Parkinson's disease (PD) is one of the most common neurodegenerative progressive disorders. Despite the dominance of neurostimulation technology, stereotactic lesioning operations play a significant ...role in the treatment of PD. The aim of the study was to evaluate the effectiveness and safety of staged bilateral asymmetric radiofrequency (RF) stereotactic lesioning in a highly selected group of PD patients.
A retrospective review of 418 consecutive patients undergoing stereotactic ablation for advanced PD at our institution revealed 28 patients who underwent staged asymmetric bilateral ablation. In this subset, after initial RF thalamotomy, contralateral pallidotomy was performed in 16 (57.1%) patients (group Vim-GPi), and contralateral lesion of the subthalamic nucleus (STN) was performed in 12 (32.9%) patients (group Vim-STN). The mean duration of disease before the first surgery was 9.9 ± 0.8 years. The mean interval between the two operations was 3.5 ± 0.4 years (range, 1-10 years); in the Vim-GPi group, it was 3.1 ± 0.4 years; and in the Vim-STN group, it was 4.3 ± 0.1 years. After the second operation, the long-term follow-up lasted from 1 to 8 years (mean 4.8 ± 0.5 years). All patients were evaluated 1 year after the second operation.
One year after staged bilateral lesioning, the mean tremor score improved from baseline, prior to the first operation, from 19.8 to 3.8 (improvement of 81%), the overall mean rigidity score improved from 11.0 to 3.7 (improvement of 66%), and hypokinesia improved from 14.8 to 8.9 (improvement of 40%). One year after staged bilateral lesioning, the total UPDRS score improved in the Vim-GPi group by 47% in the OFF and 45.9% in the ON states. In the Vim-STN group, the total UPDRS score improved from baseline, prior to the first operation, by 44.8% in the OFF and 51.6% in the ON states. Overall, levodopa dose was reduced by 43.4%. Neurological complications were observed in 4 (14.3%) cases; among them, 1 (3.6%) patient had permanent events related to local ischemia after pallidotomy.
Staged asymmetric bilateral stereotactic RF lesioning can be a safe and effective method in highly selected patients with advanced PD, particularly where deep brain stimulation is not available or desirable. Careful identification and selection of patients for ablative surgery allow achieving optimal results in the treatment of PD with bilateral symptoms.
Objective: to evaluate the effectiveness and safety of different operations in children with drug-resistant epilepsy.
Materials and Method. 91 children with drug-resistant epilepsy were enrolled in a ...retrospective study. Mean age was 10.3±5.1 years. Anterior temporal lobectomy was performed in 16 (57.1%) patients, lesionectomy – in 9 (10.0%), microsurgical callosotomy in 18 (19.8%), stereotactic callosotomy in 7 (7.7%), multifocal resections in 4 (4.4%), functional hemispherotomy in 14 (15.6%). Stereotactic radiofrequency callosotomy was performed on a CRW Stereotactic frame (Radionics Inc., USA). Ultrasound navigation and neuronavigation were used in 6 (7%) and 14 (15%) cases correspondingly. Intraoperative corticography was applied in 8 (9%) cases. Postoperative long-term follow-up lasted from 1 to 17 years (mean - 8.2±2.1 years).
Results. An epileptogenic zone within single hemisphere was indentified in 66 (72.2%) cases, while bilateral epileptiform activity was observed in 25 (27.5%) children. The most common etiologies of epilepsy included hypoxic-ischemic encephalopathy, intracerebral hemorrhage, meningoencephalitis, Rasmussen syndrome, cortical dysplasia, tumors.After surgery 51 (56%) patients became seizures free (Engel 1), 14 (15.4%) patients had rare auras or focal seizures (Engel 2). In 25 (27.5%) cases, seizure frequency reduction was less than 75% or did not change significantly. The most favorable outcomes were associated with resection procedures, resulting in complete seizure control in 46 (69.7%) out of 66 children, with significant improvement observed in 9 (13.6%) cases. After callosotomy drop-attacks stopped in 14 (78%) out of 18 who had them before surgery. Operative complications were encountered in 6 (6.6%) cases, postoperative mortality occurred in 1 (1.1%) case.
Conclusions. The key to the effectiveness of surgical treatment of childhood epilepsy is early surgical intervention, which leads to the control of epileptic seizures, correction of psychological and cognitive emotional disorders and improvement of quality of life. The combination of resection procedures and disconnections contributes to the reduction of epileptogenic neurons and suppression of epileptic discharges.
Цель: оценить эффективность дифференцированных методов хирургического лечения тяжелых форм эпилепсии у детей.
Материалы и методы. В ретроспективное исследование было вовлечено 91 ребенка с разными формами эпилепсии. Средний возраст составил (10,3±5,1) года. Передняя височная лобэктомия проведена 39 (43,3%) больным, топектомия – 9 (10,0%), микрохирургическая калозотомия – 18 (19,8%), стереотаксическая калозотомия – 7 (7,7%), мультифокальные резекции – 4 (4,4%), функциональная гемисферотомия – 14 (15,6%). Стереотаксическую радиочастотную калозотомию выполняли с использованием стереотаксической рамки CRW Radionics (Radionics Inc., США). При проведении микрохирургических вмешательств ультразвуковая навигация использована в 6 (7%) случаях, нейронавигация – в 14 (15%), интраоперационная кортикография – в 8 (9%). Послеоперационный катамнез прослежен в сроки от 1 до 17 лет (в среднем – (8,2±2,1) года).
Результаты. Эпилептогенная зона в пределах одного полушария выявлена у 66 (72,5%) больных, двустороннюю пароксизмальную активность – у остальных. Наиболее частыми причинами эпилепсии были перинатальная гипоксически ишемическая энцефалопатия, последствия внутримозгового кровоизлияния и менингоэнцефалита, синдром Расмуссена, кортикальная дисплазия, опухоли. После операции эпилептические приступы прекратились у 51 (56,0%) больного (Энгел 1), в 14 (15,4%) случаях наблюдались редкие кратковременные ауры или фокальные приступы (Энгел 2), у 25 (27,5%) – частота приступов уменьшилось менее чем на 75% или существенно не изменилось. Наилучшие результаты были получены у больных, которым проведены резекционные операции. Эпилептические приступы прекратились у 46 (69,7%) из 66 (Энгел 1), у 9 (13.6%) пациентов зарегистрировано значительное улучшение (Энгел 2). После калозотомии прекращение приступов в виде дроп-атак отмечено у 14 (78%) из 18 больных, у которых они имели место до операции. Операционные осложнения развились в 6 (6,6%) случаях. Послеоперационная летальность – 1 (1,1%) случай.
Выводы. Залогом эффективности хирургического лечения детской эпилепсии является раннее проведение хирургического вмешательства, способствующего контролю за эпилептическими приступами, коррекции психоэмоциональных расстройств, улучшению качества жизни и социальной адаптации. Сочетание резекционных операций и дисконекции уменьшает количество нейрональных клеток, которые генерируют эпилептиформную активность и блокируют распространение пароксизмальной активности.
Мета: оцінити ефективність диференційованих методів хірургічного лікування тяжких форм епілепсії у дітей.
Матеріали і методи. У ретроспективне дослідження було залучено 91 дитину з різними формами епілепсії. Середній вік становив (10,3±5,1) року. Передню скроневу лобектомію проведено 39 (43,3%) хворим, топектомію – 9 (10,0%), мікрохірургічну калозотомію – 18 (19,8%), стереотаксичну калозотомію – 7 (7,7%), мультифокальні резекції – 4 (4,4%), функціональну гемісферотомію – 14 (15,6%). Стереотаксичну радіочастотну калозотомію виконували з використанням стереотаксичної рамки CRW Radionics (Radionics Inc., США). Під час проведення мікрохірургічних втручань ультразвукову навігацію використано у 6 (7%) випадках, нейронавігацію – у 14 (15%), інтраопераційну кортикографію – у 8 (9%). Післяопераційний катамнез простежено у терміни від 1 до 17 років (у середньому – (8,2±2,1) року).
Результати. Епілептогенну зону в межах однієї півкулі виявлено у 66 (72,5%) хворих, двобічну пароксизмальну активність ‒ у решти. Найчастішими причинами епілепсії були перинатальна гіпоксично-ішемічна енцефалопатія, наслідки внутрішньомозкового крововиливу та менінгоенцефаліту, синдром Расмуссена, кортикальна дисплазія, пухлини. Після операції епілептичні напади припинилися у 51 (56,0%) хворого (Енгел 1), у 14 (15,4%) випадках спостерігалися рідкі короткочасні аури або фокальні напади (Енгел 2), у 25 (27,5%) ‒ частота нападів зменшилася менше ніж на 75% або суттєво не змінилася. Найкращі результати отримано у хворих, яким проведено резекційні операції. Епілептичні напади припинилися у 46 (69,7%) із 66 (Енгел 1), у 9 (13.6%) пацієнтів зареєстровано значне поліпшення (Енгел 2). Після калозотомії припинення нападів у вигляді дроп-атак відзначено у 14 (78%) із 18 хворих, у яких вони мали місце до операції. Операційні ускладнення розвинулися в 6 (6,6%) випадках. Післяопераційна летальність ‒ 1 (1,1%) випадок.
Висновки. Запорукою ефективності хірургічного лікування дитячої епілепсії є раннє проведення хірургічного втручання, що сприяє контролю над епілептичними нападами, корекції психоемоційних розладів, поліпшенню якості життя та соціальної адаптації. Поєднання резекційних операцій і дисконекції зменшує кількість нейрональних клітин, які генерують епілептиформну активність та блокує поширення пароксизмальної активності.
The “Co-Pilot Project” and Ukraine Tomycz, Luke; Kurilets, Igor; Markosian, Christopher ...
Neurosurgery,
12/2020, Volume:
67, Issue:
Supplement_1
Journal Article
Peer reviewed
INTRODUCTION Ukraine, formerly part of the USSR, gained its independence in 1991, and has continued to rely on medical contributions in various ways including physician capacity building. The field ...of neurosurgery in the country has been improving rapidly, in part, due to the establishment of collaborative partnerships with centers of excellence throughout the world. METHODS Since August 2016, we have coordinated 15 separate trips to Ukraine with several of our American neurosurgical, neurologic, and orthopedic colleagues; we have consulted on hundreds of patients and performed scores of surgeries with our Ukrainian partners at multiple sites throughout the country. We regularly provide guidance via email communication on complex cases, send surgical instruments and equipment, conduct online epilepsy conferences, and provide training opportunities to our Ukrainian partners. RESULTS Since 2016, co-pilot physicians from the United States assisted Ukrainian partner physicians on 79 major brain and spine operations during trips to Ukraine. While we mostly operated on patients with benign brain tumors, a wide variety of cases were performed including clip ligation of aneurysm, microvascular decompression, functional hemispherotomy, temporal lobectomy, implantation of vagal nerve stimulator, spinal cord detethering, Chiari decompression, shunting, and correction of complex spinal deformities. Endovascular (e.g., coil embolization of cerebral aneurysm) and intraventricular endoscopic procedures were also performed with partners who had these capabilities. CONCLUSION The Co-Pilot Project has been successful in developing long-term relationships with Ukrainian physicians and enhancing the field of neurosurgery in the country. We believe that many of the lessons learned from our project in Ukraine can serve as a template for collaborative efforts in other countries who seek further advancement through strategic partnerships.
We aim to provide a thorough description of the efforts and outcomes of the Co-Pilot Project in Ukraine, which facilitates neurosurgical collaboration between American and Ukrainian physicians.
The ...Co-Pilot Project, which operates under its parent nonprofit organization, Razom, organized multiple trips for American physicians to Ukraine. Activities included consulting in clinic, assisting with neurosurgical operations, and providing didactic lectures. Further efforts have included coordinating training opportunities for Ukrainian surgeons. We retrospectively reviewed all operations performed by Ukrainian partner physicians alongside American co-pilot physicians across Ukraine since August 2016.
Teams of Ukrainian and American physicians operated on 78 patients (24 children and 54 adults) for a total of 84 procedures in 5 different cities (Kyiv, Lutsk, Lviv, Odessa, and Stryi) of Ukraine. Operations were classified into the following categories: adult brain tumors (n = 39), adult spine tumors (n = 1), epilepsy (n = 9), pain (n = 2), pediatric brain tumors (n = 11), vascular/endovascular (n = 10), and miscellaneous (n = 12). Four illustrative cases are described in detail. Of the patients with brain tumors, 43.5% (20/46) had giant tumors, and gross total resection or near-total resection was achieved in 78.3% (36/46).
Profound disparities in neurosurgical care exist globally, which has led to the formation of collaborative relationships between physicians from various countries. We hope that the work of the Co-Pilot Project in Ukraine can serve as a template for effective international neurosurgical collaboration in other low-to-middle-income countries.
