Zhiqiang Cui

A Portion of Inhibitory Neurons in Human Temporal Lobe Epilepsy are Functionally Upregulated: An Endogenous Mechanism for Seizure Termination

Epilepsy is one of the more common neurological disorders. The medication is often ineffective to the patients suffering from intractable temporal lobe epilepsy (TLE). As their seizures are usually self‐terminated, the elucidation of the mechanism underlying endogenous seizure termination will help to find a new strategy for epilepsy treatment. We aim to examine the role of inhibitory interneurons in endogenous seizure termination in TLE patients.

Intraoperative MRI for optimizing electrode placement for deep brain stimulation of the subthalamic nucleus in Parkinson disease

OBJECT The degree of clinical improvement achieved by deep brain stimulation (DBS) is largely dependent on the accuracy of lead placement. This study reports on the evaluation of intraoperative MRI (iMRI) for adjusting deviated electrodes to the accurate anatomical position during DBS surgery and acute intracranial changes. METHODS Two hundred and six DBS electrodes were implanted in the subthalamic nucleus (STN) in 110 patients with Parkinson disease. All patients underwent iMRI after implantation to define the accuracy of lead placement. Fifty-six DBS electrode positions in 35 patients deviated from the center of the STN, according to the result of the initial postplacement iMRI scans. Thus, we adjusted the electrode positions for placement in the center of the STN and verified this by means of second or third iMRI scans. Recording was performed in adjusted parameters in the x-, y-, and z-axes. RESULTS Fifty-six (27%) of 206 DBS electrodes were adjusted as guided by iMRI. Electrode position was adjusted on the basis of iMRI 62 times. The sum of target coordinate adjustment was -0.5 mm in the x-axis, -4 mm in the y-axis, and 15.5 mm in the z-axis; the total of distance adjustment was 74.5 mm in the x-axis, 88 mm in the y-axis, and 42.5 mm in the z-axis. After adjustment with the help of iMRI, all electrodes were located in the center of the STN. Intraoperative MRI revealed 2 intraparenchymal hemorrhages in 2 patients, brain shift in all patients, and leads penetrating the lateral ventricle in 3 patients. CONCLUSIONS The iMRI technique can guide surgeons as they adjust deviated electrodes to improve the accuracy of implanting the electrodes into the correct anatomical position. The iMRI technique can also immediately demonstrate acute changes such as hemorrhage and brain shift during DBS surgery.

Deep brain stimulation for treatment of severe Alzheimer's disease: Study protocol for a prospective, self-controlled, phase I trial (case observation)

Background: With the aging of the global population, an increasing number of people are at risk of developing Alzheimers disease. There is currently no effective treatment to hinder or postpone the progression of Alzheimers disease. Cholinesterase inhibitors and the N-methyl-D-aspartate receptor antagonist Memantine are the commonly prescribed drugs for this disease, but their therapeutic effects are still unsatisfactory. Therefore, there is an urgent need to investigate novel treatment methods. Many animal experiments have suggested that deep brain stimulation benefits Alzheimers disease, but clinical trials investigating this are still in their infancy. This study aims to investigate the safety and effectiveness of deep brain stimulation in the treatment of severe Alzheimers disease. Methods/Design: This study is a prospective, self-controlled, phase I trial (case observation), which will be performed in the Department of Neurosurgery, Chinese PLA General Hospital (Beijing, China). Six patients with severe Alzheimers disease will be enrolled to receive continuous bilateral deep brain stimulation of the fornix. Evaluations will be performed at baseline (prior to surgery) and at 1, 6, and 12 months after surgery. The primary outcome measures are disability and mortality rates during the 12-month deep brain stimulation trial period. Secondary outcome measures include the incidence of complications and Clinical Dementia Rating scale, Zarit Caregiver Burden Interview, Mini-Mental State Examination, and Barthel Index of Activities of Daily Living Scale scores. Patient recruitment will begin in August 2017, the analysis of primary outcome measures will be completed in October 2018, and the study will finish in June 2019. Discussion: The results of this study will help to determine the safety of deep brain stimulation for the treatment of severe Alzheimers disease. We will also assess whether deep brain stimulation can improve the cognition, symptoms, and activities of daily living of patients with Alzheimers disease. If the study succeeds, a novel option for patients with Alzheimers disease who respond poorly to current treatments may be provided. Trial registration: The study protocol is registered with ClinicalTrials.gov (identifier: NCT03115814). Ethics: The study protocol was approved by the Ethics Committee of Chinese PLA General Hospital (approval No. S2015-013-02) and will be performed in accordance with the Declaration of Helsinki formulated by the World Medical Association in 2013. Informed consent: Written informed consent will be obtained from each patients legal representative.

Resection or multi-lobe disconnection for intractable epilepsy with open-lip schizencephaly.

The surgical treatment of medication-resistant epilepsy with schizencephaly is difficult. A standardized method of surgical treatment for schizencephalic patients has not yet been established. We present two patients with poorly controlled epilepsy with schizencephaly. The first patient underwent a resection of the right temporal lobe and part of the posterior lip of the schizencephaly, while the other patient underwent a multi-lobe disconnection. Based on the study of these two patients, we conclude that the location of the epileptic zone, reorganization of eloquent areas and anatomical characteristics of the schizencephaly do not allow a universal surgical approach for treating epilepsy with schizencephaly. Every patient has individual characteristics.

Partial improvement in performance of patients with severe Alzheimer's disease at an early stage of fornix deep brain stimulation

Deep brain stimulation is a therapy for Alzheimers disease (AD) that has previously been used for mainly mild to moderate cases. This study provides the first evidence of early alterations in performance induced by stimulation targeted at the fornix in severe AD patients. The performance of the five cases enrolled in this study was scored with specialized assessments including the Mini-Mental State Examination and Clinical Dementia Rating, both before and at an early stage after deep brain stimulation. The burden of caregivers was also evaluated using the Zarit Caregiver Burden Interview. As a whole, the cognitive performance of patients remained stable or improved to varying degrees, and caregiver burden was decreased. Individually, an improved mental state or social performance was observed in three patients, and one of these three patients showed remarkable improvement in long-term memory. The conditions of another patient deteriorated because of inappropriate antipsychotic medications that were administered by his caregivers. Taken together, deep brain stimulation was capable of improving some cognitive aspects in patients with severe AD, and of ameliorating their emotional and social performance, at least at an early stage. However, long-term effects induced by deep brain stimulation in patients with severe AD need to be further validated. More research should focus on clarifying the mechanism of deep brain stimulation. This study was registered with ClinicalTrials.gov (NCT03115814) on April 14, 2017.

Imaging of Sodium MRI for Therapy Evaluation of Brain Metastase with Cyberknife at 7T: A Case Report

Herein we describe the case of an elderly patient who presented with a recent history of impaired vision of the right eye around three months due to brain lesions. He was diagnosed with liver cancer and underwent surgery three months prior. The pathological result is hepatocellular carcinoma. Magnetic resonance imaging (MRI) revealed the diagnosis of brain to be metastatic. The patient selected CyberKnife (Accuray Incorporated, Sunnyvale, USA) radiosurgery for the brain lesion since his physical conditions are not suitable for craniotomy. We adapt the imaging of sodium MRI and proton diffusion mapping at 7T MR system to evaluate the efficacy following CyberKnife early stage treatment. To date, we find the tissue sodium concentration (TSC) changes with the time whereas the proton MRI has no significant change within one month. The time course of sodium concentration in the tumor showed a dramatic increase in the treated brain tumor compared to the pretreatment sodium concentration and 48 hours after stereotactic radiosurgery (SRS), which is correlated to the period of the radiotherapy-induced cellular necrosis. This case demonstrates the possibility of sodium MRI as a biomarker for monitoring early radiotherapy for assessing tumor cellularity.

Intracerebral Hemorrhage and Venous Infarction after Deep Brain Stimulation Lead Placement

To the Editor: Cerebral vascular events (intracerebral hemorrhage [ICH] or venous infarction) are the most feared complications of deep brain stimulation (DBS) surgery. The estimated risk of ICH in DBS surgery reportedly varies from 0.2% to 5.6%.[1‐3] ICH may develop at one of two sites depending on the puncture tract: (1) in the basal ganglia or target area or (2) in the puncture channel or cortex area. However, venous infarction in association with DBS surgery has rarely been described.[4‐6]

Integration of Functional MRI and White Matter Tractography in CyberKnife Radiosurgery

Purpose: To investigate the efficacy of the integration of functional magnetic resonance imaging and diffusion-tensor imaging tractography data into CyberKnife radiosurgery for intracranial tumor management. Materials and Methods: Functional neuroimaging, anatomical magnetic resonance imaging, and computed tomography images of patients with brain lesions in critical areas were acquired before radiosurgery. The acquired data sets were coregistered using the MIM image fusion software module and then were imported into the CyberKnife Robotic Radiosurgery System (Multiplan 4.0.2) for delineating the target, organs at risk, and possible nearby functionally relevant cortical and subcortical areas. Radiation dose distributions with and without the functionally relevant cortical and subcortical areas into the optimization process were developed and compared. Results: There were significant differences between the treatment plans with and without the functionally relevant cortical and subcortical areas into the optimization process. An average 22.71% reduction in the maximum dose to functional areas was observed. No neurological complication due to radiation damage was observed in the follow-up period. Conclusion: The functional neuroimaging could be easily and reliably integrated into the CyberKnife treatment planning. Consideration of functional structures and fiber tracts during treatment planning could clinically reduce the radiation doses to these critical structures, thereby preserving its unique function of brain.

Protective effect of optic radiation reconstruction against the risk of visual field deficits in anterior temporal lobectomy

Objective To explore the clinical value of optic radiation reconstruction in protecting against visual field deficits (VFDs) in anterior temporal lobectomy (ATL). Methods We retrospectively analyzed 24 patients with medically refractory temporal lobe epilepsy undergoing ATL between January 2013 and June 2014. The surgical operations were aided by combining optic radiation reconstruction by diffusion tensor tractography (DTT), microscopy-based neuronavigation and intraoperative MRI (iMRI) techniques. ATL was performed according to the distance between Meyers loop and temporal pole. The visual fields were examined and seizure outcomes were evaluated by Engel class test in 3-month follow-up. Results The optic radiation was reconstructed in all patients. No bleeding was found in operative site or distant site by iMRI scan. The size of removed temporal lobe was 3.29 cm (1.90-5.10 cm). Visual field testing 3 months after operation showed no VFDs in 16 cases (66.67%) and mild VFDs (< 1/4 quadrant) in 8 cases (33.33% ). One case suffered mild VFD before operation, but did not aggravate after operation. Engel class test showed Engel classⅠin 19 patients (79.17%), class Ⅱ in 4 patients (16.67%) and class Ⅲ in one patient (4.17%). Conclusions For patients with medically refractory temporal lobe epilepsy, the techniques of combining optic radiation reconstruction, microscopy-based euronavigation and iMRI aided in precise mapping could reduce the risk of visual field deficits in anterior temporal lobectomy. DOI: 10.3969/j.issn.1672-6731.2015.09.005

Clinical study on deep brain electrode implantation assisted by ROSA system

Objective To evaluate the accuracy and safety of deep brain electrode implantation assisted by robotized stereotactic assistant (ROSA) system. Methods A total of 6 epileptic patients who had difficulty in positioning of epileptogenic focus underwent deep brain electrode implantation assisted by ROSA system. Record the maximum and minimum distance of electrode deviation according to postoperative CT and MRI and calculate the average distance, so as to evaluate the accuracy of operation. Record intraoperative electrode related bleeding events, postoperative electrode related bleeding or ischemic events and complications during the follow-up period, so as to evaluate the safety of operation. Results A total of 37 electrodes were successfully implanted in all 6 cases, with a success rate of 100%. Implanted electrodes were mainly located in medial temporal lobe, hippocampus and insular lobe (5 cases) and parieto-lobe (one case). The maximum deviation distance was 8.79 mm, and minimum was 1.14 mm, with an average of (3.65 ± 1.82) mm. Neither intraoperative electrode related bleeding event nor postoperative electrode related bleeding or ischemic event was found. No patient suffered from severe complications, such as intracranial infection, electrode disjunction, undesirable healing of scalp and wound infection, during the follow-up period from 3 to 5 months (mean 3.67 months). Conclusions Deep brain electrode implantation assisted by ROSA system is safe and accurate. DOI: 10.3969/j.issn.1672-6731.2015.09.006