotherapy and even less receive evidence-based psychotherapy. Symptoms The hallmarks of OCD are presence of obsessions and compulsions. Obsessions are repetitive, unwanted, intrusive thoughts, images or urges that are mostly ego-dystonic and cause severe distress or anxiety. Compulsions (or rituals) are repetitive behaviours or mental acts that are performed in response to an obsession to reduce anxiety/distress or prevent a dreaded consequence. Obsessions and compulsions are time consuming, distressing and are often resisted unsuccessfully. Clinical manifestations of OCD are remarkably similar across cultures and geographic locations. Common obsessions and compulsions and symptom dimensions identified through factor-analytical studies are shown in Table 1. Table 1 Common symptoms of OCD

Rivaling paradigms in psychiatric neurosurgery: adjustability versus quick fix versus minimal-invasiveness

In the wake of deep brain stimulation (DBS) development, ablative neurosurgical procedures are seeing a comeback, although they had been discredited and nearly completely abandoned in the 1970s because of their unethical practice. Modern stereotactic ablative procedures as thermal or radiofrequency ablation, and particularly radiosurgery (e.g., Gamma Knife) are much safer than the historical procedures, so that a re-evaluation of this technique is required. The different approaches of modern psychiatric neurosurgery refer to different paradigms: microsurgical ablative procedures is based on the paradigm ‘quick fix,’ radiosurgery on the paradigm ‘minimal-invasiveness,’ and DBS on the paradigm ‘adjustability.’ From a mere medical perspective, none of the procedures is absolutely superior; rather, they have different profiles of advantages and disadvantages. Therefore, individual factors are crucial in decision-making, particularly the patients’ social situation, individual preferences, and individual attitudes. The different approaches are not only rivals, but also enriching mutually. DBS is preferable for exploring new targets, which may become candidates for ablative microsurgery or radiosurgery.

Deep Brain Stimulation for Treatment-Resistant Depression

Brian did reasonably well for about 3 years, with occasional worsening of depressive symptoms but generally with good functioning, when he developed his current major depressive episode. This was his most severe episode to date, with active suicidal ideation with a plan (but no immediate intent) to shoot himself. Over the next year, he had a number of treatments, among them multiple antidepressant medications, including selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, mirtazapine, tricyclic antidepressants, and tranylcypromine, as well as augmentation with lithium, thyroid hormone, buspirone, atypical antipsychotics, anticonvulsants, stimulants, light therapy, and ongoing psychotherapy. No treatment was able to achieve remission or a persistent clinically signifi cant reduction in symptoms. Given his degree of treatment resistance and continued overall deterioration, including increased suicidal ideation, he was referred for ECT. He achieved a good response (50%‐60% symptom reduction) with eight highdose right unilateral ECT treatments. ECT was delivered concurrently with ongoing medications, and attempts were made to optimize medications during and after ECT. However, Brian relapsed in about 6 weeks, and repeat ECT (including four right unilateral and eight bitemporal treatments delivered concurrently with ongoing medications) was unsuccessful in achieving signifi cant symptom reduction but was associated with notable cognitive impairment.

PO25-TH-19 Combined ablative neurosurgical procedures in a patient with mixed spastic and dystonic cerebral palsy

PO25-TH-19 Combined ablative neurosurgical procedures in a patient with mixed spastic and dystonic cerebral palsy

脳卒中後不随意運動の脳内植込み電極と体内埋設刺激ディバイスによる制御

Involuntary movements are not uncommon consequences of stroke, which limit patients' daily activity greatly. Ablative neurosurgical procedures, such as thalamotomy and pallidotomy, for control of involuntary movements always carry a risk associated with creating additional lesions in an already damaged brain, and the results of these procedures are not always satisfactory. Due to the unpredictability of the effects and the irreversibility of the procedures, most physicians have been reluctant to recommend ablative neurosurgical treatments to their patients whose brain is already damaged by stroke. In contrast, there is not such a risk in deep brain stimulation (DBS) therapy. Based on our experience with 25 patients with post-stroke involuntary movements, clinical values of DBS are summarized. A quadripolar DBS electrode is placed in such a way that the most distal contact is located on the ventral part of thalamic VIM nucleus and the most proximal contact in the dorsal part of VOP nucleus. Complete control of involuntary movements has been achieved by DBS in many patients (76%) with hemiballism, hemichoreo-athetosis, jerky dystonic unsteady hand, distal resting and/or action tremor and proximal postural tremor. The effects have continued to be seen for the entire follow-up period ranging 1-9 years in our series. DBS is an ideal therapeutic option to control post-stroke involuntary movements due to the reversibility of the procedure, and alterability of anatomical location and extent of stimulation.

Intrathecal baclofen infusion: an innovative approach for controlling spinal spasticity.

Severe and disabling spasticity frequently occurs in people with multiple sclerosis and spinal cord injury. Approximately 30% of these people are treated with oral antispasmodic medications that do not provide adequate relief from spasticity (Hattab, 1980). Clinical trials with spinal stimulation and ablative neurosurgical procedures have not been as uniformly successful for controlling spasticity as has intrathecal baclofen injection (Kasdon, 1986). Delivered by an implantable programmable drug pump, intrathecal baclofen injection has proven to be successful in treating individuals with intractable spasticity. Significant reduction in muscle tone and frequency of spasms have contributed to improved function with activities of daily living, bladder management, overall comfort, and quality of sleep (Penn et al., 1989; Parke, Penn, Savoy, & Corcos, 1989). This article introduces an innovative therapy for controlling spasticity and discusses the nurse's role in patient selection and management.

Spontaneous epileptiform discharges in isolated human cortical slices from epileptic patients.

Human epileptic in vitro brain slices were obtained at ablative neurosurgical procedures and examined for spontaneous extracellular field potentials. Electrical events resembling interictal spikes and seizure discharges were observed in tissue from the electrocorticographic epileptic foci, but not in control tissue. It appears that important differences between the epileptic focus and normal tissue are maintained in vitro.

Sensory Thalamic Neurostimulation for Chronic Pain

Among all kinds of pain, deafferentation pain is the most physically and mentally debilitative; this affliction is often resistant to medications and to the effects of ablative neurosurgical procedures. Since the introduction of neurostimulation as a method of treatment of pain, stimulation of the sensory thalamic relay nucleus has been proven effective in the majority of cases of patients suffering from deafferentation pain. The method used for thalamic stimulation and the results obtained in a series of 89 patients treated from October 1978 to October 1985 will be presented. Postherpetic trigeminal pain has the best chance of responding to thalamic stimulation with a long-term success rate of 80%. This is also true for anesthesia dolorosa of any origin (after ablative surgery, nerve lesions, paraplegia). In the opposite, only 50% of patients with either brachial plexus avulsion or thalamic pain syndrome will have a significant benefit from thalamic stimulation. It would appear that the success of thalamic stimulation in these disorders may be dependent upon the extent of the central lesion from the periphery up to the thalamic regions (dorsal horn destruction, lesions of the thalamus).

Intrathecal morphine for intractable pain secondary to cancer of pelvic organs

Sixty-two patients with intractable pain secondary to cancer of the pelvic organs were managed with intrathecal injections of morphine. Forty-six patients experienced pain relief from an initial test dose that ranged from 0.5 to 2.0 mg. In order to provide long-term pain relief, these 46 patients were further treated with repeated single injections (14 patients), external catheter (28 patients), or implanted pump (4 patients). Twenty-four of the 46 patients received pain relief without developing tolerance or side effects or experiencing mechanical failure of the application systems. When side effects developed, they were generally itching, sphincter disorder and somnolence. No serious respiratory depression was noted. Intrathecal morphine offers a hopeful alternative to systemic narcotics or ablative neurosurgical procedures in the management of terminal cancer pain.

Surgical control of chronic migrainous neuralgia by trigeminal ganglio-rhizolysis.

Chronic migrainous neuralgia is not diagnosed as often as the periodic or "cluster" form of Horton's syndrome. The distinguishing features of chronic migrainous neuralgia, compared with the periodic variety, are the frequency and persistence of the attacks of hemicraniofacial pain and the intractability to medical management. Eight male patients ranging in age from 22 to 45 years received prompt, although transient, pain relief by blockade of the Gasserian ganglion on the side of their hemifacial pain with a local anesthetic. Prolonged relief was subsequently achieved by percutaneous radiofrequency trigeminal ganglio-rhizolysis. There were no significant complications from this procedure. Review of the literature indicated that other ablative neurosurgical procedures, such as alcohol injection of the Gasserian ganglion and trigeminal rhizotomy by the subtemporal craniectomy approach, have relieved migrainous neuralgia, but with a greater risk and incidence of complications. The characteristic clinical features of migrainous neuralgia and the medical and surgical approaches to therapy are discussed.

Escape from and avoidance of nociception elicited by intracranial stimulation of the cat subthalamus

An investigation was undertaken to find out whether cats would learn by a non-aversive auditory cue to avoid a pain-producing intracranial stimulation (ICS) of the subthalamic region. The purpose was to determine whether such ICS produces genuine pain or simply generalized evasive actions. Bipolar stimulating electrodes were implanted bilaterally [into the brain, aimed at] in the H2 (lenticular fasciculus)-H (prerubral) fields of Forel or adjacent part of the zona incerta. The animals were trained initially to escape noxious ICS and, subsequently, to avoid that same noxious ICS when presented with an auditory cue which preceded the ICS by 10 s. After training, lesions were produced through the same electrodes; controls were without lesions. After recovery, both groups were taken through the same escape and avoidance sequence. In eight animals the prelesion avoidance patterns were not significantly altered and remained intact throughout the postlesion testing period. The effective electrode placements extended through the subthalamus to the ventral part of the rostral mesencephalic tegmentum. Fiber projections, with or without terminals, were found in the zona incerta, H1 field, lateral, posterior and dorsal hypothalamus, intralaminar, ventral, and midline thalamic nuclei, and rostral mesencephalic central gray. Certain effective stimulating or ablative neurosurgical procedures for relief of pain in humans are largely consistent with these findings.