Mobile intraoperative CT-assisted frameless stereotactic biopsies achieved single-millimeter trajectory accuracy for deep-seated brain lesions in a sample of 7 patients

BACKGROUND Brain biopsies are crucial diagnostic interventions, providing valuable information for treatment and prognosis, but largely depend on a high accuracy and precision. We hypothesized that through the combination of neuronavigation-based frameless stereotaxy and MRI-guided trajectory planning with intraoperative CT examination using a mobile unit, one can achieve a seamlessly integrated approach yielding optimal target accuracy. METHODS We analyzed a total of 7 stereotactic biopsy trajectories for a variety of deep-seated locations and different patient positions. After rigid head fixation, an intraoperative pre-procedural scan using a mobile CT unit was performed for automatic image fusion with the planning MRI images and a peri-procedural scan with the biopsy cannula in situ for verification of the definite target position. We then evaluated the radial trajectory error. RESULTS Intraoperative scanning, surgery, computerized merging of MRI and CT images as well as trajectory planning were feasible without difficulties and safe in all cases. We achieved a radial trajectory deviation of 0.97 ± 0.39 mm at a trajectory length of 60 ± 12.3 mm (mean ± standard deviation). Repositioning of the biopsy cannula due to inaccurate targeting was not required. CONCLUSION Intraoperative verification using a mobile CT unit in combination with frameless neuronavigation-guided stereotaxy and pre-operative MRI-based trajectory planning was feasible, safe and highly accurate. The setting enabled single-millimeter accuracy for deep-seated brain lesions and direct detection of intraoperative complications, did not depend on a dedicated operating room and was seamlessly integrated into common stereotactic procedures

Deep brain electrical neurofeedback allows Parkinson patients to control pathological oscillations and quicken movements

Parkinsonian motor symptoms are linked to pathologically increased beta-oscillations in the basal ganglia. While pharmacological treatment and deep brain stimulation (DBS) reduce these pathological oscillations concomitantly with improving motor performance, we set out to explore neurofeedback as an endogenous modulatory method. We implemented real-time processing of pathological subthalamic beta oscillations through implanted DBS electrodes to provide deep brain electrical neurofeedback. Patients volitionally controlled ongoing beta-oscillatory activity by visual neurofeedback within minutes of training. During a single one-hour training session, the reduction of beta-oscillatory activity became gradually stronger and we observed improved motor performance. Lastly, endogenous control over deep brain activity was possible even after removing visual neurofeedback, suggesting that neurofeedback-acquired strategies were retained in the short-term. Moreover, we observed motor improvement when the learnt mental strategies were applied 2 days later without neurofeedback. Further training of deep brain neurofeedback might provide therapeutic benefits for Parkinson patients by improving symptom control using strategies optimized through neurofeedback

Combined thalamic and subthalamic deep brain stimulation for tremor-dominant Parkinson's disease.

Deep brain stimulation (DBS) in the thalamic ventral intermediate (Vim) or the subthalamic nucleus (STN) reportedly improves medication-refractory Parkinson's disease (PD) tremor. However, little is known about the potential synergic effects of combined Vim and STN DBS. We describe a 79-year-old man with medication-refractory tremor-dominant PD. Bilateral Vim DBS electrode implantation produced insufficient improvement. Therefore, the patient underwent additional unilateral left-sided STN DBS. Whereas Vim or STN stimulation alone led to partial improvement, persisting tremor resolution occurred after simultaneous stimulation. The combination of both targets may have a synergic effect and is an alternative option in suitable cases

A prospective international multi-center study on safety and efficacy of deep brain stimulation for resistant obsessive-compulsive disorder

Deep brain stimulation (DBS) has been proposed for severe, chronic, treatment-refractory obsessive-compulsive disorder (OCD) patients. Although serious adverse events can occur, only a few studies report on the safety profile of DBS for psychiatric disorders. In a prospective, open-label, interventional multi-center study, we examined the safety and efficacy of electrical stimulation in 30 patients with DBS electrodes bilaterally implanted in the anterior limb of the internal capsule. Safety, efficacy, and functionality assessments were performed at 3, 6, and 12 months post implant. An independent Clinical Events Committee classified and coded all adverse events (AEs) according to EN ISO14155:2011. All patients experienced AEs (195 in total), with the majority of these being mild (52% of all AEs) or moderate (37%). Median time to resolution was 22 days for all AEs and the etiology with the highest AE incidence was 'programming/stimulation' (in 26 patients), followed by 'New illness, injury, condition' (13 patients) and 'pre-existing condition, worsening or exacerbation' (11 patients). Sixteen patients reported a total of 36 serious AEs (eight of them in one single patient), mainly transient anxiety and affective symptoms worsening (20 SAEs). Regarding efficacy measures, Y-BOCS reduction was 42% at 12 months and the responder rate was 60%. Improvements in GAF, CGI, and EuroQol-5D index scores were also observed. In sum, although some severe AEs occurred, most AEs were mild or moderate, transient and related to programming/stimulation and tended to resolve by adjustment of stimulation. In a severely treatment-resistant population, this open-label study supports that the potential benefits outweigh the potential risks of DBS

A stereotactic frame-based drill guide-aided setting for laser interstitial thermal therapy

BACKGROUND Magnetic resonance imaging (MRI)-guided laser interstitial thermal therapy (MRIgLITT) was demonstrated to be a viable neurosurgical tool. Apart from its variety of indications, different operative and technical nuances exist. In the present report, for the first time, the use and ability of a traditional Riechert-Mundinger (RM) stereotactic system combined with a novel drill guide kit for MRIgLITT are described. METHODS A stereotactic frame-based setting was developed by combining an RM system with a drill guide kit and centering bone anchor screwing aid for application together with an MRIgLITT neuro-accessory kit and cooled laser applicator system. The apparatus was used for stereotactic biopsy and consecutive MRIgLITT with an intraoperative high-field MRI scanner in a brain tumor case. RESULTS The feasibility of an RM stereotactic apparatus and a drill guide kit for MRIgLITT was successfully assessed. Both stereotactic biopsy and subsequent MRIgLITT in a neurooncological patient could easily and safely be performed. No technical problems or complications were observed. CONCLUSION The combination of a traditional RM stereotactic system, a new drill guide tool, and intraoperative high-field MRI provides neurosurgeons with the opportunity to reliably confirm the diagnosis by frame-based biopsy and allows for stable and accurate real-time MRIgLITT

Bewegungsstörungen: Was machen Sie? Was können wir?

Movement Disorders: What Are You Doing? What Can We Do? Abstract. Disturbances of movement are common and varied. Frequent causes are systemic diseases such as Parkinson's syndromes and the essential tremor. Treatment options in practice and hospital include conservative, predominantly drug strategies such as oral administration of dopamine precursors or agonists, and pharmacological or non-pharmacological escalation strategies such as intramuscular botulinum toxin A injections, the subcutaneous or enteral drug pumps for apomorphine or levodopa and carbidopa, the effective deep brain stimulation and the novel focused ultrasound therapy, which are bound to highly specialized centers and should be considered as treatment option quite earlier and more frequently

A new tool for frameless stereotactic placement of ventricular catheters

The accurate position of the ventricular catheter inside the frontal horn of the lateral ventricle is essential to prevent proximal failure in shunt surgery. For optimal placement, endoscopic- and image-guided techniques are available

Peroral Trigeminal Rhizotomy Using a Novel 3-Dimensional Printed Patient-Specific Guidance Tool

BACKGROUND Ganglion Gasseri rhizotomy is a viable therapeutic option for trigeminal pain (TP). For this neurosurgical procedure, different potential operative and technical nuances exist. OBJECTIVE To evaluate a novel peroral trigeminal rhizotomy method and 3-dimensional printed patient-specific guidance tool (3D-PSGT) with respect to their applicability and safety. METHODS Between March 2018 and February 2021, 20 peroral balloon compression rhizotomy procedures with a 3D-PSGT were performed in 18 consecutive TP patients (13 female, mean age 58 yr). We registered the procedure duration, side effects, complications, and trigeminal function. The therapeutic effect was gauged from reduction of TP and use of analgesics. RESULTS All catheter insertions and rhizotomy procedures were successful at the first attempt. Apart from fluoroscopy, no auxiliary material was necessary. The average length of surgery was 19 min (range, 11-27 min). In total, 8 patients indicated complete analgesia and 6 patients pain relief; in 4 patients, persistence of TP was observed during follow-up examinations of up to 20 mo. In total, 6 patients reported of new mild to moderate facial hypesthesia affecting the trigeminal branches V2, V3, or V1-3. No masticatory musculature or corneal affections and device-related complications occurred. CONCLUSION The peroral 3D-PSGT trigeminal rhizotomy is straightforward for the neurosurgeon. This operative approach allows for rapid, safe, and simple foramen ovale cannulation in TP patients and reduces the use of additional equipment, radiation exposure, and procedure time

Bilateral Focused Ultrasound Pallidotomy for Parkinson-Related Facial Dyskinesia—A Case Report

Background For safety reasons, both magnetic resonance-guided high-intensity focused ultrasound (MRgHiFUS) thalamotomy and pallidotomy are currently approved exclusively for unilateral treatment, but axial symptoms like levodopa-induced orofacial dyskinesia require a bilateral approach. Objectives We report the first case of successful bilateral MRgHiFUS pallidotomy for peak-dose dyskinesia in a patient with Parkinson's disease (PD). Methods The treatment decision was based on the patient's reluctance toward brain implants and pump therapies and the fact that he had limited access to a deep brain stimulation center in his home country. The treatment was planned as staged procedure with an interval of 18 months because of travel restrictions because of the coronavirus disease (COVID)-19 pandemic. Results After the second treatment, levodopa-induced orofacial dyskinesia remitted and improved bradykinesia and rigidity with stable gait and good postural reflexes. Conclusions This promising result suggests that in selected PD patients with dyskinesia, staged bilateral MRgHiFUS pallidotomy might be considered