J. Molet

Deep brain stimulation of the subcallosal cingulate gyrus: further evidence in treatment-resistant major depression

Deep brain stimulation (DBS) is currently tested as an experimental therapy for patients with treatment-resistant depression (TRD). Here we report on the short- and long-term (1 yr) clinical outcomes and tolerance of DBS in eight TRD patients. Electrodes were implanted bilaterally in the subgenual cingulate gyrus (SCG; Broadman areas 24-25), and stimulated at 135 Hz (90-μs pulsewidth). Voltage and active electrode contacts were adjusted to maximize short-term responses. Clinical assessments included the 17-item Hamilton Depression Rating Scale (HAMD17; primary measure), the Montgomery-Åsberg Depression Rating Scale (MADRS) and the Clinical Global Impression (CGI) Scale. In the first week after surgery, response and remission (HAMD ⩽7) rates were, respectively 87.5% and 50%. These early responses were followed by an overall worsening, with a response and remission rates of 37.5% (3/8) at 1 month. From then onwards, patients showed a progressive improvement, with response and remission rates of 87.5% and 37.5%, respectively, at 6 months. The corresponding figures at 1 yr were 62.5% and 50%, respectively. Clinical effects were seen in all HAMD subscales without a significant incidence of side-effects. Surgical procedure and post-operative period were well-tolerated for all patients. This is the second independent study on the use of DBS of the SCG to treat chronic depression resistant to current therapeutic strategies. DBS fully remitted 50% of the patients at 1 yr, supporting its validity as a new therapeutic strategy for TRD.

Bilateral pallidal stimulation for cervical dystonia: Dissociated pain and motor improvement

Pallidotomy and deep brain stimulation (DBS) of the globus pallidus internus (GPi) has been investigated for medically intractable dystonia.1,2⇓ Attention has mainly focused on motor function; little is known about modification of dystonia-associated pain, which contributes considerably to functional disability.3 We report two patients with idiopathic cervical dystonia (ICD) with only mild motor improvement but marked amelioration of pain symptoms following bilateral DBS of the posteroventral GPi. A 35-year-old woman presented with a 20-year medically intractable segmental ICD and severe pain in her neck and shoulders. At age 34 she experienced reactive depression and attempted suicide. Results of blood analysis—including copper, ceruloplasmin, and acanthocytes—cranial MRI, and muscle biopsy were normal. She received various unsuccessful trials with diazepam, trihexyphenidyl, botulinum toxin, and opioid and nonopioid analgesics. Depressive symptoms improved only mildly with fluoxetine. Preoperative examination disclosed dysphonia, left torticollis and laterocollis, left shoulder elevation, and dystonic postural tremor in both arms (torticollis rating scale of Tsui et al.4 [RST] total score = 21; Hamilton depression score = 36). Palpation over dystonic muscles reproduced the pain that brought the patient to …

Spontaneous thrombosis of an intracranial aneurysm

A case of spontaneous thrombosis of a previously ruptured anterior communicating artery aneurysm is reported. The patient was referred by another hospital to our service 4 months after the bleeding episode. He had developed a symptomatic normal pressure hydrocephalus, successfully treated by ventriculoperitoneal shunt. Follow-up angiographies, the first performed 4 months and the second 1 year after the bleeding, did not show the aneurysm. Furthermore, the parent artery was not occluded. The literature relative to the subject is reviewed and the possible mechanisms of spontaneous thrombosis are discussed.

Manejo actual de las malformaciones arteriovenosas: Estudio retrospectivo de 31 casos y revisión de la literatura

Resumen Objetivos Establecer unos criterios terapeuticos en las malformaciones arteriovenosas (MAVs) grados III, IV y V de Spetzler y Martin y analisis de resultados en el subgrupo de tratamiento con embolizacion mas cirugia. Material y metodos Estudio retrospectivo de 31 pacientes con MAVs cerebrales tratados en nuestro servicio entre 1999 y 2004. Se trata de 19 mujeres y 12 hombres, con una edad media de 31,6 anos (rango de 1 a 62a). La forma de presentacion fue en un 77,4% hemorragia intracraneal, en un 12,9% crisis comicial y en un 3,2% cefalea, infarto isquemico y hallazgo casual en cada uno de ellos. En 29 casos se realizo arteriografia diagnostica y en 2 casos el diagnostico fue anatomopatologico. Segun la clasificacion de Spetzler y Martin, 10,3% fueron de Grado I, 24,1% de Grado II, 37,9% de Grado Ill, 24,1% de Grado IV y 3,4% de Grado V. Se clasificaron en 6 grupos segun el tratamiento realizado (cirugia, embolizacion, radiocirugia, embolizacion mas cirugia, embolizacion mas radiocirugia y tratamiento conservador). Resultados Las MAVs grado III, IV y V (19 pacientes) fueron tratadas en su mayoria por cirugia (6 casos) y embolizacion mas cirugia (5 casos) pero tambien se utilizaron otras modalidades de tratamiento (embolizacion, radiocirugia y conservador). Los resultados funcionales de estos 3 subgrupos muestra un 36,8% (7 casos) de asintomaticos o con minimos sintomas (Rankin m 0-1), un 52,6% (10 casos) de discapacidad leve pero independientes (Rankin m=2), un 5,3% (1 caso) de moderada discapacidad (Rankin m=3), y un 5,3% (1 caso) de mortalidad. En el manejo combinado embolizacion mas cirugia de malformaciones complejas, se observa un alto porcentaje de sangrado postembolizacion que motivo cirugia precoz con buen resultado funcional. Hubo un caso de mortalidad postquirurgica. Conclusiones En el tratamiento de las MAVs cerebrales se debe tener en cuenta factores como la historia natural, la forma de presentacion (hemorragia), las caracteristicas angioestructurales (presencia de aporte arterial profundo, aneurismas), la escala de Spetzler y Martin y el estado clinico del paciente. En el tratamiento con embolizacion mas cirugia es recomendable obtener una embolizacion prequirurgica subtotal > 50%, no ocluir mas del 50% por sesion, mantener un intervalo entre sesiones de embolizacion entre 4 y 6 semanas y un intervalo entre ultima embolizacion y cirugia entre 1 y 3 semanas.

Cognitive functioning after deep brain stimulation in subcallosal cingulate gyrus for treatment-resistant depression: An exploratory study

Deep brain stimulation (DBS) is being investigated as a therapeutic alternative for patients with treatment-resistant depression (TRD), but its cognitive safety has been scarcely explored. The aim of this exploratory study is to evaluate cognitive function of patients before and after deep brain stimulation of the subgenual cingulate gyrus (SCG). Eight treatment-resistant depressed patients were implanted in subgenual cingulate gyrus. A neuropsychological battery was used to evaluate patients before surgery and 1-year after. A matched group of eight first-episode patients was also assessed. A MANOVA was performed for each cognitive domain and those tests showing main time effects were then correlated with depressive symptoms and with medication load. There were significant group and time effects for memory and a group effect for language. No significant interactions between groups or cognitive domains were observed. Medication load was negatively correlated with memory at time 1, and clinical change negatively correlated with memory improvement. These findings support the cognitive safety of DBS of subgenual cingulate gyrus, as cognitive function did not worsen after chronic stimulation and memory performance even improved. The results, though, should be interpreted cautiously given the small sample size and the fact that some treatment-resistant patients received electroconvulsive therapy (ECT) before implantation.

Usefulness of an Intraoperative Electrophysiological Navigator System for Subthalamic Nucleus Surgery in Parkinson’s Disease

Objects: The characteristics and benefits are presented of an intraoperative neurophysiological navigator computerized system developed in our center (Columbus-Track 1.0) that helps the surgical team in neuronal identification and in strategy processes in subthalamic nucleus surgery for Parkinson’s disease (PD). Methods: The navigator consists of three assembled parts: (1) neuronal identification, based on wavelet processing, filtering and gaussian characteristics of the signal; (2) track identification, based on anatomical coincidence, somatomotor response and microstimulation quotient, and (3) strategy, coordinating correction for the next track. A retrospective comparative study was performed with 15 consecutive PD patients (30 targets) operated without the system and the next 15 consecutive patients operated with the aid of the system. With the aid of the computerized navigation system, a significant reduction in the number of tracks was observed (t = –2.503, p = 0.0015), with a mean difference of 1.2 tracks per hemisphere. A non-significant reduction in the total intervention time was also observed, with a mean difference of 20 min per hemisphere (t = –1.418, p = 0.161). Conclusions: The intraoperative computerized navigation system can aid the surgical team in better identifying the neuronal signal and in defining the optimal track to achieve the target.

Immediate cerebral metabolic changes induced by discontinuation of deep brain stimulation of subcallosal cingulate gyrus in treatment-resistant depression

BACKGROUND Positron emission tomography (PET) studies have shown that the antidepressant effect of chronic deep brain stimulation (DBS) of the subcallosal cingulate gyrus (SCG) may be consequence of modifications of brain metabolism at key structures involved in depression. Like clinical benefits, these metabolic changes may reverse when the stimulation is discontinued, even preceding clinical worsening. However no data on immediate effects of DBS discontinuation are available. The aim of this study was to determine immediate cerebral metabolism changes during a short switch-off of electrical stimulation in implanted patients with treatment-resistant depression (TRD) who had achieved clinical improvement after a period of chronic DBS. METHODS Seven patients with TRD who had been previously implanted for DBS in SCG were included. After a period of clinical stabilization two consecutive FDG-PET were acquired, the first with active stimulation and the second after 48 h of inactive stimulation. A HAMD-17 to assess depressive symptoms was performed before both scans. Analyses were performed with SnPM8. RESULTS Inactive stimulation was characterized by metabolism decreases in dorsal anterior cingulate (Broadmann Area, BA24), premotor region (BA6) and putamen with respect to active stimulation. No clinical changes according to HAMD-17 were detected. LIMITATIONS The main limitation of this study is the small sample size. CONCLUSION Our results point to immediate effects of DBS discontinuation on metabolism of brain depressive network which precede clinical changes, helping to disentangle the rationale behind DBS efficacy in TRD.

Preservación de la audición en la cirugía del neurinoma del acústico

Resumen En la actualidad el diagnostico de neurinoma del VIII par craneal en pacientes con tumores de pequeno tamano y audicion conservada ha hecho que la preservacion de la audicion, en estos casos, sea un objetivo especifico. Presentamos los resultados de nuestra serie que abarca 73 casos de neurinoma del VIII p.c, intervenidos en el periodo 84–94. En 16 pacientes se cumplian criterios de audicion util, segun la American Medical Association y en todos ellos, se intento la preservacion de la audicion, lo que se consiguio en el 50%, con criterios de audicion util en 3 casos (19%). En 5 casos (31%) quedo audicion remanente sin criterios de audicion util. La preservacion anatomica del VIII p.c. se consiguio en 12 casos (75%). Los resultados se correlacionaron de forma inversamente proporcional con el tamano del tumor (

Microdescompresión vascular en neuralgias del glosofaríngeo

Resumen Presentamos tres pacientes con neuralgia esencial del glosofaringeo tratados mediante microdescompresion vascular. El tiempo de evolucion clinica oscilo entre 4 meses y 19 anos. Todos los pacientes presentaron una exploracion neurologica normal, y habian recibido tratamiento con carbamazepina sin respuesta terapeutica. Un paciente que presento ademas neuralgia del trigemino fue intervenido quirurgicamente en dos ocasiones; en la primera se realizo microdescompresion vascular (MDV) del trigemino sin remision completa del cuadro algico, por lo que reorientado el diagnostico se reinterviene practicandose MDV del glosofaringeo. En otro paciente con diagnostico inicial de neuralgia del trigemino se realizo previamente termocoagulacion del ganglio de Gasser. Los resultados postoperatorios fueron: Excelentes en dos pacientes que estan asintomaticos sin ninguna medicacion. En otro paciente el resultado fue bueno, pero presenta parestesia facial secundaria a la termocoagulacion del ganglio de Gasser. El seguimiento oscilo entre 1 y 3 anos.

Tuberculoma cerebral. A propósito de un caso

Resumen Presentamos el caso de una paciente de 48 anos de edad, con una lesion expansiva de caracter infiltrativo a nivel fronto-parietal izquierdo y clinica focal de 5 meses de evolucion. El estudio neurorradiologico evidenciaba una lesion expansiva con efecto de masa y captacion irregular de contraste sugestiva de metastasis o glioma cerebral a nivel rolandico izquierdo. Se intervino quirurgicamente consiguiendose la reseccion total de la lesion. El estudio anatomopatologico objetivo la existencia de zonas de necrosis caseosa y permitio visualizar formas de BK en varios cortes. Consideramos de interes el caso, dada la escasa incidencia de tuberculomas cerebrales y la atipica forma de presentacion.