Peri-insular hemispherotomy in paediatric epilepsy

Objects: Outline the indications, investigation, surgical technique, pitfalls, complications and benefits of peri-insular hemispherotomy (PIH) in the surgical treatment of paediatric epilepsy. Materials and methods: This report is based on a consecutive series of 43 children who underwent PIH. Sixty percent were males; there were slightly more left-sided surgeries. Median interval between seizure onset and surgery was 5 years. In more than half the cases, the anatomical substrate was congenital. There were few complications: one death, one hydrocephalus and two anatomically remote haemorrhages. Ninety percent of the patients have remained in Engel's class I epilepsy outcome. Conclusions: There are clear indications for hemispherectomy in children. In some instances of incomplete deficit, timing of surgery remains a major concern. The less invasive approach to eliminate the influence of the diseased hemisphere, in our opinion, is with disconnective techniques of hemispherectomy, and among the latter, peri-insular hemispherotomy provides, in our opinion, the best complications-benefits rati

Validation of Experts versus Atlas-based and Automatic Registration Methods for Subthalamic Nucleus Targeting on MRI

Objects In functional stereotactic neurosurgery, one of the cornerstones upon which the success and the operating time depends is an accurate targeting. The subthalamic nucleus (STN) is the usual target involved when applying deep brain stimulation for Parkinson's disease (PD). Unfortunately, STN is usually not clearly visible in common medical imaging modalities, which justifies the use of atlas-based segmentation techniques to infer the STN location. Materials and methods Eight bilaterally implanted PD patients were included in this study. A three-dimensional T1-weighted sequence and inversion recovery T2-weighted coronal slices were acquired pre-operatively. We propose a methodology for the construction of a ground truth of the STN location and a scheme that allows both, to perform a comparison between different non-rigid registration algorithms and to evaluate their usability to locate the STN automatically. Results The intra-expert variability in identifying the STN location is 1.06±0.61mm while the best non-rigid registration method gives an error of 1.80±0.62mm. On the other hand, statistical tests show that an affine registration with only 12 degrees of freedom is not enough for this application. Conclusions Using our validation-evaluation scheme, we demonstrate that automatic STN localization is possible and accurate with non-rigid registration algorithm

Validation of Experts versus Atlas-based and Automatic Registration Methods for Subthalamic Nucleus Targeting on MRI

Objects In functional stereotactic neurosurgery, one of the cornerstones upon which the success and the operating time depends is an accurate targeting. The subthalamic nucleus (STN) is the usual target involved when applying deep brain stimulation for Parkinson's disease (PD). Unfortunately, STN is usually not clearly visible in common medical imaging modalities, which justifies the use of atlas-based segmentation techniques to infer the STN location. Materials and methods Eight bilaterally implanted PD patients were included in this study. A three-dimensional T1-weighted sequence and inversion recovery T2-weighted coronal slices were acquired pre-operatively. We propose a methodology for the construction of a ground truth of the STN location and a scheme that allows both, to perform a comparison between different non-rigid registration algorithms and to evaluate their usability to locate the STN automatically. Results The intra-expert variability in identifying the STN location is 1.06±0.61mm while the best non-rigid registration method gives an error of 1.80±0.62mm. On the other hand, statistical tests show that an affine registration with only 12 degrees of freedom is not enough for this application. Conclusions Using our validation-evaluation scheme, we demonstrate that automatic STN localization is possible and accurate with non-rigid registration algorithm

Sound recognition and localization in man: specialized cortical networks and effects of acute circumscribed lesions

Functional imaging studies have shown that information relevant to sound recognition and sound localization are processed in anatomically distinct cortical networks. We have investigated the functional organization of these specialized networks by evaluating acute effects of circumscribed hemispheric lesions. Thirty patients with a primary unilateral hemispheric lesion, 15 with right-hemispheric damage (RHD) and 15 with left-hemispheric damage (LHD), were evaluated for their capacity to recognise environmental sounds, to localize sounds in space and to perceive sound motion. One patient with RHD and 2 with LHD had a selective deficit in sound recognition; 3 with RHD a selective deficit in sound localization; 2 with LHD a selective deficit in sound motion perception; 4 with RHD and 3 with LHD a combined deficit of sound localization and motion perception; 2 with RHD and 1 with LHD a combined deficit of sound recognition and motion perception; and 1 with LHD a combined deficit of sound recognition, localization and motion perception. Five patients with RHD and 6 with LHD had normal performance in all three domains. Deficient performance in sound recognition, sound localization and/or sound motion perception was always associated with a lesion that involved the shared auditory structures and the specialized What and/or Where networks, while normal performance was associated with lesions within or outside these territories. Thus, damage to regions known to be involved in auditory processing in normal subjects is necessary, but not sufficient for a deficit to occur. Lesions of a specialized network was not always associated with the corresponding deficit. Conversely, specific deficits tended not be associated predominantly with lesions of the corresponding network; e.g. deficits in auditory spatial tasks were observed in patients whose lesions involved to a larger extent the shared auditory structures and the specialized What network than the specialized Where network, and deficits in sound recognition in patients whose lesions involved mostly the shared auditory structures and to a varying degree the specialized What network. The human auditory cortex consists of functionally defined auditory areas, whose intrinsic organization is currently not understood. In particular, areas involved in the What and Where pathways can be conceived as: (1) specialized regions, in which lesions cause dysfunction limited to the damaged part; observed deficits should be then related to the specialization of the damaged region and their magnitude to the extent of the damage; or (2) specialized networks, in which lesions cause dysfunction that may spread over the two specialized networks; observed deficits may then not be related to the damaged region and their magnitude not proportional to the extent of the damage. Our results support strongly the network hypothesi

Adjuvant or radical fractionated stereotactic radiotherapy for patients with pituitary functional and nonfunctional macroadenoma

Purpose: To evaluate the efficacy and toxicity of stereotactic fractionated radiotherapy (SFRT) for patients with pituitary macroadenoma (PMA).Methods and Materials: Between March 2000 and March 2009, 27 patients (male to female ratio, 1.25) with PMA underwent SFRT (median dose, 50.4 Gy). Mean age of the patients was 56.5 years (range, 20.3 - 77.4). In all but one patient, SFRT was administered for salvage treatment after surgical resection (transphenoidal resection in 23, transphenoidal resection followed by craniotomy in 2 and multiple transphenoidal resections in another patient). In 10 (37%) patients, the PMAs were functional (3 ACTH-secreting, 3 prolactinomas, 2 growth hormone-secreting and 2 multiple hormone-secretion). Three (11.1%) and 9 (33.3%) patients had PMA abutting and compressing the optic chiasm, respectively. Mean tumor volume was 2.9 +/- 4.6 cm(3). Eighteen (66.7%) patients had hypopituitarism prior to SFRT. The mean follow-up period after SFRT was 72.4 +/- 37.2 months.Results: Tumor size decreased for 6 (22.2%) patients and remained unchanged for 19 (70.4%) other patients. Two (7.4%) patients had tumor growth inside the prescribed treatment volume. The estimated 5-year tumor growth control was 95.5% after SFRT. Biochemical remission occurred in 3 (30%) patients with functional PMA. Two patients with normal anterior pituitary function before SFRT developed new deficits 25 and 65 months after treatment. The 5-year survival without new anterior pituitary deficit was thus 95.8%. Five patients with visual field defect had improved visual function and 1 patient with no visual defect prior to SFRT, but an optic chiasm abutting tumor, had a decline in visual function. The estimated 5-year vision and pituitary function preservation rates were 93.2% and 95.8%, respectively.Conclusions: SFRT is a safe and effective treatment for patients with PMA, although longer follow-up is needed to evaluate long-term outcomes. In this study, approximately 1 patient with visual field defect out of two had an improved visual

Primate adult brain cell autotransplantation, a new tool for brain repair ?

If successful, autologous brain cell transplantation is an attractive approach to repair lesions and restore function of the central nervous system. We demonstrate that monkey adult brain cells obtained from cortical biopsy and kept in culture for 4 weeks exhibit neural progenitor characteristics. After reimplantation into a lesion area of the donor cerebral cortex, these cells can successfully survive and acquire neuronal characteristics over time. These results open new perspectives in the field of brain repair and may lead to future clinical applications

Traitement actuel de la maladie de Parkinson : difficultés et controverses

Treating patients with Parkinson's disease is not an easy task for the physician who is facing a disease well responsive to symptomatic therapy, yet escaping any curative approaches. In spite of the large therapeutic armamentarium available, many issues remained unsolved, as indications of a particular therapeutic agent are only loosely defined and evolving according to various parameters such as disease progression and severity, the profile of potentially serious adverse effects, the physician's level of expertise and patient's expectations. The growing experience acquired with subthalamic nucleus deep brain stimulation has shown that indications for such a surgery have to be cautiously examined. After initial therapeutic enthusiasm, we are now at a time of problems and controversies

Cryopreservation of human brain tissue allowing timely production of viable adult human brain cells for autologous transplantation

BACKGROUND: Autologous transplantation is an attractive approach to treat some neurological diseases. A major obstacle is the capacity to produce cells for transplantation at the appropriate time. We describe a cryopreservation procedure for adult human brain tissue allowing the generation of cells in vitro. METHODS: Neurological resections were dissected to separate white and grey matter. Fractions were frozen in a specific cryopreservation medium containing a selected serum and stored in liquid nitrogen. Tissue was thawed, cells were mechanically dissociated, expanded in culture and characterized by immunochemistry. RESULTS: Adult human brain tissue cryopreserved for up to two years was successfully used to generate brain cells that could be maintained in culture for up to 100 days. Cells expressed a variety of neuroectodermal markers including GFAP, S100beta, and neurofilament. CONCLUSION: A successful procedure for cryopreservation of adult human brain tissue has been established that might facilitate future autologous transplantation strategies