Delayed intracerebral hemorrhage associated with placement of a deep brain stimulating electrode over two years prior

INTRODUCTION AND IMPORTANCE

Most severe complications of DBS appear in the perioperative period. There are no published case reports of delayed ICH occurring more than three months from electrode implantation. The pathogenesis of delayed ICH remains unclear.

CASE PRESENTATION

We present a 64-year-old male with essential tremor who sustained a delayed intracerebral hemorrhage (ICH) 2.5 years after implantation of a deep brain stimulating electrode.

DISCUSSION

The patient sustained a thalamic-midbrain ICH that may have been related to the positioning of the electrode. An analysis was performed to determine the cause and risk factors that may have contributed. Based on these findings, it is possible that the proximity of the cannula or electrode may have mildly injured the wall of the superior thalamic vein during implantation, or perhaps being in contact with the vein over a longer-term having an effect, which in either of these scenarios can subsequently lead to ICH formation on the sudden rise of intracranial pressure.

CONCLUSION

It emphasizes the importance of proper surgical navigation planning, image- guidance, and the use of image verification.

Claims of Safety in Neurosurgical Literature: We Shouldn't Call Something Safe Without Strong Justification

BACKGROUND

Many articles published in the neurosurgical literature make claims of safety regarding interventions. The strength of evidence supporting these claims has not been systematically evaluated.

OBJECTIVE

To evaluate the quality of evidence supporting claims of safety in the neurosurgery literature.

METHODS

The 14 neurosurgical journals listed in the Web of Science database with the highest impact factors for 2018 were included in the study. The titles and abstracts of all the articles published in these journals in 2018 were searched for the word "safety" and reviewed by 2 independent observers to identify those making a claim of safety and assess their evidence.

RESULTS

The search identified 323 articles, representing 5% of the articles published in the 14 searched journals in 2018. Of these, 114 (1.8% of all articles and 35% of the identified articles) were judged to make a claim of safety of a neurosurgical intervention. A total of 98 (86%) of the 114 articles making a safety claim were retrospective cohort studies. Patient cohort sizes ranged from 1 to 1565 (median of 34), leading to wide variations in the CIs for estimated complication rates. No article made a statement of the assumptions underlying its claim of safety.

CONCLUSION

Almost no articles that make claims of safety for neurosurgical interventions explicitly state the (1) patient population, (2) comparison intervention, nor (3) specific outcomes. To assure that claims of safety are supported by high-quality evidence, authors should address these elements early and systematically when designing studies.

Deep Brain Stimulation and L-DOPA Therapy: Concepts of Action and Clinical Applications in Parkinson's Disease

L-DOPA is still the most effective pharmacological therapy for the treatment of motor symptoms in Parkinson's disease (PD) almost four decades after it was first used. Deep brain stimulation (DBS) is a safe and highly effective treatment option in patients with PD. Even though a clear understanding of the mechanisms of both treatment methods is yet to be obtained, the combination of both treatments is the most effective standard evidenced-based therapy to date. Recent studies have demonstrated that DBS is a therapy option even in the early course of the disease, when first complications arise despite a rigorous adjustment of the pharmacological treatment. The unique feature of this therapeutic approach is the ability to preferentially modulate specific brain networks through the choice of stimulation site. The clinical effects have been unequivocally confirmed in recent studies; however, the impact of DBS and the supplementary effect of L-DOPA on the neuronal network are not yet fully understood. In this review, we present emerging data on the presumable mechanisms of DBS in patients with PD and discuss the pathophysiological similarities and differences in the effects of DBS in comparison to dopaminergic medication. Targeted, selective modulation of brain networks by DBS and pharmacodynamic effects of L-DOPA therapy on the central nervous system are presented. Moreover, we outline the perioperative algorithms for PD patients before and directly after the implantation of DBS electrodes and strategies for the reduction of side effects and optimization of motor and non-motor symptoms.

Bilateral stereotactic lesions and chronic stimulation of the anterior thalamic nuclei for treatment of pharmacoresistant epilepsy

Background:

The use of the anterior nucleus of thalamus (ANT) as a target for treatment of pharmacoresistant epilepsy is based on its crucial role in seizure propagation. We describe results of chronic bilateral ANT stimulation and bilateral ANT lesions in 31 patients with refractory epilepsy.

Methods:

ANT DBS was performed in 12 patients (group I) and bilateral stereotactic radiofrequency lesions of ANT were performed in 19 patients (group II). Targeting was based on stereotactic atlas information with correction of the final coordinates according to the location of anatomical landmarks and intraoperative microelectrode recording data.

Results:

Both groups were similar in age, gender, seizures frequency, and duration of disease. The median x, y, and z coordinates of ANT were found to be 2.9, 5, and 11 mm anterior, lateral, and superior to the mid-commissural point, respectively. Mean seizures reduction reached 80.3% in group of patients with ANT DBS with two nonresponders and 91.2% in group of patients with lesions. Five patients from group I and three patients from group II became seizure-free. The morbidity rate was low in both groups.

Conclusions:

Stereotactic anterior thalamotomy and chronic ANT stimulation are both effective for seizure control in epilepsy originated from frontal and temporal lobes. ANT lesions and stimulation were more effective for secondary-generalized seizures compared to simple partial seizures.