Jürgen Schlaier

Image fusion of MR images and real-time ultrasonography: evaluation of fusion accuracy combining two commercial instruments, a neuronavigation system and a ultrasound system

SummaryObjective. The aim of our study was to evaluate MRI/Ultrasonography fusion accuracy depending on three ultrasonographic parameters. Method. An ultrasonography and MRI compatible model was created, consisting of a plastic box, which contained 3 objects. MRI scans were performed with 128 sagittal slices. The objects were segmented and 3D reconstructions were created. A special ultrasound adapter with 3 reflective markers was fixed to the ultrasound probe. Thus, the probe could be tracked by the navigation system (Vector Vision2, BrainLab, Heimstetten, Germany) and the segmented shape of the 3D-objects obtained from the MR images were overlaid onto the ultrasound display (Elegra, Siemens, Erlangen, Germany). The dependency of fusion accuracy on different depth of ultrasound display, different distances between probe and objects and different angles between the axis of the ultrasound probe and the centre of the spheres was evaluated. 435 single measurements were performed. Findings. Overall fusion accuracy was 1.08 mm±0.61 mm (mean ± standard deviation) for spheres and 1.6 mm±1.1 mm for arrow heads. If the ultrasound probe was directed more tangentially to the surface of the spheres the fusion became increasingly inaccurate (P<0.05). Fusion accuracy decreased the more distant the US probe was held to the object (P<0.05). Different depth of ultrasound display had no significant effect on fusion accuracy. Conclusions. Highly accurate fusion of MR images and real-time ultrasonography could be achieved. However, careful interpretation of the fused data is necessary, when different angles and distances of the US probe to the object are concerned.

Levetiracetam compared to phenytoin for the prevention of postoperative seizures after craniotomy for intracranial tumours in patients without epilepsy

Anticonvulsant drugs are frequently given after craniotomy. Phenytoin (PHT) is the most commonly used agent; levetiracetam (LEV) is a new anticonvulsant drug with fewer side effects. To compare the incidence of seizures in patients receiving either prophylactic PHT or LEV perioperatively, 971 patients undergoing a craniotomy were analysed retrospectively during a 2-year period. PHT was used routinely and LEV was administered when PHT was contraindicated. Seizures documented during the first 7 days after craniotomy were considered. A total of 235 patients were treated with an antiepileptic drug: 81 patients received LEV, and 154 patients, PHT. Two patients receiving LEV (2.5%) and seven receiving PHT (4.5%) had a seizure despite this treatment. No patient had a documented side effect or drug interaction. The data show that LEV may be an alternative option in patients with contraindications to PHT.

Reliability of atlas-derived coordinates in deep brain stimulation

SummaryBackground. In deep brain stimulation the way to define and localize the optimal target for the individual patient is still under debate. The objective of our study was to investigate the reliability of atlas derived data by comparing them with direct targeting on MR images. Method. We investigated 28 STN targets in 14 volunteers. The stereotactic coordinates of the dorso-lateral subthalamic nucleus (STN), were determined in 5 different ways for both STNs of each individual volunteer: 1. directly, on axial T2WI spin echo slices, 2. directly, on coronal T2WI spin echo slices and after fusion of data sets: 3. indirectly, on an axial atlas plate, 4. indirectly, on a coronal atlas plate, 5. indirectly, 12 mm lateral, 3 mm posterior and 3 mm inferior to mid-AC-PC. Findings. The differences between MRI derived targets on axial vs. coronal slices were not statistically significant. After detection of the atlas derived targets the resulting x-coordinates were found more lateral than after direct detection on both, axial and coronal T2-weighted images (p<0.001). On axial images y-coordinates were located more anterior (p=0.240) on atlas derived targets and more posterior when target localizations were compared on coronal slices (p<0.001). z-Coordinates were more superior after atlas targeting compared to MRI targeting (p<0.001). Differences up to 6.21 mm occurred. Conclusions. Despite the limitations concerning image distortions and slice thickness, direct target planning on MRI, regarding our results, is more reliable than targeting solely based on atlas derived data. Only MRI gives us detailed information about the individual configurations of central structures in every single patient. However, targets, which are not detectable on MRI like the nucleus ventralis intermedius have to be planned using stereotactic atlas information. In these cases intra-operative micro-electrode recording might help to better define the target region.

Effects of spinal cord stimulation on cortical excitability in patients with chronic neuropathic pain: A pilot study

Background: Despite a broad clinical use, the mechanism of action of SCS is poorly understood. Current information suggests that the effects of SCS are mediated by a complex set of interactions at several levels of the nervous system including spinal and supraspinal mechanisms.

Predictors of facet joint syndrome after lumbar disc surgery

Postoperative facet joint syndrome (pFJS) requiring intervention is a common problem following lumbar disc surgery (LDS). The aim of this retrospective study was to identify possible predictors, surgical aspects or individual characteristics that may contribute to the development of pFJS and may allow prevention of this frequent postoperative problem. We included 509 patients who underwent open, microsurgical discectomy in our neurosurgical department between 2006 and 2009 and who presented to our outpatient clinic for follow-up. We recorded gender, age, preoperative and postoperative clinical and neurological status, surgical technique, duration of the surgical procedure, disc herniation relapse, rehabilitation treatment and development of pFJS. Forty-three patients (8.4%) developed clinically evident pFJS, confirmed by a successful facet joint injection. Patients with pFJS were significantly older than those without pFJS (55.7 years compared with 50.9 years; p=0.03) and had more frequent recurrent disc herniation (p=0.001). Furthermore, the duration of the surgical procedure (p=0.01), intraoperative and postoperative complications (for example, postoperative bleeding, dural injury; p=0.001) and general comorbidity (p=0.001) were associated with pFJS. In addition, an extended discectomy compared with sequesterotomy (p=0.049) and rehabilitation treatment compared with no rehabilitation (p=0.019) were correlated to pFJS in the multivariate analysis. Thus, we were able to identify factors associated with the development of pFJS following LDS: advanced age, long operative time, intraoperative complications, history of recurrent disc prolapse, discectomy and lack of rehabilitation. Our results characterize a profile for patients at high risk for the development of clinically evident pFJS.

Functional MRI of the motor cortex using a conventional gradient system: comparison of FLASH and EPI techniques

Gradient echo (GE) and echo planar imaging (EPI) techniques are two different approaches to functional MRI (fMRI). In contrast to GE sequences, the ultra short EPI technique facilitates fMRI experiments with high spatial and temporal resolution or mapping of the whole brain. Although it has become the method of choice for fMRI, EPI is generally restricted to modern scanners with a strong gradient system. The aim of our study was to evaluate the applicability of EPI for fMRI of the motor cortex using a 1.5 T scanner with a conventional gradient system of 10 mT/m (rise time: 1 ms). Therefore, EPI was compared with a well-established high-resolution fast low-angle shot (FLASH) technique (matrix size 1282). The FLASH technique was applied additionally with a 64(2) matrix size to exclude influences caused by different spatial resolution, because the EPI sequence was restricted to a 64(2) matrix size. A total of 35 healthy volunteers were included in this study. The task consisted of clenching and spreading of the right hand. FLASH and EPI techniques were compared regarding geometric distortions as well as qualitative and quantitative fMRI criteria: Mean signal increase between activation and rest and the area of activation were measured within the contralateral, ipsilateral, and supplementary motor cortex. The quality of subtraction images between activation and rest, as well as the quality of z-maps and time course within activated regions of interest, was evaluated visually. EPI revealed significant distortions of the anterior and posterior brain margins; lateral distortions (relevant for the motor cortex) could be neglected in most cases. The mean signal increase was significantly higher using FLASH 1282 compared to FLASH 64(2) and EPI 64(2), whereas the activated areas proved to be smaller in FLASH 1282 functional images. Both results can be explained by well-documented partial volume effects, caused by different voxel size. Similar quality of the subtraction images and of the time courses in different regions of interest were found for all techniques under investigation, but slightly reduced quality of z-map in FLASH 1282. Within the limits of reproducibility and measurement accuracy, the location of contralateral activation was similar using FLASH and EPI sequences. In conclusion, EPI proved to be a reliable technique for fMRI of the motor cortex, even on an MR scanner with a conventional gradient system.

Underutilization of deep brain stimulation for Parkinson’s disease? A survey on possible clinical reasons

BackgroundOnly 10% of the up to 15% of patients with advanced Parkinson’s disease (PD) eligible for deep brain stimulation (DBS) are referred to specialized centers. This survey evaluated the reasons for the reluctance of patients and referring physicians regarding DBS.MethodsTwo different questionnaires containing multiple choice and open verbalized questions were developed, one for neurologists and one for patients with PD. The first questionnaire was sent to 87 neurologists in private practice in the catchment area of the authors’ medical center, the second to patient support groups in the same region with the help of the German Parkinson Association.ResultsOf the addressed neurologists, 56.3% completed the questionnaire; 61.2% of them estimated the risk of intracerebral hemorrhage as the most severe complication at 4.3% on average; 30.6% were concerned about patients developing mood changes or depression after DBS. Only 16.3% felt unable to care for patients after DBS; 61.2% already had personal experience with patients after DBS and reported good clinical outcome in 90.0% of patients. Although 87.8% claimed to know the specific criteria for DBS, only 40.8% could actively describe them. Only 14.0% could state each of the three main criteria. Of the 46 patients, 88.1% completing the questionnaire had obtained information on DBS from regional patient organizations and 54.8% also from a physician; 44.7% assumed the risk of severe complications to be ≥5.0%. Not being satisfied with their medical treatment was reported by 22.2%, of whom more than 70% considered DBS a further treatment option.ConclusionsThe latter numbers indicate that treating neurologists tend to overestimate the reluctance of their patients to undergo DBS. Therefore, education of patients and neurologists should be improved and give more realistic figures on the actual outcomes and frequencies of possible complications.

The quality of functional MR images in patients with brain tumors : influences of neurological disorders and tumor location

The aim of our study was to investigate the influence of neurological disorders, and the influence of tumor and perifocal edema location on functional magnetic resonance imaging (fMRI) quality. fMRI quality tended to be better the closer the tumor and the perifocal edema were located to the pmc. Hemipareses and seizures had no significant influence on fMRI quality. Therefore, hemiparetic patients do not have to be excluded beforehand. The evaluation of time courses is essential before using z-maps to localize eloquent brain regions preoperatively.

Analysis of risk factors influencing the development of severe dizziness in patients with vestibular schwannomas in the immediate postoperative phase.

OBJECTIVE Dizziness, a common postoperative symptom in patients with vestibular schwannomas (VSs) has a negative effect on the course of recovery, particularly in patients with severe symptoms. Reports on incidence and possible risk factors contributing to these symptoms are inconsistent and sometimes even contradictory. In order to establish a profile of patients at risk of severe symptoms in the immediate postoperative phase we retrospectively analyzed data of patients with unilateral VSs focusing on the incidence of severe dizziness and nausea during the immediate postoperative period and up to 1 year after surgery. METHODS In a retrospective study data of 104 consecutive patients with VSs were analyzed. All patients underwent microsurgical tumor resection via a lateral-suboccipital approach. Factors that were assumed to affect the development of severe dizziness, such as age, gender, tumor size, tumor side, and cranial nerve function, were analyzed by means of univariate and multivariate logistic regression analyses. A three step grading system was used to describe symptoms of patients included in this study: 0=no symptoms of dizziness, 1=slight dizziness including light-headedness or feeling of disequilibrium and 2=severe dizziness with nausea including imbalance or insecurity when walking, requiring antiemetic treatment. RESULTS Data of 92 patients, 41 men and 51 women, were available for analyses. Mean age of treated patients was 53 years (range 17-81). There was no predilection of side (52.2% right/47.8% left). Before surgery 39 patients (42.4%) were symptom free (grade 0), 13 patients (14.1%) had slight symptoms (grade 1) and 40 patients (43.5%) suffered from severe symptoms (grade 2). Immediately after surgery two patients (2.2%) where symptom free (grade 0), 19 patients (20.7%) had slight symptoms (grade 1) and 71 patients (77.2%) suffered from severe symptoms (grade 2). All patients with grade 2 symptoms required antiemetic treatment ranging between 1 and 10 days (mean 4 days). Logistic regression analyses showed young age, large tumor size (T3/T4), female gender, and severe preoperative symptoms to be main factors increasing the odds for patients to develop severe symptoms postoperatively. CONCLUSION Patients at risk to develop severe symptoms should receive antiemetic treatment even before surgery. If in doubt about the actual risk for a specific patient with a large tumor (T3 or T4) available data suggests that patients will benefit if antiemetic treatment is started early, even before surgery.

The impact of white matter lesions on the cognitive outcome of subthalamic nucleus deep brain stimulation in Parkinson’s disease

OBJECTIVES White Matter lesions (WML) are a risk factor for cognitive impairment in Parkinsons disease. There is no clear evidence of reduced general cognitive function after DBS. However, a subgroup of patients develops dementia rapidly after DBS despite careful patient selection processes. The aim of this study was to evaluate the load of WML as a possible risk factor for cognitive decline following STN DBS. PATIENTS AND METHODS 40 PD-patients receiving bilateral STN-DBS were followed at least three years after surgery to detect dementia. All patients underwent comprehensive neuropsychological assessment and MRI before surgery. The extent of WML was assessed using an automated approach. WML volume was correlated to the onset of dementia and the decline of a cognitive composite score retrospectively. RESULTS Patients with a rapid onset of dementia within one, respective three following DBS showed significant higher WML volumes compared to cognitive normal and MCI patients (55.8cm3±18.836 vs. 9.3cm3±12.2; p=0.002). The same significant association was found in a multivariable model, including the covariables age, gender and PD disease duration (p=0.01). WML volume was associated to the rate of decline in cognitive composite score within three years after DBS surgery (p=0.006; R2=0.40) after correction for age. CONCLUSIONS Damaged white matter may lead to a reduced compensation of disconnections in cognitive circuits caused by the implantation of the DBS electrodes or by chronic stimulation. The role of WML as a prognostic factor for the cognitive outcome after DBS may be underestimated. The WML burden should be taken seriously in preoperative risk stratification.