Summary
Objective
Evaluate the seizure‐reduction response and safety of mesial temporal lobe (MTL) brain‐responsive stimulation in adults with medically intractable partial‐onset seizures of mesial ...temporal lobe origin.
Methods
Subjects with mesial temporal lobe epilepsy (MTLE) were identified from prospective clinical trials of a brain‐responsive neurostimulator (RNS System, NeuroPace). The seizure reduction over years 2–6 postimplantation was calculated by assessing the seizure frequency compared to a preimplantation baseline. Safety was assessed based on reported adverse events.
Results
There were 111 subjects with MTLE; 72% of subjects had bilateral MTL onsets and 28% had unilateral onsets. Subjects had one to four leads placed; only two leads could be connected to the device. Seventy‐six subjects had depth leads only, 29 had both depth and strip leads, and 6 had only strip leads. The mean follow‐up was 6.1 ± (standard deviation) 2.2 years. The median percent seizure reduction was 70% (last observation carried forward). Twenty‐nine percent of subjects experienced at least one seizure‐free period of 6 months or longer, and 15% experienced at least one seizure‐free period of 1 year or longer. There was no difference in seizure reduction in subjects with and without mesial temporal sclerosis (MTS), bilateral MTL onsets, prior resection, prior intracranial monitoring, and prior vagus nerve stimulation. In addition, seizure reduction was not dependent on the location of depth leads relative to the hippocampus. The most frequent serious device‐related adverse event was soft tissue implant‐site infection (overall rate, including events categorized as device‐related, uncertain, or not device‐related: 0.03 per implant year, which is not greater than with other neurostimulation devices).
Significance
Brain‐responsive stimulation represents a safe and effective treatment option for patients with medically intractable epilepsy, including patients with unilateral or bilateral MTLE who are not candidates for temporal lobectomy or who have failed a prior MTL resection.
Summary
Objective
To demonstrate the safety and effectiveness of responsive stimulation at the seizure focus as an adjunctive therapy to reduce the frequency of seizures in adults with medically ...intractable partial onset seizures arising from one or two seizure foci.
Methods
Randomized multicenter double‐blinded controlled trial of responsive focal cortical stimulation (RNS System). Subjects with medically intractable partial onset seizures from one or two foci were implanted, and 1 month postimplant were randomized 1:1 to active or sham stimulation. After the fifth postimplant month, all subjects received responsive stimulation in an open label period (OLP) to complete 2 years of postimplant follow‐up.
Results
All 191 subjects were randomized. The percent change in seizures at the end of the blinded period was −37.9% in the active and −17.3% in the sham stimulation group (p = 0.012, Generalized Estimating Equations). The median percent reduction in seizures in the OLP was 44% at 1 year and 53% at 2 years, which represents a progressive and significant improvement with time (p < 0.0001). The serious adverse event rate was not different between subjects receiving active and sham stimulation. Adverse events were consistent with the known risks of an implanted medical device, seizures, and of other epilepsy treatments. There were no adverse effects on neuropsychological function or mood.
Significance
Responsive stimulation to the seizure focus reduced the frequency of partial‐onset seizures acutely, showed improving seizure reduction over time, was well tolerated, and was acceptably safe. The RNS System provides an additional treatment option for patients with medically intractable partial‐onset seizures.
Summary
Objective
To study the incidence and clinical features of sudden unexpected death in epilepsy (SUDEP) in patients treated with direct brain‐responsive stimulation with the RNS System.
Methods
...All deaths in patients treated in clinical trials (N = 256) or following U.S. Food and Drug Administration (FDA) approval (N = 451) through May 5, 2016, were adjudicated for SUDEP.
Results
There were 14 deaths among 707 patients (2208 postimplantation years), including 2 possible, 1 probable, and 4 definite SUDEP events. The rate of probable or definite SUDEP was 2.0/1000 (95% confidence interval CI 0.7‐5.2) over 2036 patient stimulation years and 2.3/1000 (95% CI 0.9‐5.4) over 2208 patient implant years. Stored electrocorticograms around the time of death were available for 4 patients with probable/definite SUDEP and revealed the following: frequent epileptiform activity ending abruptly (n = 2), no epileptiform activity or seizures (n = 1), and an electrographic and witnessed seizure with cessation of postictal electrocorticography (ECoG) activity associated with apnea and pulselessness (n = 1).
Significance
The SUDEP rate of 2.0/1000 patient stimulation years among patients treated with the RNS System is favorable relative to treatment‐resistant epilepsy patients randomized to the placebo arm of add‐on drug studies or with seizures after resective surgery. Our findings support that treatments that reduce seizures reduce SUDEP risk and that not all SUDEPs follow seizures.
Object
The use of deep brain stimulation (DBS) has recently been expanded to the investigational treatment of specific psychiatric disorders. Much like movement disorders, the targets selected for ...DBS are based on past experience with stereotactic lesions. A literature review of past studies incorporating stereotactic lesions for psychiatric disorders was performed to provide historical context and possible guidance for current and future attempts at treating psychiatric disorders with DBS.
Methods
Original copies of the proceedings of the second, third, fourth, and fifth World Congresses of Psychiatric Surgery meetings were reviewed, and a Medline search was conducted for studies with the word “psychosurgery” and each of 14 highly prevalent psychiatric conditions identified by the National Institute of Mental Health. Postoperative results for 1145 patients with stereotactic brain lesions targeting various anatomical foci were standardized using a 5-point scale (3 free of symptoms to −1 worse). Each patient was entered into a database as a unique data point and used for this literature review.
Results
General anxiety disorder and obsessive-compulsive disorder had the greatest reported improvements from anterior capsulotomy, and bipolar disorder, depression, and schizoaffective disorder had the greatest reported improvements from anterior cingulotomy, supporting these areas for DBS investigation. Addiction and schizophrenia showed the least improvement from surgery. Therefore, pursuing the treatment of these disorders with DBS using the targets in these studies may be ineffective.
Conclusions
This study provides retrospective data that suggest which anatomical focus may be effective to lesion or stimulate for the treatment of each of several psychiatric disorders.
The use of deep brain stimulation (DBS) has recently been expanded to the investigational treatment of specific psychiatric disorders. Much like movement disorders, the targets selected for DBS are ...based on past experience with stereotactic lesions. A literature review of past studies incorporating stereotactic lesions for psychiatric disorders was performed to provide historical context and possible guidance for current and future attempts at treating psychiatric disorders with DBS.
Original copies of the proceedings of the second, third, fourth, and fifth World Congresses of Psychiatric Surgery meetings were reviewed, and a Medline search was conducted for studies with the word "psychosurgery" and each of 14 highly prevalent psychiatric conditions identified by the National Institute of Mental Health. Postoperative results for 1145 patients with stereotactic brain lesions targeting various anatomical foci were standardized using a 5-point scale (3 free of symptoms to -1 worse). Each patient was entered into a database as a unique data point and used for this literature review.
General anxiety disorder and obsessive-compulsive disorder had the greatest reported improvements from anterior capsulotomy, and bipolar disorder, depression, and schizoaffective disorder had the greatest reported improvements from anterior cingulotomy, supporting these areas for DBS investigation. Addiction and schizophrenia showed the least improvement from surgery. Therefore, pursuing the treatment of these disorders with DBS using the targets in these studies may be ineffective.
This study provides retrospective data that suggest which anatomical focus may be effective to lesion or stimulate for the treatment of each of several psychiatric disorders.
Background
Complex facial pain is a debilitating condition with varying etiologies that overall responds poorly to both medical and traditional surgical management. Cortical stimulation is a unique ...therapeutic intervention which can be effective for some types of complex facial pain syndromes (CFPS). However, the novel use of preoperative functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) coupled with intraoperative stimulation mapping and phase reversal to improve the accuracy for placement of spinal paddle electrodes in motor cortex stimulation, to our knowledge, has not been reported in the literature.
Case presentation
Here, we present a unique case of a 56-year-old male who developed left-sided complex facial pain syndrome after a stroke refractory to medical management and peripheral nerve stimulation. He previously underwent microvascular decompression (MVD) with limited control of his left-sided facial pain. In order to treat this, the patient underwent motor cortex stimulation. The motor strip of the face and tongue was identified preoperatively with functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI). Intraoperatively, phase reversal was used to identify corticospinal tracts and stimulus mapping confirmed the location before the epidural placement of two spinal paddle electrodes. Postoperatively, the patient reported significant reduction in pain levels, burning dysesthesias, and intensity and frequency of symptoms. This trend continued, and the patient experienced equivalent levels of relief at 6 months.
Conclusions
This is a rare case report of successful motor cortex stimulation with the novel preoperative use of fMRI and DTI, coupled with intraoperative functional mapping, to successfully guide the placement of spinal paddle electrodes for the treatment of CFPS.
Abstract Purpose Most deep brain stimulation targets for movement disorders were derived from effective ablative surgery targets. Similarly effective lesion targets for epilepsy control may help ...refine brain stimulation targeting for epilepsy. A literature review of past stereotactic lesions for epilepsy treatment was performed to provide historical context and possible anatomical guidance for current and future attempts at controlling epilepsy with electrical stimulation. This work was undertaken to provide insights for electrical stimulation targets in epilepsy treatment based on outcomes from previous ablative therapies. Methods A MEDLINE search was conducted for studies with the words “stereotactic surgery” and “epilepsy.” Post-operative results for 619 patients with stereotactic brain lesions targeting various anatomical foci were standardized using a modified Engel scale (1 ‘free of seizures’ to 3 ‘no significant improvement’). Each individual patient was entered into a database as a unique data point. Results There was a statistically significant difference in reported seizure control among the different procedures and seizure types. The procedures that produced the best seizure control outcomes were the hippocampectomy, pallido-amygdalotomy, and amygdalohippocampectomy. Simple partial motor and combined generalized tonic clonic with complex partial seizure types demonstrated the best outcomes following surgery; complex partial and generalized tonic had the worst outcomes. Conclusions The results of this study demonstrate the location of brain lesions has a significant effect on seizure control. Thus, future research designed to optimize brain stimulation targets for epilepsy control may be informed by previous ablative outcomes.
Abstract Background Treatment modalities for degenerative cervical spine disease are widely debated and refined as new surgical techniques are developed. The current case series compares two common ...cervical spine procedures, anterior cervical discectomy and fusion (ACDF) and minimally invasive posterior keyhole foraminotomy (MIPKF). The decision making process of the two surgical approaches is discussed, and the long term outcomes are presented. Methods A retrospective chart review of surgical patients having either an ACDF or MIPKF with an extensive chart review. Over 570 patient charts were identified and reviewed between 1994 and 2011. After exclusion, a total of 268 patients were identified in the ACDF group, and 112 patients were identified in the MIPKF group. Primary outcome measurement was the need for any reoperation, whether at the same level or adjacent levels due to recurrence of disease or adjacent level disease. Results An average follow-up of 11.8 (± 3.0) years in the ACDF group and 6.4 (± 4.4) years in the MIPKF group was determined over a 17 year period. There was a reoperation rate of 2.6% in the ACDF group and 2.7% in the MIPKF group during the 17 year time period. Conclusion ACDF has been demonstrated to be an effective surgical procedure in treating degenerative spine disease in patients with radiculopathy and/or myelopathy. However, in a population with isolated radiculopathy and radiological imaging confirming an anterolateral disc or osteophyte complex, the MIPKF can provide similar results without the associated risks that accompany an anterior cervical spine fusion.
Bilateral Subacute Subdural Hematomas Wind, Joshua J.; Leiphart, James W.
The New England journal of medicine,
04/2009, Letnik:
360, Številka:
17
Journal Article
Recenzirano
Computed tomography (CT) of the brain, performed without the administration of contrast material, revealed a loss of cortical sulci but failed to show a lesion clearly.
Acute postoperative pain has demonstrated effects on appetite and weight gain in human studies. This study was designed to test the hypothesis that chronic neuropathic pain has a more significant ...effect on weight than acute postsurgical pain.
One hundred eighteen rats were separated into 3 groups: common sciatic nerve ligation, surgery without ligation, and no surgery. Each group was further divided to undergo testing at 3, 7, and 14 days. On the day of testing, the rats were tested for signs of pressure and heat hyperalgesia and were weighed.
The effect on the percentage of change in body weight from the day of surgery to the day of testing was statistically significant for both the condition (F = 15.0, p < 0.0001) and the day of testing (F = 43.3, p < 0.0001). The rats that received no surgery had a change in weight of 2.3% on Day 3, 4.0% on Day 7, and 10.7% on Day 14. In the nonligation surgery group, the change was -3.8% on Day 3, 2.0% on Day 7, and 9.7% on Day 14. In the ligation surgery group, the change was -6.3% on Day 3, -0.7% on Day 7, and 4.9% on Day 14. This group began gaining weight by Day 14 but continued to have less weight gain than the other groups by Day 14.
Neuropathic pain inhibits weight gain more than normal, postsurgical pain. Recognizing the difference and initiating effective treatment for neuropathic pain may have an impact on the patient's nutrition.
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