Pneumocephalus Volume Research Articles

Safety and efficiency of deep brain stimulation in the elderly patients with Parkinson's disease.

Deep brain stimulation (DBS) is not routinely performed in elderly patients (≥75 years old) to date because of concerns about complications and decreased benefit. This study aimed to evaluate the safety and efficacy of DBS in elderly patients with Parkinson's disease. A retrospective analysis was performed using data from 40 elderly patients from four centers who were treated with neurosurgical robot-assisted DBS between September 2016 and December 2021. These patients were followed up for a minimum period of 2 years, with a subgroup of nine patients followed up for 5-7 years. Patient demographic characteristics, surgical information, pre- and postoperative motor scores, non-motor scores, activities of daily living, and complications were retrospectively analyzed. The mean surgical procedure duration was 1.65 ± 0.24 h, with a mean electrode implantation duration of 1.10 ± 0.23 h and a mean pulse generator implantation duration of 0.55 ± 0.07 h. The mean pneumocephalus volume, electrode fusion error, and Tao's DBS surgery scale were 16.23 ± 12.81 cm3, 0.81 ± 0.23 mm, and 77.63 ± 8.08, respectively. One patient developed a skin infection, and the device was removed. The Unified Parkinson's disease rating scale, Unified Parkinson's disease rating scale of Part III, tremor, rigidity, bradykinesia, axial, and Barthel index for activities of daily living (ADL-Barthel) scores significantly improved at the 2-year follow-up (p < 0.05). The levodopa equivalent daily dose (LEDD) was significantly reduced at the 2-year follow-up (p < 0.05). However, the Montreal cognitive assessment, Hamilton depression scale, and Hamilton anxiety scale scores did not significantly change during the 2-year follow-up (p > 0.05). Additionally, in the subgroup with a 5-year follow-up, the motor symptoms, ADL-Barthel score, and cognitive function worsened over time compared to baseline. However, there was still an improvement in motor symptoms and ADL with DBS on-stimulation compared with the off-stimulation state. The LEDD increased 5 years after surgery compared to that at baseline. Eleven patients had passed away during follow-up, the mean survival time was 38.3 ± 17.3 months after surgery, and the mean age at the time of death was 81.2 (range 75-87) years. Robot-assisted DBS surgery for the elderly patients with Parkinson's disease is accurate and safe. Motor symptoms and ADL significantly improve and patients can benefit from long-term neuromodulation, which may decrease the risk of death.

The efficacy analysis of neurosurgical robot-assisted DBS in the treatment of elderly Parkinson's disease

Objective: To investigate the surgical efficacy of neurosurgery robot deep brain stimulation(DBS) in the treatment of elderly Parkinson's disease(PD). Methods: The clinical data of elderly patients (≥75 years) with PD who underwent neurosurgical robot-assisted DBS surgery in the Department of Neurosurgery of the General Hospital of Northern Theater Command from September 2016 to September 2022 were collected retrospectively. Operation time, electrode implantation duration, postoperative pneumocephalus volume, electrode implantation accuracy, the Tao's DBS surgery scale, perioperative complications were analyzed.The unified Parkinson's disease rating scales (UPDRS), UPDRS-Ⅲ, tremor, rigidity, bradykinesia, axial, Barthel Activities of Daily Living (ADL-Barthel), Levodopa Equivalent Daily Dose (LEDD), Montreal Cognitive Assessment (MoCA), Hamilton Anxiety Scale (HAMA) and Hamilton Depression Scale (HAMD) scores and mortality were assessed respectively before operation, 6, 12 and 24 months after operation and last follow-up. Results: A total of 25 elderly patients were enrolled, including 14 males and 11 females, aged(78.3±3.2) years. Nine patients had underlying diseases. Nine patients (36%) underwent bilateral Globus Pallidus pars Interna deep brain stimulation (GPi-DBS) and 16 patients (64%) underwent bilateral subthalamic nucleus deep brain stimulation (STN-DBS).The operation time was (1.56±0.19) hours, the electrode implantation duration was (1.01±0.19) hours, the pneumocephalus volume was 9.8(4.7, 23.3) cm3, and the electrode implantation accuracy was (0.84±0.24) mm, the Tao's DBS surgery scale was (80.2±6.2).The follow-up time [M(Q1, Q3)] was 57.3(27.9, 75.7) months. No serious complications such as intracranial hemorrhage, infection or poor wound healing occurred during the perioperative period. The improvement rate of UPDRS, UPDRS-Ⅲ, rigidity, bradykinesia, and LEDD at 6 months after surgery was significantly higher than that at 24 months after surgery and at the last follow-up (all P<0.05); the improvement rate of axial symptoms, ADL-Barthel score, and MoCA score at 6 months after surgery was significantly higher than that at the last follow-up (P<0.05). HAMD and HAMA scores showed no significant improvement during follow-up after surgery (both P>0.05). At the last follow-up, 12 patients died, with death time of (35.1±20.2) months after operation, and the death age of [M(Q1, Q3)] 80(79, 83)years. Conclusions: Robot-assisted DBS surgery for elderly patients with PD is accurate and safe, and the postoperative symptoms are significantly improved, and they can benefit from neuromodulation for long term, and the risks are controllable.

The Related Factors and Effect of Electrode Displacement on Motor Outcome of Subthalamic Nuclei Deep Brain Stimulation in Parkinson's Disease.

Previous studies have revealed the existence of electrode displacement during subthalamic nucleus deep brain stimulation (STN-DBS). However, the effect of electrode displacement on treatment outcomes is still unclear. In this study, we aimed to analyze the related factors of electrode displacement and assess postoperative electrode displacement in relation to the motor outcomes of STN-DBS. A total of 88 patients aged 62.73 ± 6.35 years (55 males and 33 females) with Parkinson's disease undergoing STN-DBS, with comprehensive clinical characterization before and 1 month after surgery, were involved retrospectively and divided into a cross-incision group and cannula puncture group according to different dura opening methods. The electrode displacement, unilateral pneumocephalus volume percent (uPVP), and brain volume percent were estimated. A significant anterior and lateral electrode displacement was observed among all implanted electrodes after pneumocephalus absorption (p < 0.0001). The degree of electrode displacement was positively correlated with the uPVP (p = 0.005) and smaller in females than males (p = 0.0384). Electrode displacement was negatively correlated with motor improvement following STN-DBS in both on-medication and off-medication conditions (p < 0.05). Dural puncture reduced the uPVP (p < 0.0001) and postoperative electrode displacement (p = 0.0086) compared with dural incision. Electrode displacement had a negative impact on the therapeutic efficacy of STN-DBS. Opening the dura via cannula puncture is recommended to increase the accuracy of the lead implantation.

Modified Puerto Rico Recurrence Scale for chronic subdural hematomas: augmenting the grading scale with postoperative pneumocephalus volume.

Chronic subdural hematomas (CSDHs) are common in the elderly, with a relatively high rate of recurrence after initial surgical intervention. Our research team previously created a predictive grading system, the Puerto Rico Recurrence Scale (PRRS), to identify patients at high risk of CSDH recurrence. In this study, we introduce a modification of the (mPRRS) that includes pneumocephalus volume, which has been independently associated with recurrence. A single-center Puerto Rican population-based retrospective study was performed to analyze data for patients treated for CSDH at 1 institution between July 1, 2017, and December 31, 2019. Univariate and multivariate analyses were used to create a grading scale predictive of recurrence. Retrospective validation was conducted for the cohort. Of 108 patients included in the study, 42 had recurrence, and 66 had nonrecurrence. Postoperative subdural space, postoperative midline shift, and pneumocephalus volume were all higher with recurrence (P = 0.002, P = 0.009, and P < 0.001, respectively). Multivariate analysis was used to create a 6-point grading scale comprising 3 variables (pneumocephalus volume [< 10, 10-20, 21-30, and > 30 cm3], postoperative midline shift [< 0.4, 0.41-1.0, and > 1.0cm], and laterality [unilateral and bilateral]). Recurrence rates progressively increased in low-risk to high-risk groups (2/18 [11%] vs 21/34 [62%]; P < 0.003). The mPRRS incorporating pneumocephalus measurement improves CSDH recurrence prediction. The mPRRS indicated that patients with higher scores have a greater risk of recurrence and emphasized the importance of measuring postoperative variables for prediction. The mPRRS grading scale for CSDHs may be applicable not only to the Puerto Rican population but also to the general population.

ID: 214384 Postoperative DBS Pneumocephalus Volume in Patients With Parkinson's Disease: Correlating Burr-Hole Size and Intraoperative Duration

Pneumocephalus can be linked to brain shift and impact the accuracy of stereotactic Deep Brain Stimulation (DBS) surgery. Previous literature has been unable to establish a correlation between burr hole size and the amount of pneumocephalus seen. Consequently, this work sought to determine if intraoperative burr hole size positively correlated with the volume of pneumocephalus observed on postoperative CT imaging in patients who underwent DBS. The duration of the surgery was also considered in order to see its impact on the pneumocephalus volume.

Pneumocephalus secondary to epidural analgesia: a case report

IntroductionEpidural anesthesia is commonly used for analgesia during labor, and headache is a common complaint following this procedure. Pneumocephalus, on the other hand, is a rare and potentially serious complication of epidural anesthesia, which is most often caused by accidental puncture of the dura with the introduction of air into intrathecal space.Case presentationWe present the case of a 19-year-old Hispanic female who developed a severe frontal headache and neck pain eight hours following epidural catheter placement to deliver analgesia during labor. Physical examination was within normal limits without any neurological deficits. Computed tomography of the head and neck would later demonstrate small to moderate amounts of pneumocephalus, predominantly within the frontal horn of the lateral ventricles, and a moderate amount of air within the spinal canal. She was treated conservatively with analgesia. Though headache recurred after discharge, repeat imaging showed improvement in the volume of pneumocephalus and conservative management was continued.ConclusionsAlthough a rare complication and an uncommon cause of headache following epidural anesthesia, a high index of suspicion must remain for pneumocephalus as it may cause significant morbidity and, in some cases, be potentially life-threatening.

Tension Pneumocephalus: A Potentially Fatal Complication of Expanded Endoscopic Endonasal Approach.

While some volume of pneumocephalus occurs following any surgery entailing dural breach, tension pneumocephalus (TP) is a rare complication of endoscopic endonasal surgery described in less than 1% cases including expanded endoscopic endonasal approaches (EEEA). It is a neurosurgical emergency warranting urgent decompression. Two cases, who developed TP following EEEA are presented. One had sinonasal malignancy (adenoid cystic carcinoma) eroding the anterior skull-base (T4N0M0) and the other was a large olfactory groove meningioma. TP was heralded in both by sudden deterioration in neurological status. Both cases underwent bifrontal craniotomy for decompression with simultaneous skull-base repair incorporating a vascularised pericranial flap. Brief literature review regarding the pathophysiology, contributing factors, diagnosis, management, and prevention of TP following EEEA is presented. TP, a life-threatening neurosurgical emergency, warrants meticulous precautions for its prevention, and vigilant postoperative monitoring for early detection. Urgent decompression with thorough skull-base repair is imperative to prevent complications.

Frameless Robot-Assisted Asleep Centromedian Thalamic Nucleus Deep Brain Stimulation Surgery in Patients with Drug-Resistant Epilepsy: Technical Description and Short-Term Clinical Results.

This purpose of this work is to give a detailed description of a surgical technique for frameless robot-assisted asleep deep brain stimulation (DBS) of the centromedian thalamic nucleus (CMT) in drug-resistant epilepsy (DRE). Ten consecutively enrolled patients who underwent CMT-DBS were included in the study. The FreeSurfer "Thalamic Kernel Segmentation" module and experience target coordinates were used for locating the CMT, and quantitative susceptibility mapping (QSM) images were used to check the target. The patient's head was secured with a head clip, and electrode implantation was performed with the assistance of the neurosurgical robot Sinovation®. After opening the dura, the burr hole was continuously flushed with physiological saline to stop air from entering the skull. All procedures were performed under general anesthesia without intraoperative microelectrode recording (MER). The mean age of the patients at surgery and onset of seizures was 22years (range 11-41years) and 11years (range 1-21years), respectively. The median duration of seizures before CMT-DBS surgery was 10years (2-26years). CMT was successfully segmented, and its position was verified by experience target coordinates and QSM images in all ten patients. The mean surgical time for bilateral CMT-DBS in this cohort was 165 ± 18min. The mean pneumocephalus volume was 2 cm3. The median absolute errors in the x-, y-, and z-axes were 0.7mm, 0.5mm, and 0.9mm, respectively. The median Euclidean distance (ED) and radial error (RE) was 1.3 ± 0.5mm and 1.0 ± 0.3mm, respectively. No significant difference was found between right- and left-sided electrodes regarding the RE nor the ED. After a mean 12-month follow-up, the average reduction in seizures was 61%, and six patients experienced a ≥ 50% reduction in seizures, including one patient who had no seizures after the operation. All patients tolerated the anesthesia operation, and no permanent or serious complications were reported. Frameless robot-assisted asleep surgery is a precise and safe approach for placing CMT electrodes in patients with DRE, shortening the surgery time. The segmentation of the thalamic nuclei enables the precise location of the CMT, and the flow of physiological saline to seal the burr holes is a good way to reduce the influx of air. CMT-DBS is an effective method to reduce seizures.

The Value of Suction Drainage for a Chronic Subdural Hematoma in Elderly Patients: A Retrospective Cohort study

Background: The use of suction in the subgaleal drainage system after the burr-hole evacuation of chronic subdural hematoma (CSDH) is still debatable. This study aimed to investigate the value of adding suction to the drainage system of CSDH in elderly patients. Methods: This cohort study retrospectively reviewed the data of the CSDH patients operated on at our university hospital in the last eight years. The inclusion criteria were elderly patients who underwent evacuation of a unilateral CSDH through two burr holes followed by placing a subgaleal drainage tube. Two hundred seventy-three consecutive patients met the inclusion criteria. Seventy-six patients (27.8%) received suction drainage. The comparison between groups with qualitative data was done using the chi-square test. The comparison between groups with quantitative data was done using the t-test. The statistical analyses were conducted using SPSS software version 21 (IBM Corp., Armonk, New York, USA). Results: There were no statistically significant differences between the suction and the non-suction drainage groups regarding the hospitalization period, the postoperative seizures, or the recurrence rate. However, the postoperative pneumocephalus volume in the suction drainage group was significantly lower than in the non-suction drainage group. None of the patients developed acute subdural or intracerebral hemorrhage. Conclusions: Suction drainage did not add statistically significant value to the closed drainage system regarding the hospitalization period, postoperative seizures, or recurrence rate of the CSDH. A prospective controlled study is needed to increase the evidence for this finding.

Accurate Deep Brain Stimulation Lead Placement Concurrent With Research Electrocorticography.

Using electrocorticography for research (R-ECoG) during deep brain stimulation (DBS) surgery has advanced our understanding of human cortical-basal ganglia neurophysiology and mechanisms of therapeutic circuit modulation. The safety of R-ECoG has been established, but potential effects of temporary ECoG strip placement on targeting accuracy have not been reported. To determine whether temporary subdural electrode strip placement during DBS implantation surgery affects lead implantation accuracy. Twenty-four consecutive patients enrolled in a prospective database who underwent awake DBS surgery were identified. Ten of 24 subjects participated in R-ECoG. Lead locations were determined after fusing postoperative computed tomography scans into the surgical planning software. The effect of brain shift was quantified using Lead-DBS and analyzed in a mixed-effects model controlling for time interval to postoperative computed tomography. Targeting accuracy was reported as radial and Euclidean distance errors and compared with Mann-Whitney tests. Neither radial error nor Euclidean distance error differed significantly between R-ECoG participants and nonparticipants. Pneumocephalus volume did not differ between the 2 groups, but brain shift was slightly greater with R-ECoG. Pneumocephalus volume correlated with brain shift, but neither of these measures significantly correlated with Euclidean distance error. There were no complications in either group. In addition to an excellent general safety profile as has been reported previously, these results suggest that performing R-ECoG during DBS implantation surgery does not affect the accuracy of lead placement.

The semi-sitting position in patients with indwelling CSF shunts: perioperative management and avoidance of complications

ObjectivePosterior fossa or midline tumors are often associated with hydrocephalus and primary tumor removal with or without perioperative placement of an external ventricular drain (EVD) is commonly accepted as first-line treatment. Shunting prior to posterior fossa surgery (PFS) is mostly reserved for symptomatic cases or special circumstances. There are limited data regarding the anticipated risk for symptomatic pneumocephalus and the perioperative management using the semi-sitting position (SSP) in such a scenario. Here, we therefore assessed the safety of performing PFS in a consecutive series of patients over a period of 15 years to allow the elaboration of recommendations for perioperative management.MethodsAccording to specific inclusion and exclusion criteria a total of 13 patients who underwent 17 operations was identified. Supratentorial pneumocephalus was evaluated with semiautomatic-volumetric segmentation. The volume of pneumocephalus was evaluated according to age and ventricular size.ResultsTen of the 13 patients had a programmable valve (preoperative valve setting range 6–14 cmH20; mean 7.5 cmH20) while 3 patients had non programmable valves. A variable amount of supratentorial air collection was evident in all patients postoperatively (range 3.2–331 ml; mean 122.32 ml). Positive predictors for the volume of postoperative pneumocephalus were higher age and a preoperative Evans ratio > 0.3. In our series, we encountered no cases of tension pneumocephalus necessitating an air replacement procedure as well as no obstruction, disconnection, infection or hardware malfunction of the shunt system.ConclusionsOur findings indicate that a CSF shunt in situ is not a contraindication for performing PFS in the semi-sitting position and it does not increase the pre-existing risk for postoperative tension pneumocephalus. In cases of primary shunting for hydrocephalus associated with posterior fossa tumors a programmable valve set at a medium opening pressure with a gravitational device is a valid option when PFS in the semi-sitting position is opted. In patients with an indwelling shunt diversion system special caution is indicated in order to prevent and detect overdrainage especially in not adjustable valves or shunts without antisiphon devices.

The Effect of Surgical Positioning on Pneumocephalus in Subthalamic Nucleus Deep Brain Stimulation Surgery for Parkinson Disease

ObjectivesThis research analyzed the effect of surgical positioning on postoperative pneumocephalus and assessed additional potential risk factors of pneumocephalus in subthalamic nucleus (STN) deep brain stimulation (DBS) for Parkinson disease (PD). Materials and MethodsIn this study, 255 consecutive patients with PD who received bilateral STN DBS under general anesthesia were retrospectively included. Of these, 180 patients underwent surgery with their heads in an elevated position, and 75 patients underwent surgery in a supine position. The postoperative pneumocephalus volume was compared between the two groups. Other potential risk factors for pneumocephalus also were analyzed. ResultsThe mean pneumocephalus volume for the group with elevated-head positioning (16.76 ± 15.23 cm3) was greater than for the supine group (3.25 ± 8.78 cm3) (p < 0.001). Multivariable analysis indicated that the pneumocephalus volume was related to surgical positioning, lateral trajectory angle, intraoperative mean arterial pressure (MAP), microelectrode recording (MER) passage number, brain atrophy degree, and the anterior trajectory angle. No correlation was found between pneumocephalus and age, sex, duration of PD, surgery length, or intracranial volume. In the subgroup analysis, the pneumocephalus volume exhibited a negative correlation with intraoperative MAP (r = −0.210, p = 0.005) and positive correlations with degree of brain atrophy (r = 0.242, p = 0.001) and MER passage number (r = 0.184, p = 0.014) in the elevated-head group. Specifically, an MER passage number > 3 was a significant risk factor for pneumocephalus in the elevated-head group. A positive correlation was observed between the pneumocephalus volume and the lateral trajectory angle in both groups (elevated-head positioning, r = 0.153, p = 0.041; supine positioning, r = 0.546, p < 0.001). ConclusionsIn patients with PD who were anesthetized and receiving STN DBS, supine positioning reduced pneumocephalus volume compared with patients with PD receiving STN DBS with their heads elevated. The pneumocephalus volume was negatively correlated with intraoperative MAP and positively correlated with the degree of brain atrophy, the lateral trajectory angle, and the MER passage number.

ABC/2 formula for “bedside” postoperative pneumocephalus volume measurement

BackgroundPostoperative pneumocephalus is associated with a higher risk of recurrence of chronic subdural hematoma (cSDH). However, there is no verified simple way to measure the pneumocephalus volume at the bedside for daily clinical use. The ABC/2 method was shown to be a simple and reliable technique to estimate volumes of intracranial lesions, such as intracranial hematomas. This study aims to evaluate the accuracy of the ABC/2 formula in estimating volumes of pneumocephalus, as compared to the gold standard with computer-assisted volumetric analysis.MethodsA total of 141 postoperative computed tomographic (CT) brain scans of cSDH patients with burr-hole drainage were analysed. Pneumocephalus volume was measured independently by both the ABC/2 formula and the computer-assisted volumetric measurement. For the computer-assisted measurement, the volume of the air was semiautomatically segmented and calculated by computer software. Linear regression was used to determine the correlation between the ABC/2 method and computer-assisted measurement.ResultsThe postoperative pneumocephalus volume after bilateral burr-hole drainage was significantly larger than that of unilateral burr-hole drainage (29.34 ml versus 12.21 ml, p < 0.001). The estimated volumes by the formula ABC/2 significantly correlated to the volumes as measured by the computer-assisted volumetric technique, with r = 0.992 (p < 0.001). The Pearson correlation coefficient is very close to 1, which signifies a very strong positive correlation, and it is statistically significant.ConclusionsAn excellent correlation is observed between the ABC/2 method and the computer-assisted measurement. This study verified that the ABC/2 method is an accurate and simple “bedside” technique to estimate pneumocephalus volume.

Association between postoperative pneumocephalus and chronic subdural hematoma recurrence: A single-center population-based study in Puerto Rico

BackgroundChronic subdural hematomas (CSDHs) are common conditions in neurosurgery, and their recurrence rate after initial surgery is high. Many studies have attempted to use radiographic features to predict recurrence, including postoperative pneumocephalus. However, to our knowledge, no study has directly measured the volume of pneumocephalus and its association with CSDH recurrence at the population-based level. MethodsA single-center Puerto Rican population-based retrospective review was performed on patients surgically treated for CSDH from July 2017 to December 2019. The volume of postoperative pneumocephalus was measured using open-source imaging software. Univariate and multivariate analyses were used to compare recurrence and nonrecurrence groups. ResultsA total of 108 patients were included in the study: 42 patients (39%) with recurrence and 66 patients (61%) without recurrence. The median postoperative pneumocephalus volume was 7.0 cm3 (Q1-Q3: 2.3–23.6). After the univariate analysis, sex, size of subdural space, postoperative midline shift, and volume of postoperative pneumocephalus differed significantly between recurrence and nonrecurrence groups (p ≤ 0.04). Multivariate logistic regression analysis showed that the volume of postoperative pneumocephalus was the only independent variable associated with CSDH recurrence (p = 0.01). ConclusionsPostoperative pneumocephalus is common after the evacuation of a CSDH. In our sample population, postoperative pneumocephalus volume was the only independent variable that differed between recurrence and nonrecurrence patients. Our results indicate that for every cubic centimeter of air introduced into the cranial cavity after burr-hole drainage, the risk of CSDH recurrence increases by 4%.

A Modified Dura Puncture Procedure to Reduce Brain Shift in Deep Brain Stimulation Surgery: One Institution's Experience.

ObjectiveThe therapeutic effect of deep brain stimulation (DBS) surgery mainly depends on the accuracy of electrode placement and the reduction in brain shift. Among the standard procedures, cerebrospinal fluid (CSF) loss or pneumocephalus caused by dura incision (DI) is thought to be the main reason for brain shift and inaccuracy of electrode placement. In the current study, we described a modified dura puncture (DP) procedure to reduce brain shift and compare it with the general procedure of DBS surgery in terms of electrode placement accuracy.Materials and MethodsWe retrospectively analyzed a series of 132 patients who underwent DBS surgery in Wuhan Union Hospital from December 2015 to April 2021. According to the different surgery procedures, patients were classified into two cohorts: the DI group (DI cohort) had 49 patients who receive the general procedure, and the DP group (DP cohort) had 83 patients who receive the modified procedure. Postoperative pneumocephalus volume (PPV) and CSF loss volume, electrode fusion error (EFE), and trajectory number were calculated. Meanwhile, intraoperative electrophysiological signal length (IESL), electrode implantation duration, and other parameters were analyzed.ResultsIn the current study, we introduced an improved electrode implantation procedure for DBS surgery named the DP procedure. Compared with the general DI cohort (n = 49), the modified DP cohort (n = 83) had a shorter electrode implantation duration (p < 0.0001), smaller PPV, lower CSF leakage volume (p < 0.0001), and smaller EFE (p < 0.0001). There was no significant difference in IESL (p > 0.05) or adverse events (perioperative cerebral haematoma, skin erosion, epilepsy, p > 0.05) between the two cohorts.ConclusionThe DP procedure is a modified procedure that can reduce brain shift and ensure implantation accuracy during DBS surgery without adverse events.

Rigid Neuroendoscopy Assisted Hematoma Resection Reduces the Recurrence Rate of Chronic Subdural Hematoma With Mixed Density: A Retrospective Analytic Cohort Study.

BackgroundThe mixed density hematoma (MDH) has a high recurrence rate in chronic subdural hematoma (CSDH). This study adopted rigid neuroendoscopy assisted hematoma resection to evacuate CSDH and investigated its efficacy as compared with the traditional burr-hole craniostomy (BHC) in CSDH with mixed density.MethodsA retrospective cohort study was conducted at two centers between January 2015 and December 2020. The data of 124 patients who underwent BHC for CSDH with mixed density were collected and analyzed. A total of 41 patients underwent rigid neuroendoscopy assisted hematoma resection (neuroendoscopy group) and 83 patients were treated by the traditional BHC (control group). Follow-ups were conducted 6 months after the surgery.ResultsThere was no significant difference in the baseline characteristics and preoperative CT features between the two groups (p > 0.05). The neuroendoscopy group had a lower recurrence rate than the control group (p = 0.043). Besides the neuroendoscopy group had a higher rate of hematoma evacuation (p < 0.001), less pneumocephalus volume (p < 0.001), shorter hospital stay (p < 0.001) and better Markwalder score (p < 0.001) than the control group within 24–48 h after operation. However, there was no significant difference between the two groups in the incidence of pneumocephalus, Markwalder score (at discharge and 6 months after surgery) and mortality. Moreover, the operation time was longer in the neuroendoscopy group (p < 0.001).ConclusionsWhen compared with the traditional BHC, rigid neuroendoscopy assisted hematoma resection can better reduce the recurrence rate of CSDH with mixed density. Also, it surpassed the results obtained from BHC in reducing the volume of pneumocephalus, improving hematoma evacuation rate, promoting short-term neurological recovery, and shortening hospital stays.

Non-acute subdural hematoma: estimation of recurrence using CT-volumetric measurements.

To identify risk factors for unilateral non-acute subdural hematomas NASH recurrence, as well as to perform volumetric quantitative analysis of hematoma, postoperative pneumocephalus and extent of hematoma evacuation. Recurrence of NASH increases morbidity and mortality and has negative socio-economic consequences. Its accurate prediction could improve patient specific care. Records of 102 patients after unilateral NASH evacuation during the period from 2014 to 2020 with a 4-month follow-up were evaluated. Impacts of preoperative clinical signs and factors on the incidence of NASH recurrence were evaluated, namely those of age, gender, timing of surgery, hematoma side, surgical technique (number of burr holes, trepanation versus craniotomy), duration of drainage, antithrombotic agents, morphological type of hematoma, preoperative hematoma volume (PHV), post-evacuation hematoma cavity volume (PHCV), pneumocephalus volume (PCV) and extent of hematoma evacuation (EHE) on the incidence of NASH recurrence were evaluated. An overall recurrence rate of 13.7 % was observed. Preoperative hematoma volume, postoperative hematoma cavity volume and postoperative pneumocephalus volume had a significant impact on incidence of recurrence. Pre- and postoperative volumetric evaluations, of patients with NASH, particularly the measurements of preoperative hematoma volume and postoperative volume of hematoma cavity and pneumocephalus have a potential to improve the prediction of clinically significant recurrence (Tab. 6, Fig. 3, Ref. 51). Text in PDF www.elis.sk Keywords: subdural hematoma, recurrence, pneumocephalus, risk factors.

The Magnetic Resonance Imaging (MRI)-Directed Implantable Guide Tube Technique: Accuracy and Applications in Deep Brain Stimulation

The magnetic resonance imaging (MRI)-directed implantable guide tube technique allows for direct targeting of deep brain structures without microelectrode recording or intraoperative clinical assessment. This study describes a 10-year institutional experience of this technique including nuances that enable performance of surgery using readily available equipment. Eighty-seven patients underwent deep brain stimulation surgery using the guide tube technique for Parkinson disease (n= 59), essential tremor (n= 16), and dystonia (n= 12). Preoperative and intraoperative MRI was analyzed to measure lead accuracy, volume of pneumocephalus, and the ability to safely plan a trajectory for multiple electrode contacts. Mean target error was measured to be 0.7 mm (95% confidence interval [CI] 0.6-0.8 mm) in the anteroposterior plane, 0.6 mm (95% CI 0.5-0.7 mm) in the mediolateral plane, and 0.8 mm (95% CI 0.7-0.9 mm) in the superoinferior plane. Net deviation (Euclidean error) from the planned target was 1.3 mm (95% CI 1.2-1.4 mm). Mean intracranial air volume per lead was 0.2 mL (95% CI 0.1-0.4 mL). In total, 52 patients had no intracranial air on postoperative imaging. In all patients, a safe trajectory could be planned to target for multiple electrode contacts without violating critical neural structures, the lateral ventricle, sulci, or cerebral blood vessels. The MRI-directed implantable guide tube technique is a highly accurate, low-cost, reliable method for introducing deep brain electrodes. This technique reduces brain shift secondary to pneumocephalus and allows for whole trajectory planning of multiple electrode contacts.

Effect of Intraoperative Computed Tomography in Microelectrode Recording during Frameless Stereotactic Deep Brain Stimulation for Parkinson Disease

Microelectrode recording (MER)-guided deep brain stimulation (DBS) remains the standard electrophysiological procedure to place the DBS lead at the optimal target. When single-track MER or test stimulation yields suboptimal results, trajectory adjustments are needed. Intraoperative computed tomography (iCT) can be useful to visualize the microelectrode and verify possible adjustments. The aim of this study was to evaluate the effect of iCT in MER during frameless stereotactic DBS for Parkinson disease (PD). We retrospectively collected 28 PD patients, of whom 19 received iCT and 9 did not, and measured intracranial volume, cerebral volume, cerebrospinal fluid volume, and pneumocephalus volume. Euclidean distance was assessed according to merged preoperative brain CT and magnetic resonance imaging and postoperative brain CT. Fifty-six hemispheres in the 28 patients were analyzed for MER tracks. The patients who received iCT had a significantly lower mean number of MER tracks (1.6 vs. 2.6, P= 0.013) and lower mean Euclidean distance (2.2 mm vs. 2.7 mm, P= 0.033) compared with those who did not receive iCT. Although there was a trend of a decrease in pneumocephalus using intraoperative imaging, there was no significant difference in surgical time. iCT can reduce the number of MER tracks and increase surgical accuracy. Further studies are warranted to investigate whether iCT can reduce surgical complications and improve surgical outcomes.

Electrode Fixation with Bone Cement or Stimloc® in Deep Brain Stimulation Surgery: A Comparative Study.

To examine the postoperative outcomes of electrode fixation using bone cement and Stimloc® in patients with Parkinson?s disease (PD) who underwent subthalamic nucleus (STN) deep brain stimulation (DBS). Between 2016 and 2018, permanent electrode fixation was performed in 30 patients with PD, of which 15 received bone cement and the remaining 15 received Stimloc®. Data regarding preoperative Unified Parkinson?s Disease Rating Scale (UPDRS) III scores, levodopa equivalent daily dose (LEDD) values, surgery duration, and the fixation technique used were recorded. Brain computed tomography was performed for early postoperative evaluation of pneumocephalus and possible hematoma as well as for the determination of migration 1 year postoperatively. UPDRS III scores and LEDD values were re-evaluated 1 year postoperatively; surgery duration, clinical effectiveness, and complication rates were compared between the two fixation techniques. A statistically significant difference in application time was observed between the two techniques (bone cement: 21 min, Stimloc®: 6 min). After 1 year from surgery, 0.92- and 0.88-mm migrations were observed in the bone cement and Stimloc® groups, respectively. A significant correlation between migration and the pneumocephalus volume was observed in both groups. No differences were observed between the groups regarding infection, migration, pneumocephalus volume, wound erosion, and clinical outcomes. Stimloc® is preferred over bone cement for electrode fixation in DBS surgeries as it is associated with shorter application duration; this increases patient comfort and tolerance during awake surgery. Clinical efficacy and complication rates associated with both techniques are similar.