Marek Harat

Nucleus accumbens stimulation in pathological obesity.

One of the potential treatment methods of obesity is deep brain stimulation (DBS) of nucleus accumbens. We describe the case of 19 years old woman with hypothalamic obesity. She weighted 151.4 kg before DBS and the non-surgical methods proved to be inefficient. She was treated with implantation of DBS electrode to nucleus accumbens bilaterally. Results were measured with body mass index and neuropsychological tests. Follow-up was 14 months. Fourteen months after surgery weight was 138 kg, BMI was 48.3. Neuropsychological test results were intact. The presented case supports the thesis of treatment of obesity with nucleus accumbens stimulation.

Deep anterior cerebellar stimulation reduces symptoms of secondary dystonia in patients with cerebral palsy treated due to spasticity.

INTRODUCTION Deep anterior cerebellar stimulation (DACS) is a neuromodulation therapy of spasticity. Bilateral DACS is applied in young patients with cerebral palsy (CP). In these patients symptoms of spasticity coexist with symptoms of focal or segmental dystonia, which can cause chronic pain. We performed the study to investigate the therapeutic effects of DACS in spasticity, secondary dystonia and pain. METHODS We examined 10 from 13 patients with CP treated with DACS due to spasticity in years 2006-2012. We compared Ashworth scores of spasticity, VAS scale of pain and UDRS (Unified Dystonia Rating Scale) score before DACS and after it in follow-up lasting from 2 to 11 years it in these patients basing on clinical examination and evaluating forms given by the patients or parents. RESULTS We received statistically significant reduction of spasticity in upper extremities (median: from 3 to 1,5 in Ashworth scale) in 8 patients (p = 0,01), in lower extremities in 7 patients (median: from 3 to 1,75) (p = 0,02). Symptoms of focal dystonia were reduced. Total score for the UDRS (median = 18,0 before surgery) after DACS decreased significantly (median = 10,3) (p = 0,043). Change in consecutive parts of UDRS before (median = 1,6) and after (median = 1,0) surgery in 7 patients had statistical significance (p = 0,0179). There were not significant changes in intensity of pain before and after surgery (p = 0,108). DISCUSSION Chronic bilateral DACS aimed for spasticity treatment not only decreases muscular tone in quadriplegic or paraplegic patients with CP but also is associated with reduction of symptoms of focal or segmental, secondary dystonia.

Motor Cortex Stimulation in Patients with Chronic Central Pain

BACKGROUND Motor cortex stimulation is one of the neuromodulation methods of treating refractory central neurogenic pain. OBJECTIVES The aim of this study was to retrospectively evaluate the effects of motor cortex stimulation. MATERIAL AND METHODS The study group consisted of 14 consecutive patients with thalamic pain, atypical facial pain, post-brachial plexus avulsion injury pain, phantom pain and pain in syringomyelia who were treated with motor cortex stimulation at the Department of Neurosurgery of the Military Research Hospital in Bydgoszcz, Poland, from 2005 to 2013. The procedures were conducted with the use of neurosurgical navigation and intraoperative neurophysiological monitoring. The outcomes were assessed in terms of visual analog scale scores. The long-term follow-up ranged from one to six years. RESULTS A statistically significant reduction in the intensity of pain was noted in patients treated with motor cortex stimulation (pre-surgery median visual analog scale=9, short-term result median visual analog scale=3, p=0.0009; long-term result median visual analog scale=5, p=0.0036). Over the long term, with follow-ups ranging from one to six years, the results were excellent (over 80% reduction in pain) in 31% of the patients and satisfactory (50-80% reduction in pain) in 23% of the patients. Unsatisfactory pain control (less than 50%) was noted in 31% of the patients and no improvement was noted in 15%. Significantly better relief of pain was observed in the early postoperative period. In this series of patients, the highest efficacy of motor cortex stimulation was observed in post-stroke or post-hemorrhagic thalamic pain (5/7 patients-71%). Long-term outcomes were not related to the age or sex of the patient, the preoperative duration of the pain, or to the position or number of implanted electrodes. CONCLUSIONS MCS significantly reduces the intensity of neurogenic pain. The best long-term results in the present study were achieved in patients with thalamic syndrome. No significant predictors were found for a successful final outcome. The authors consider appropriate selection of patients, accurate placement of the electrodes and frequent adjusting of the stimulation parameters to be important factors increasing the efficacy of MCS.

Deep Brain Stimulation in Pathological Aggression

Background: We describe a case of deep brain stimulation in a patient with severe aggression refractory to conservative treatment. The targets of the stimulation were set bilaterally in the posteromedial hypothalamus and - in a second procedure due to its ineffectiveness - in the nucleus accumbens (NAcc) bilaterally. Methods: In the first stage, we implanted electrodes into the posteromedial hypothalamus, after obtaining consent of the Bioethics Committee. In the early postoperative period, we observed significant improvement in the range of 50-90% in terms of quantity and quality of the attacks of aggression. After about 3 weeks, attacks of aggression started to return. Despite changes in the stimulation parameters there was no improvement. For this reason, based on the experience of surgery in patients with obsessive-compulsive disorder, Tourette syndrome and with morbid obesity, we decided to implant electrodes into the NAcc. Results: After 15 months of follow-up, the patient has no aggressive behavior, with no side effects. Conclusions: Although the stimulation of the posterior-medial hypothalamus did not bring long-term benefits, its combination with bilateral stimulation of the NAcc practically freed the patient from aggressive disorders. It significantly improved the patients quality of life.

Sacral roots stimulation in chronic pelvic pain.

INTRODUCTION Chronic pelvic pain is a syndrome of chronic non-malignant pain of multifactorial pathophysiology. Perineal, anal and coccygeal pain can be a form of failed-back surgery syndrome or complex regional pain syndrome. Apart from conservative treatment interventional methods are useful in this condition as neurolytic blocks or non-destructive neuromodulation procedures. Peripheral nerve, spinal cord stimulation or sacral stimulation can be applied. AIM We describe a minimally invasive method of sacral roots stimulation with percutaneous electrodes implanted through the sacral hiatus in the treatment of chronic pelvic pain. MATERIALS AND METHODS We evaluated a series of nine female patients with pelvic pain treated with sacral roots stimulation in regard of efficacy and complications of this method. RESULTS Short-term results in all patients were satisfactory with statistically significant improvement (median VAS=9 before surgery) (median VAS=2 after implantation, p=0.001), (median VAS=3 after 6 months, p=0.043). The long-term follow-up revealed less satisfactory result (median VAS=6 after 12 months). High incidence of complications was noted: mainly infection in 3/9 patients. CONCLUSION Sacral roots stimulation is a non-destructive and minimally invasive neuromodulation method in the treatment of chronic pelvic pain. It can be effective even in the long-term observation but special care is advised to secure aseptic conditions in the implantation and to prevent the infection which leads to removal of the stimulating system.

Tibial nerve stimulation with a miniature, wireless stimulator in chronic peripheral neuropathic pain

Peripheral neuropathic pain (PNP) and complex regional pain syndrome (CRPS) can be effectively treated with peripheral nerve stimulation. In this clinical trial report, effectiveness of novel, miniature, wirelessly controlled microstimulator of tibial nerve in PNP and CRPS was evaluated. In this pilot study the average preoperative visual analog scale (VAS) score in six patients was 7.5, with 1, 3 and 6 months: 2.6 (p=0.03), 1.6 (p=0.03), and 1.3 (p=0.02), respectively. The mean average score in the six patients a week preceding the baseline visit was 7.96, preceding the 1, 3 and 6 month visits: 3.32 (p=0.043), 3.65 (p=0.045), and 2.49 (p=0.002), respectively. The average short-form McGill pain score before surgery was 23.8, and after 1, 3 and 6 months it was 11.0 (p=0.45), 6.3 (p=0.043), and 4.5 (p=0.01), respectively. Applied therapy caused a reduction of pain immediately after its application and clinical improvement was sustained on a similar level in all patients for six months. No complications of the treatment were observed. Intermittent tibial nerve stimulation by using a novel, miniature, wirelessly controlled device can be effective and feasible in PNP and CRPS. It is a safe, minimally invasive, and convenient neuromodulative method.

Results of neuromodulation for the management of chronic pain

Background and purpose : Neuromodulative treatment of chronic pain syndromes is a modern mode of treatment of neuropathic and ischaemic pain. Its effectiveness is well documented in the literature. The objective of this work is to present the results of treatment of chronic pain syndromes on the basis of eight-year experience in our department. Material and methods : Since 2002, we have conducted 9 operations of motor cortex stimulation (MCS), 2 of deep brain stimulation (DBS), 45 of spinal cord stimulation (SCS) and 5 of sacral root stimulation (SRS) in the treatment of chronic pain. Results : We obtained good long-term results of neuromodulation in the form of clinical improvement (> 50%) in 4 of 9 patients with MCS (44%), in 13 diagnosed with failed back surgery syndrome (FBSS), 8 with other neuropathic pain, and 11 with angina pectoris from a group of 45 treated with SCS. Sacral root stimulation has been successful in 3 of 5 patients with perianal pain. The best treatment results in SCS, although not statistically significant, were observed in patients treated due to FBSS (13 out of 15) and angina pectoris (11 out of 15) (p = 0.12). In patients with neuropathic pain, peripheral and central, improvement was obtained in 8 out of 15 patients. Conclusions : A good indication for spinal cord stimulation is FBSS and angina pectoris. Motor cortex stimulation is helpful in the treatment of chronic central neuropathic pain. Further observations and a larger group of patients are necessary for a reliable assessment of the effectiveness of neuromodulative treatment of chronic pain in our clinic.

Combination of Neuroendoscopic and Stereotactic Procedures for Total Resection of Colloid Cysts with Favorable Neurological and Cognitive Outcomes

BACKGROUND Despite a wide range of surgical procedures, an unresolved debate remains regarding which attempt is optimal for the treatment of colloid cysts in the third ventricle. In this article, we present a new combination of stereotactic and endoscopic techniques. METHODS This prospective study includes 27 consecutive patients with symptomatic primary and recurrent colloid cysts. All cysts were removed via a neuroendoscope through a rostral transfrontal, transforaminal approach. The endoscope was supported by an additional cannula fixed in the stereotactic frame. Both tools were inserted into one lateral ventricle through two separate burr holes using stereotactic guidance. RESULTS The median operating time was 135 minutes. All cysts were removed completely, and no mortality or permanent complications related to surgery occurred. The mean time of observation was 43.5 months (range, 3-78 months), and no clinical or radiologic recurrences were observed. One patient with a history of an infected ventriculoperitoneal shunt did not improve after cyst removal, but improved after subsequent reimplantation of the shunt. In all other cases, symptoms resolved (67%) or decreased (30%). Cognitive functions improved or remained unchanged in all 10 elective cases examined neuropsychologically before and after surgery. CONCLUSIONS The techniques we describe for removal of colloid cysts are safe and effective, even for recurrent cases, and they provide 100% total resection, favorable cognitive outcomes, low risk of recurrence, and low risk of morbidity. The disadvantages of this method are a longer time for surgery and the need for more complex instrumentation compared with conventional endoscopic resection.

Wpływ umiejscowienia guza mózgu na wydolność funkcjonalną chorego

Introduction . The vast majority of lesions of the nervous system are located intra cranially. Their location in each brain structure results in the appearance of different deficits affecting the functional capacity of patients, and ultimately their quality of life. Aim . The aim of the study is to investigate the effect of tumor location on the functional capacity of patients with such tumors in the preoperative and postoperative periods. Material and Methods . Material includes 236 patients hospitalized in the Department of Neurosurgery 10th Military Hospital with Policlinic IP HCC Bydgoszcz. The research was approved by the Bioethics Committee at Collegium Medicum in Bydgoszcz (KB 222/2011). The analysis included 5 subgroups of patients taking into account the location of intracranial lesions in these patients. There were defined: a group of patients with tumors located in the temporal lobe (1), frontal lobe (2), parietal lobe (3), cerebral chamber (4), and cerebral lesions (5). The functional capacity was assessed by the KPS Scale (Karnofsky’s Performance Scale) (three times: on the day of admission to the Clinic, on the 5th and 30th day after the surgery) and by the GOS Scale (Glasgow’s Outcome Scale) (twice: on the 5th and 30th day following the surgery). Results . On the fifth day of the postoperative period, a statistically significant decrease in the functional capacity was observed in patients with tumors located in the cerebral, the extra cranial tumors, in the frontal and temporal lobes (p<0.05). In the postoperative period, significant increase in functioning was observed in patients with ventricular tumors cerebral and extra cranial (p<0.05). The final outcome of the treatment was improved on the 30th day in patients with extra cranial tumors (p<0.05). Conclusions . In the early postoperative period the functional capacity of most patients decreases, and the lowest functional capacity decline is observed in patients with parietal lobe tumors. 30 days after the surgery, the functionality of the patients increases, particularly with tumors located in the cerebral cortex as well as with extra cranial tumors. (JNNN 2017;6(2):66–72)

Diagnostic Difficulties in Slit Ventricle Syndrome

Slit ventricle syndrome is a rare complication of the treatment of hydrocephalus in infancy. Symptoms usually appear several years after the placing of the shunt system. They can cause diagnostic difficulties. The diagnosis is usually wrong or delayed. The authors describe a patient with SVS, the course of hospitalization and examinations performed.