Vagus nerve stimulation for treatment-resistant mood disorders: a long-term naturalistic study

BACKGROUND: Limited therapeutic options are available for patients with treatment-refractory major depression who do not respond to routinely available therapies. Vagus nerve stimulation showed adjunctive antidepressant effect in chronic treatment resistant depression, even though available studies rarely exceed 2-year follow up. We report a naturalistic 5-year follow up of five patients who received VNS implant for resistant depression (3 patients with major depressive disorder and 2 with bipolar disorder). METHODS: Response was defined as a reduction of the 17-item HDRS total score 6550% with respect to baseline, remission as a score 647. RESULTS: Response and remission rates were both 40% (2/5) after 1 year, and 60% (3/5) at 5 years. Two patients withdrew from the study because of side effects or inefficacy of stimulation. CONCLUSIONS: Our case series showed that long-term VNS may be effective in reducing severity of depression in a small but significant minority of patients, although two patients had stimulation terminated because of adverse effects and/or refusal to continue the study

Hardware-Related Skin Erosion in Deep Brain Stimulation for Parkinson’s Disease: How Far Can We Go? An Illustrative Case Report

Skin erosion is a hardware-related complication commonly described after deep brain stimulation (DBS). Hardware exposure is often associated with the development of infection that can lead to implant removal. However, in selected cases, it is possible to manage skin erosion without having to remove the hardware. This article presents the case of a patient with recurrent skin erosions above the IPG, who underwent multiple surgeries. Given the failure of less invasive approaches, a more complex surgery with the employment of a pedunculated flap of pectoralis major in order to cover the IPG was attempted. Nevertheless, the IPG removal was finally unavoidable, resulting in a rapid decline in clinical performance. This illustrative case suggests how, in patients with sustained stimulation who benefit from a good degree of autonomy, it may be useful to use invasive surgical techniques to resolve skin erosions and save the DBS system. In spite of everything, sometimes complete or partial removal of the implant still becomes unavoidable, but this can lead to a severe worsening of PD symptoms. Definitive removal of the system should therefore be considered only in cases of frank infection or after failure of all other approaches

Spontaneous subarachnoid hemorrhage in the emergency department

Subarachnoid hemorrhage (SAH) is one of the major cause of mortality for stroke. The leading cause is the rupture of an intracrnial aneurym. Acute aneurysmal subarachnoid hemorrhage (SAH) is a complex multifaceted disorder that plays out over days to weeks. The development of aneurysms is mainly due to a hemodynamic stress. Considerableadvances have been made in endovascular techniques, diagnostic methods, and surgical and perioperative management guidelines. Rebleeding remains the most imminent danger until the aneurysm is excluded from cerebral circulation. The only effective prevention of rebleeding is repair the aneurysm; choosing the right way with surgical or an endovascular approach. Outcome for patients with SAH remains poor, with population-based mortality rates as high as 45% and significant morbidity among survivors. In this work we analyzed the diagnostic-therapeutic course of patients presenting SAH. We analyzed the types and the occurrence of complications. We present two cases report to better demonstrate that treatments for specific patients need to be individualized

Intra-Operative Ultrasound: Tips and Tricks for Making the Most in Neurosurgery

Purpose: Advances in intraoperative imaging and neuronavigation techniques have positively affected glioma surgery. The desire to reduce brain-shift-related problems while achieving the real-time identification of lesions and residual and anatomical relationships has strongly supported the introduction of intraoperative ultrasound (ioUS) in neuro-oncological surgery. This paper presents tips based on our experience with ioUS in neurosurgery. Methods: We retrospectively analyzed 264 patients who underwent high-grade glioma (HGG) resection at the University of Turin and 60 patients who were treated at the University of Rome. Results: The main issues are the correct choice of the probe and how to evaluate the anatomy to understand how the information from the three common US planes (axial, sagittal and coronal plane) can be used in each case. It is also important to correctly identify anatomical structures in ioUS imaging. In a normal brain, the sulci, sickle, tentorium, choroid plexus, ependyma and the walls of the vessels are all hyperechoic. In addition, some structures are hypoechoic with a homogeneous acoustic gradient: ventricles, cysts and everything that contains liquor. Tumors are usually hyperechoic in ioUS because of their higher cellularity. Conversely, acute edema that contains fluid is hypoechoic, while chronic edema is hyperechoic. Conclusions: IoUS is a real-time, accurate and inexpensive imaging method. The difficulties of interpretation can be overcome by experience in US imaging and a better understanding of the interaction between navigation and imaging fusion techniques. Training on a large number of cases is important for the correct assessment of ioUS information to obtain valuable, real-time information during HGG surgery