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Drexler R, Ricklefs FL, Ben-Haim S, Rada A, Wörmann F, Cloppenborg T, Bien CG, Simon M, Kalbhenn T, Colon A, Rijkers K, Schijns O, Borger V, Surges R, Vatter H, Rizzi M, de Curtis M, Didato G, Castelli N, Carpentier A, Mathon B, Yasuda CL, Cendes F, Chandra PS, Tripathi M, Clusmann H, Delev D, Guenot M, Haegelen C, Catenoix H, Lang J, Hamer H, Brandner S, Walther K, Hauptmann JS, Jeffree RL, Kegele J, Weinbrenner E, Naros G, Velz J, Krayenbühl N, Onken J, Schneider UC, Holtkamp M, Rössler K, Spyrantis A, Strzelczyk A, Rosenow F, Stodieck S, Alonso-Vanegas MA, Wellmer J, Wehner T, Dührsen L, Gempt J, Sauvigny T. Defining benchmark outcomes for mesial temporal lobe epilepsy surgery: A global multicenter analysis of 1119 cases. Epilepsia 2024. [PMID: 38400789 DOI: 10.1111/epi.17923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 02/06/2024] [Accepted: 02/06/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE Benchmarking has been proposed to reflect surgical quality and represents the highest standard reference values for desirable results. We sought to determine benchmark outcomes in patients after surgery for drug-resistant mesial temporal lobe epilepsy (MTLE). METHODS This retrospective multicenter study included patients who underwent MTLE surgery at 19 expert centers on five continents. Benchmarks were defined for 15 endpoints covering surgery and epilepsy outcome at discharge, 1 year after surgery, and the last available follow-up. Patients were risk-stratified by applying outcome-relevant comorbidities, and benchmarks were calculated for low-risk ("benchmark") cases. Respective measures were derived from the median value at each center, and the 75th percentile was considered the benchmark cutoff. RESULTS A total of 1119 patients with a mean age (range) of 36.7 (1-74) years and a male-to-female ratio of 1:1.1 were included. Most patients (59.2%) underwent anterior temporal lobe resection with amygdalohippocampectomy. The overall rate of complications or neurological deficits was 14.4%, with no in-hospital death. After risk stratification, 377 (33.7%) benchmark cases of 1119 patients were identified, representing 13.6%-72.9% of cases per center and leaving 742 patients in the high-risk cohort. Benchmark cutoffs for any complication, clinically apparent stroke, and reoperation rate at discharge were ≤24.6%, ≤.5%, and ≤3.9%, respectively. A favorable seizure outcome (defined as International League Against Epilepsy class I and II) was reached in 83.6% at 1 year and 79.0% at the last follow-up in benchmark cases, leading to benchmark cutoffs of ≥75.2% (1-year follow-up) and ≥69.5% (mean follow-up of 39.0 months). SIGNIFICANCE This study presents internationally applicable benchmark outcomes for the efficacy and safety of MTLE surgery. It may allow for comparison between centers, patient registries, and novel surgical and interventional techniques.
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sharona Ben-Haim
- Department of Neurosurgery, University of California, San Diego, San Diego, California, USA
| | - Anna Rada
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Friedrich Wörmann
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Thomas Cloppenborg
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Christian G Bien
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
| | - Matthias Simon
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
- Department of Neurosurgery (Evangelisches Klinikum Bethel), Medical School, Bielefeld University, Bielefeld, Germany
| | - Thilo Kalbhenn
- Department of Epileptology (Krankenhaus Mara), Medical School, Bielefeld University, Bielefeld, Germany
- Department of Neurosurgery (Evangelisches Klinikum Bethel), Medical School, Bielefeld University, Bielefeld, Germany
| | - Albert Colon
- Department of Epileptology, Academic Center for Epileptology Kempenhaeghe, Heeze, the Netherlands
- ACE Work Group Epilepsy Surgery Kempenhaeghe/Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Kim Rijkers
- ACE Work Group Epilepsy Surgery Kempenhaeghe/Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Neurosurgery, Academic Center for Epileptology UMC/Maastricht University Medical Center+, Maastricht, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Olaf Schijns
- ACE Work Group Epilepsy Surgery Kempenhaeghe/Maastricht University Medical Center+, Maastricht, the Netherlands
- Department of Neurosurgery, Academic Center for Epileptology UMC/Maastricht University Medical Center+, Maastricht, the Netherlands
- School for Mental Health and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Rainer Surges
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
- Department of Epileptology, University Hospital Bonn, Bonn, Germany
| | - Michele Rizzi
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Marco de Curtis
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Giuseppe Didato
- Epilepsy Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Nicoló Castelli
- Functional Neurosurgery Unit, Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | | | - Bertrand Mathon
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | | | - Fernando Cendes
- Department of Neurology, University of Campinas, Campinas, Brazil
| | - Poodipedi Sarat Chandra
- Department of Neurosurgery and Neurology, AIIMS, and MEG Resource Facility, New Delhi, India
| | - Manjari Tripathi
- Department of Neurosurgery and Neurology, AIIMS, and MEG Resource Facility, New Delhi, India
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Daniel Delev
- Department of Neurosurgery, RWTH Aachen University Hospital, Aachen, Germany
| | - Marc Guenot
- Department of Functional Neurosurgery, Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Claire Haegelen
- Department of Functional Neurosurgery, Hospital Pierre Wertheimer, Hospices Civils de Lyon, Lyon, France
| | - Hélène Catenoix
- Department of Neurology, Hospices Civils de Lyon, Lyon, France
| | - Johannes Lang
- Epilepsy Center, Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Hajo Hamer
- Epilepsy Center, Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian Brandner
- Epilepsy Center, Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Katrin Walther
- Epilepsy Center, Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jason S Hauptmann
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | - Rosalind L Jeffree
- Department of Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Josua Kegele
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Eliane Weinbrenner
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Georgios Naros
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Julia Velz
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Niklaus Krayenbühl
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Julia Onken
- Institute for Diagnostics of Epilepsy, Epilepsy Center Berlin-Brandenburg, Berlin, Germany
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ulf C Schneider
- Department of Neurosurgery, Lucerne Cantonal Hospital, Lucerne, Switzerland
| | - Martin Holtkamp
- Institute for Diagnostics of Epilepsy, Epilepsy Center Berlin-Brandenburg, Berlin, Germany
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Karl Rössler
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Andrea Spyrantis
- Department of Neurosurgery and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Adam Strzelczyk
- Department of Neurosurgery and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Felix Rosenow
- Department of Neurosurgery and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Stefan Stodieck
- Department of Neurology and Epileptology, Hamburg Epilepsy Center, Protestant Hospital Alsterdorf, Hamburg, Germany
| | - Mario A Alonso-Vanegas
- National Institute of Neurology and Neurosurgery "Manuel Velasco Suarez", Mexico City, Mexico
| | - Jörg Wellmer
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Tim Wehner
- Ruhr-Epileptology, Department of Neurology, University Hospital Knappschaftskrankenhaus, Ruhr University Bochum, Bochum, Germany
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Gempt
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Machetanz K, Oberle L, Wang SS, Weinbrenner E, Gorbachuk M, Lauer H, Daigeler A, Tatagiba M, Naros G, Schäfer RC. Outpatient care for facial palsy-a survey on patient satisfaction in uni- and interdisciplinary approaches. Front Neurol 2024; 15:1354583. [PMID: 38385047 PMCID: PMC10880734 DOI: 10.3389/fneur.2024.1354583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 01/16/2024] [Indexed: 02/23/2024] Open
Abstract
Objective The various causes of facial palsy, diagnostic methods and treatment approaches frequently involve different medical specialities. Nevertheless, there exist only few specialized consultation and therapy services for patients with facial palsy (FP) in Germany. The aim of the present study was to evaluate factors affecting quality of life (QoL) and treatment satisfaction of patients presenting to an interdisciplinary facial nerve outpatient clinic. Methods The study analyzed patients presenting to the interdisciplinary facial palsy outpatient clinic in Tuebingen between February 2019 and December 2022. General satisfaction and QoL was estimated by numerous self-rating questionnaires: ZUF-8, SF-36, FDI, FaCE, PHQ-9. An ANOVA was performed to analyze determinants affecting the ZUF-8. Correlation analyses between cause and regeneration of FP as well as questionnaire scores were performed. Results were compared with a group of patients who were managed in an unidisciplinary setting. Results In total, 66 patients with FP were enrolled. FP patients showed increased levels of depression (PHQ-9: 14.52 ± 3.8) correlating with recovery of the palsy (p = 0.008), FaCE (p < 0.001) and FDI ratings (p < 0.001). There was a high level of satisfaction with the services provided during the uni-and interdisciplinary consultation (ZUF-8: 24.59 ± 6.2), especially among the 12/66 patients who received reconstructive, surgical treatment. However, some patients requested more psychological and ophthalmological support. Conclusion High levels of treatment satisfaction can be achieved in both an uni-and interdisciplinary setting. However, multimodal therapy approaches should be applied, considering physical and psychological aspects. In the absence of recovery, surgical interventions must be considered as treatment options. Further studies should continue to investigate potential differences between uni-and interdisciplinary treatment.
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Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Linda Oberle
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Sophie S. Wang
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Eliane Weinbrenner
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Mykola Gorbachuk
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Henrik Lauer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Tuebingen, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Georgios Naros
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Ruth C. Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Unfallklinik Tuebingen, Tuebingen, Germany
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Machetanz K, Roegele M, Liebsch M, Oberle L, Weinbrenner E, Gorbachuk M, Wang SS, Tatagiba M, Naros G. Predictive value of facial motor-evoked potential and electromyography for facial motor function in vestibular schwannoma surgery. Acta Neurochir (Wien) 2024; 166:23. [PMID: 38240816 PMCID: PMC10799139 DOI: 10.1007/s00701-024-05927-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/02/2024] [Indexed: 01/22/2024]
Abstract
PURPOSE Intraoperative neuromonitoring (IONM) aims to preserve facial nerve (FN) function during vestibular schwannoma (VS) surgery. However, current techniques such as facial nerve motor evoked potentials (FNMEP) or electromyography (fEMG) alone are limited in predicting postoperative facial palsy (FP). The objective of this study was to analyze a compound fEMG/FNMEP approach. METHODS Intraoperative FNMEP amplitude and the occurrence of fEMG-based A-trains were prospectively determined for the orbicularis oris (ORI) and oculi (OCU) muscle in 322 VS patients. Sensitivity and specificity of techniques to predict postoperative FN function were calculated. Confounding factors as tumor size, volume of intracranial air, or IONM duration were analyzed. RESULTS A relevant immediate postoperative FP was captured in 105/322 patients with a significant higher risk in large VS. While fEMG demonstrated a high sensitivity (77% and 86% immediately and 15 month postoperative, respectively) for identifying relevant FP, specificity was low. In contrast, FNMEP have a significantly higher specificity of 80.8% for predicting postoperative FP, whereas the sensitivity is low. A retrospective combination of techniques demonstrated still an incorrect prediction of FP in ~ 1/3 of patients. CONCLUSIONS FNMEP and fEMG differ in sensitivity and specificity to predict postoperative FP. Although a combination of IONM techniques during VS surgery may improve prediction of FN function, current techniques are still inaccurate. Further development is necessary to improve IONM approaches for FP prediction.
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Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Martin Roegele
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marina Liebsch
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Linda Oberle
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Eliane Weinbrenner
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Mykola Gorbachuk
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Sophie S Wang
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Georgios Naros
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
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Gorbachuk M, Machetanz K, Weinbrenner E, Grimm F, Wuttke TV, Wang S, Ethofer S, Tatagiba M, Rona S, Honegger J, Naros G. Robot-assisted stereoencephalography vs subdural electrodes in the evaluation of temporal lobe epilepsy. Epilepsia Open 2023; 8:888-897. [PMID: 37149851 PMCID: PMC10472365 DOI: 10.1002/epi4.12756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 04/30/2023] [Indexed: 05/09/2023] Open
Abstract
OBJECTIVE Invasive video-electroencephalography (iVEEG) is the gold standard for evaluation of refractory temporal lobe epilepsy before second stage resective surgery (SSRS). Traditionally, the presumed seizure onset zone (SOZ) has been covered with subdural electrodes (SDE), a very invasive procedure prone to complications. Temporal stereoelectroencephalography (SEEG) with conventional frame-based stereotaxy is time-consuming and impeded by the geometry of the frame. The introduction of robotic assistance promised a simplification of temporal SEEG implantation. However, the efficacy of temporal SEEG in iVEEG remains unclear. The aim of this study was therefore to describe the efficiency and efficacy of SEEG in iVEEG of temporal lobe epilepsy. METHODS This retrospective study enrolled 60 consecutive patients with medically intractable epilepsy who underwent iVEEG of a potential temporal SOZ by SDE (n = 40) or SEEG (n = 20). Surgical time efficiency was analyzed by the skin-to-skin time (STS) and the total procedure time (TPT) and compared between groups (SDE vs SEEG). Surgical risk was depicted by the 90-day complication rate. Temporal SOZ were treated by SSRS. Favorable outcome (Engel°1) was assessed after 1 year of follow-up. RESULTS Robot-assisted SEEG significantly reduced the duration of surgery (STS and TPT) compared to SDE implantations. There was no significant difference in complication rates. Notably, all surgical revisions in this study were attributed to SDE. Unilateral temporal SOZ was detected in 34/60 cases. Of the 34 patients, 30 underwent second stage SSRS. Both SDE and SEEG had a good predictive value for the outcome of temporal SSRS with no significant group difference. SIGNIFICANCE Robot-assisted SEEG improves the accessibility of the temporal lobe for iVEEG by increasing surgical time efficiency and by simplifying trajectory selection without losing its predictive value for SSRS.
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Affiliation(s)
- Mykola Gorbachuk
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Kathrin Machetanz
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Eliane Weinbrenner
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Florian Grimm
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Thomas V. Wuttke
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Sophie Wang
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Silke Ethofer
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Marcos Tatagiba
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Sabine Rona
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Jürgen Honegger
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
| | - Georgios Naros
- Neurosurgical Clinic, Department of Neurosurgery and NeurotechnologyEberhard Karls UniversityTuebingenGermany
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Machetanz K, Wang SS, Oberle L, Tatagiba M, Naros G. Sex Differences in Vestibular Schwannoma. Cancers (Basel) 2023; 15:4365. [PMID: 37686642 PMCID: PMC10486905 DOI: 10.3390/cancers15174365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 08/22/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
Vestibular schwannoma (VS) are equally common in men and woman. A number of epidemiological studies have reported on sex-specific aspects of incidence, tumor size, tinnitus and hearing loss. However, data on sex-specific, pre- and post-surgically quality of life (QoL) are rare. The objective of the present study was to determine sex-specific aspects on QoL in VS. Health-related QoL was analyzed in 260 patients (112 male/148 female) with unilateral sporadic VS using general (SF-36: general Short-Form Health Survey), disease-specific (PANQOL: Penn Acoustic Neuroma Quality-of-Life Scale, PANQOL) and symptom-specific (DHI: Dizziness Handicap Inventory; HHI: Hearing Handicap Inventory; THI: Tinnitus Handicap Inventory; FDI: Facial Disability Index) QoL questionnaires. Sex differences were evaluated pre- and postoperative by multi- and univariate analyses based on 200 preoperative and 88 postoperative questionnaires. Female patients were significantly more affected by dizziness, headaches, reduced energy and anxiety. Energy and balance changed similarly in both sexes after surgery. However, postoperative women tended to be more affected by facial palsy and headaches than men. Despite the greater physical impairment, general health improved equivalently or even more in female patients than in males. In conclusion, self-rated QoL in VS is significantly affected by sex and surgery. This should be taken into account when counseling VS patients regarding observation, radiotherapy, and surgery.
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Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, 72074 Tuebingen, Germany
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Machetanz K, Lee L, Wang SS, Tatagiba M, Naros G. Trading mental and physical health in vestibular schwannoma treatment decision. Front Oncol 2023; 13:1152833. [PMID: 37434979 PMCID: PMC10332305 DOI: 10.3389/fonc.2023.1152833] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 06/08/2023] [Indexed: 07/13/2023] Open
Abstract
Objective Observation, radiotherapy and surgery are treatment options in vestibular schwannomas (VS). Decision making differs between centers and is usually based on tumor characteristics (e.g., size) and the expected physical health (PH) outcome (i.e., hearing and facial function). However, mental health (MH) is often under-reported. The objective of the present study was to ascertain the impact of VS treatment on PH and MH. Methods PH and MH were assessed in a prospective cross-sectional study including 226 patients with unilateral sporadic VS before and after surgical removal (SURG). Quality-of-life (QoL) was estimated by self-rating questionnaires: general Short-Form Health Survey (SF-36), Penn Acoustic Neuroma Quality-of-Life Scale (PANQOL), Dizziness Handicap Inventory (DHI), Hearing Handicap Inventory (HHI), Tinnitus Handicap Inventory (THI), and Facial Disability Index (FDI). QoL changes over time as well as predictive factors were accessed by multivariate analyses of covariance (MANCOVA). Results In total, 173 preoperative and 80 postoperative questionnaires were analyzed. There was a significant PH deterioration related to facial function (FDI, PANQOL-face) after surgery. In line with facial rehabilitation, however, FDI improved within the first five years after surgery and did not differ compared to the preoperative patient cohort, eventually. In contrast, MH (i.e., PANQOL-anxiety) and general health (i.e., PANQOL-GH) improved with surgery and correlated with the extent-of-resection. Conclusion Physical and mental health is significantly influenced by VS surgery. While PH might decrease after surgery, MH potentially increases when patient is cured. Practitioners should take MH into account before advising an incompletely VS treatment (e.g., subtotal resection, observation or radiosurgery).
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Affiliation(s)
- Kathrin Machetanz
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Larissa Lee
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Sophie S Wang
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Marcos Tatagiba
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Georgios Naros
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
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Wang SSY, Machetanz K, Ebner F, Naros G, Tatagiba M. Association of extent of resection on recurrence-free survival and functional outcome in vestibular schwannoma of the elderly. Front Oncol 2023; 13:1153698. [PMID: 37342182 PMCID: PMC10277928 DOI: 10.3389/fonc.2023.1153698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/02/2023] [Indexed: 06/22/2023] Open
Abstract
Background Despite the ongoing debate on the risk-benefit ratio of vestibular schwannoma (VS) treatment options, watchful observation and radiation are usually favored in the elderly (>65 years). If surgery is inevitable, a multimodal approach after deliberate subtotal resection has been described as a valid option. The relationship between the extent of resection (EOR) of surgical and functional outcomes and recurrence-free survival (RFS) remains unclear. This present study aims to evaluate the functional outcome and RFS of the elderly in relation to the EOR. Methods This matched cohort study analyzed all consecutive elderly VS patients treated at a tertiary referral center since 2005. A separate cohort (<65 years) served as a matched control group (young). Clinical status was assessed by the Charlson Comorbidity Index (CCI), the Karnofsky Performance (KPS), and the Gardner and Robertson (GR) and House & Brackmann (H&B) scales. RFS was evaluated by Kaplan-Meier analysis using contrast-enhanced magnetic resonance imaging to identify tumor recurrence. Results Among 2,191 patients, 296 (14%) patients were classified as elderly, of whom 133 (41%) were treated surgically. The elderly were characterized by a higher preoperative morbidity and worse gait uncertainty. Postoperative mortality (0.8% and 1%), morbidity (13% and 14%), and the functional outcome (G&R, H&B, and KPS) did not differ between the elderly and the young. There was a significant benefit in regard to the preoperative imbalance. Gross total resection (GTR) was accomplished in 74% of all cases. Lower grades of the EOR (subtotal and decompressive surgery) raised the incidence of recurrence significantly. Mean time to recurrence in the surgELDERLY was 67.33 ± 42.02 months and 63.2 ± 70.98 months in the surgCONTROL. Conclusions Surgical VS treatment aiming for complete tumor resection is feasible and safe, even in advanced age. A higher EOR is not associated with cranial nerve deterioration in the elderly compared to the young. In contrast, the EOR determines RFS and the incidence of recurrence/progression in both study cohorts. If surgery is indicated in the elderly, GTR can be intended safely, and if only subtotal resection is achieved, further adjuvant therapy, e.g., radiotherapy, should be discussed in the elderly, as the incidence of recurrence is not significantly lower compared to the young.
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Affiliation(s)
- Sophie Shih-Yüng Wang
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Kathrin Machetanz
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Florian Ebner
- Department of Neurosurgery, Alfried Krupp Hospital, Essen, Germany
| | - Georgios Naros
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University Tübingen, Tübingen, Germany
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8
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Breit S, Milosevic L, Naros G, Cebi I, Weiss D, Gharabaghi A. Structural-Functional Correlates of Response to Pedunculopontine Stimulation in a Randomized Clinical Trial for Axial Symptoms of Parkinson's Disease. J Parkinsons Dis 2023:JPD225031. [PMID: 37092235 DOI: 10.3233/jpd-225031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
BACKGROUND Axial symptoms of Parkinson's disease (PD) can be debilitating and are often refractory to conventional therapies such as dopamine replacement therapy and deep brain stimulation (DBS) of the subthalamic nuclei (STN). OBJECTIVE Evaluate the efficacy of bilateral DBS of the pedunculopontine nucleus area (PPNa) and investigate structural and physiological correlates of clinical response. METHODS A randomized, double-blind, cross-over clinical trial was employed to evaluate the efficacy of bilateral PPNa-DBS on axial symptoms. Lead positions and neuronal activity were evaluated with respect to clinical response. Connectomic cortical activation profiles were generated based on the volumes of tissue activated. RESULTS PPNa-DBS modestly improved (p = 0.057) axial symptoms in the medication-off condition, with greatest positive effects on gait symptoms (p = 0.027). Electrode placements towards the anterior commissure (ρ= 0.912; p = 0.011) or foramen caecum (ρ= 0.853; p = 0.031), near the 50% mark of the ponto-mesencephalic junction, yielded better therapeutic responses. Recording trajectories of patients with better therapeutic responses (i.e., more anterior electrode placements) had neurons with lower firing-rates (p = 0.003) and higher burst indexes (p = 0.007). Structural connectomic profiles implicated activation of fibers of the posterior parietal lobule which is involved in orienting behavior and locomotion. CONCLUSION Bilateral PPNa-DBS influenced gait symptoms in patients with PD. Anatomical and physiological information may aid in localization of a favorable stimulation target.
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Affiliation(s)
- Sorin Breit
- Department for Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, and German Centre of Neurodegenerative Diseases (DZNE), University Hospital and University Tübingen, Tübingen, Germany
| | - Luka Milosevic
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen, Germany
- Krembil Research Institute, Clinical and Computational Neuroscience, University Health Network, Toronto, Canada
| | - Georgios Naros
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen, Germany
| | - Idil Cebi
- Department for Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, and German Centre of Neurodegenerative Diseases (DZNE), University Hospital and University Tübingen, Tübingen, Germany
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen, Germany
| | - Daniel Weiss
- Department for Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, and German Centre of Neurodegenerative Diseases (DZNE), University Hospital and University Tübingen, Tübingen, Germany
| | - Alireza Gharabaghi
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen, Germany
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9
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Tatagiba M, Wang SS, Rizk A, Ebner F, van Eck ATCJ, Naros G, Horstmann G. A comparative study of microsurgery and gamma knife radiosurgery in vestibular schwannoma evaluating tumor control and functional outcome. Neurooncol Adv 2023; 5:vdad146. [PMID: 38024239 PMCID: PMC10681278 DOI: 10.1093/noajnl/vdad146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023] Open
Abstract
Background Both stereotactic radiosurgery (SRS) and microsurgical resection (SURGERY) are available as treatment options for sporadic vestibular schwannoma (VS). There are very few direct comparative studies comparing both treatment modalities in large cohorts allowing detailed subgroup analysis. This present study aimed to compare the nuances in the treatment of VS by SURGERY and SRS in 2 highly specialized neurosurgical centers. Methods This is a retrospective bicentric cohort study. Data from patients treated between 2005 and 2011 were collected retrospectively. Recurrence-free survival (RFS) was assessed radiographically by contrast-enhanced magnetic resonance imaging. Results The study population included N = 901 patients with a mean follow-up of 7 years. Overall, the incidence of recurrence was 7% after SURGERY, and 11% after SRS with superior tumor control in SURGERY in the Kaplan-Meier-analysis (P = 0.031). In small tumors (Koos I and II), tumor control was equivalent in both treatment arms. In large VS (Koos III and IV), however, RFS was superior in SURGERY. The extent of resection correlated with RFS (P < .001). Facial and hearing deterioration was similar in both treatment arms in small VS, but more pronounced in SURGERY of large VS. Tinnitus, vertigo, imbalance, and trigeminal symptoms were more often improved by SURGERY than SRS. Conclusions SRS can achieve similar tumor control compared to SURGERY in smaller VS (Koos I and II)-with similar postinterventional morbidities. In large VS (Koos III and IV), long-term tumor control of SRS is inferior to SURGERY. Based on these results, we suggest that if combination therapy is chosen, the residual tumor should not exceed the size of Koos II.
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Affiliation(s)
- Marcos Tatagiba
- Department of Neurosurgery, Eberhard Karls University, Tubingen, Germany
| | - Sophie S Wang
- Department of Neurosurgery, Eberhard Karls University, Tubingen, Germany
| | - Ahmed Rizk
- Department of Neurosurgery, Eberhard Karls University, Tubingen, Germany
| | - Florian Ebner
- Department of Neurosurgery, Eberhard Karls University, Tubingen, Germany
| | | | - Georgios Naros
- Department of Neurosurgery, Eberhard Karls University, Tubingen, Germany
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10
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Khademi F, Naros G, Nicksirat A, Kraus D, Gharabaghi A. Rewiring Cortico-Muscular Control in the Healthy and Poststroke Human Brain with Proprioceptive β-Band Neurofeedback. J Neurosci 2022; 42:6861-6877. [PMID: 35940874 PMCID: PMC9463986 DOI: 10.1523/jneurosci.1530-20.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 11/21/2022] Open
Abstract
In severely affected stroke survivors, cortico-muscular control is disturbed and volitional upper limb movements often absent. Mental rehearsal of the impaired movement in conjunction with sensory feedback provision are suggested as promising rehabilitation exercises. Knowledge about the underlying neural processes, however, remains vague. In male and female chronic stroke patients with hand paralysis, a brain-computer interface controlled a robotic orthosis and turned sensorimotor β-band desynchronization during motor imagery (MI) of finger extension into contingent hand opening. Healthy control subjects performed the same task and received the same proprioceptive feedback with a robotic orthosis or visual feedback only. Only when proprioceptive feedback was provided, cortico-muscular coherence (CMC) increased with a predominant information flow from the sensorimotor cortex to the finger extensors. This effect (1) was specific to the β frequency band, (2) transferred to a motor task (MT), (3) was proportional to subsequent corticospinal excitability (CSE) and correlated with behavioral changes in the (4) healthy and (5) poststroke condition; notably, MI-related enhancement of β-band CMC in the ipsilesional premotor cortex correlated with motor improvements after the intervention. In the healthy and injured human nervous system, synchronized activation of motor-related cortical and spinal neural pools facilitates, in accordance with the communication-through-coherence hypothesis, cortico-spinal communication and may, thereby, be therapeutically relevant for functional restoration after stroke, when voluntary movements are no longer possible.SIGNIFICANCE STATEMENT This study provides insights into the neural processes that transfer effects of brain-computer interface neurofeedback to subsequent motor behavior. Specifically, volitional control of cortical oscillations and proprioceptive feedback enhances both cortical activity and behaviorally relevant connectivity to the periphery in a topographically circumscribed and frequency-specific way. This enhanced cortico-muscular control can be induced in the healthy and poststroke brain. Thereby, activating the motor cortex with mental rehearsal of the impaired movement and closing the loop by robot-assisted feedback synchronizes ipsilesional premotor cortex and spinal neural pools in the β frequency band. This facilitates, in accordance with the communication-through-coherence hypothesis, cortico-spinal communication and may, thereby, be therapeutically relevant for functional restoration after stroke, when voluntary movements are no longer possible.
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Affiliation(s)
- Fatemeh Khademi
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen 72076, Germany
| | - Georgios Naros
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen 72076, Germany
| | - Ali Nicksirat
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen 72076, Germany
| | - Dominic Kraus
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen 72076, Germany
| | - Alireza Gharabaghi
- Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Tübingen 72076, Germany
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11
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Machetanz K, Grimm F, Schäfer R, Trakolis L, Hurth H, Haas P, Gharabaghi A, Tatagiba M, Naros G. Design and Evaluation of a Custom-Made Electromyographic Biofeedback System for Facial Rehabilitation. Front Neurosci 2022; 16:666173. [PMID: 35310106 PMCID: PMC8931662 DOI: 10.3389/fnins.2022.666173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 01/12/2022] [Indexed: 11/19/2022] Open
Abstract
Background In the rehabilitation of postoperative facial palsy, physical therapy is of paramount importance. However, in the early rehabilitation phase, voluntary movements are often limited, and thus, the motivation of patients is impacted. In these situations, biofeedback of facial electromyographic (EMG) signals enables the visual representation of the rehabilitation progress, even without apparent facial movements. In the present study, we designed and evaluated a custom-made EMG biofeedback system enabling cost-effective facial rehabilitation. Methods This prospective study describes a custom-made EMG system, consisting of a microcontroller board and muscle sensors, which was used to record the EMG of frontal and zygomatic facial muscles during frowning and smiling. First, the mean EMG amplitudes and movement onset detection rates (ACC) achieved with the custom-made EMG system were compared with a commercial EMG device in 12 healthy subjects. Subsequently, the custom-made device was applied to 12 patients with and without postoperative facial paresis after neurosurgical intervention. Here, the ratio [laterality index (LI)] between the mean EMG amplitude of the healthy and affected side was calculated and related to the facial function as measured by the House and Brackmann scale (H&B) ranging from 1 (normal) to 6 (total paralysis). Results In healthy subjects, a good correlation was measured between the mean EMG amplitudes of the custom-made and commercial EMG device for both frontal (r = 0.84, p = 0.001) and zygomatic muscles (r = 0.8, p = 0.002). In patients, the LI of the frontal and zygomatic muscles correlated significantly with the H&B (r = −0.83, p = 0.001 and r = −0.65, p = 0.023). The ACC of the custom-made EMG system varied between 65 and 79% depending on the recorded muscle and cohort. Conclusion The present study demonstrates a good application potential of our custom-made EMG biofeedback device to detect facial EMG activity in healthy subjects as well as patients with facial palsies. There is a correlation between the electrophysiological measurements and the clinical outcome. Such a device might enable cost-efficient home-based facial EMG biofeedback. However, movement detection accuracy should be improved in future studies to reach ranges of commercial devices.
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Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- *Correspondence: Kathrin Machetanz,
| | - Florian Grimm
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Ruth Schäfer
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Clinic, Tübingen, Germany
| | - Leonidas Trakolis
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Helene Hurth
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Patrick Haas
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Alireza Gharabaghi
- Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Georgios Naros
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tübingen, Tübingen, Germany
- Georgios Naros,
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12
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Naros G, Machetanz K, Leao MT, Wang S, Tatagiba M, Gharabaghi A. Impaired phase synchronization of motor-evoked potentials reflects the degree of motor dysfunction in the lesioned human brain. Hum Brain Mapp 2022; 43:2668-2682. [PMID: 35199903 PMCID: PMC9057086 DOI: 10.1002/hbm.25812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 01/17/2022] [Accepted: 02/09/2022] [Indexed: 11/10/2022] Open
Abstract
The functional corticospinal integrity (CSI) can be indexed by motor-evoked potentials (MEP) following transcranial magnetic stimulation of the motor cortex. Glial brain tumors in motor-eloquent areas are frequently disturbing CSI resulting in different degrees of motor dysfunction. However, this is unreliably mirrored by MEP characteristics. In 59 consecutive patients with diffuse glial tumors and 21 healthy controls (CTRL), we investigated the conventional MEP features, that is, resting motor threshold (RMT), amplitudes and latencies. In addition, frequency-domain MEP features were analyzed to estimate the event-related spectral perturbation (ERSP), and the induced phase synchronization by intertrial coherence (ITC). The clinical motor status was captured including the Medical Research Council Scale (MRCS), the Grooved Pegboard Test (GPT), and the intake of antiepileptic drugs (AED). Motor function was classified according to MRCS and GPT as no motor deficit (NMD), fine motor deficits (FMD) and gross motor deficits (GMD). CSI was assessed by diffusion-tensor imaging (DTI). Motor competent subjects (CTRL and NMD) had similar ERSP and ITC values. The presence of a motor deficit (FMD and GMD) was associated with an impairment of high-frequency ITC (150-300 Hz). GMD and damage to the CSI demonstrated an additional reduction of high-frequency ERSP (150-300 Hz). GABAergic AED increased ERSP but not ITC. Notably, groups were indistinguishable based on conventional MEP features. Estimating MEP phase synchronization provides information about the corticospinal transmission after transcranial magnetic stimulation and reflects the degree of motor impairment that is not captured by conventional measures.
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Affiliation(s)
- Georgios Naros
- Department of Neurosurgery and Neurotechnology, Neurosurgical Clinic, Eberhard Karls University, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University Tuebingen, Germany
| | - Kathrin Machetanz
- Department of Neurosurgery and Neurotechnology, Neurosurgical Clinic, Eberhard Karls University, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University Tuebingen, Germany
| | - Maria Teresa Leao
- Department of Neurosurgery and Neurotechnology, Neurosurgical Clinic, Eberhard Karls University, Tuebingen, Germany
| | - Sophie Wang
- Department of Neurosurgery and Neurotechnology, Neurosurgical Clinic, Eberhard Karls University, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery and Neurotechnology, Neurosurgical Clinic, Eberhard Karls University, Tuebingen, Germany
| | - Alireza Gharabaghi
- Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University Tuebingen, Germany
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13
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Machetanz K, Grimm F, Wang S, Schuhmann MU, Tatagiba M, Gharabaghi A, Naros G. Rediscovery of the transcerebellar approach: improving the risk-benefit ratio in robot-assisted brainstem biopsies. Neurosurg Focus 2022; 52:E12. [DOI: 10.3171/2021.10.focus21359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 10/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Conventional frame-based stereotaxy through a transfrontal approach (TFA) is the gold standard in brainstem biopsies. Because of the high surgical morbidity and limited impact on therapy, brainstem biopsies are controversial. The introduction of robot-assisted stereotaxy potentially improves the risk-benefit ratio by simplifying a transcerebellar approach (TCA). The aim of this single-center cohort study was to evaluate the risk-benefit ratio of transcerebellar brainstem biopsies performed by 2 different robotic systems. In addition to standard quality indicators, a special focus was set on trajectory selection for reducing surgical morbidity.
METHODS
This study included 25 pediatric (n = 7) and adult (n = 18) patients who underwent 26 robot-assisted biopsies via a TCA. The diagnostic yield, complication rate, trajectory characteristics (i.e., length, anatomical entry, and target-point location), and skin-to-skin (STS) time were evaluated. Transcerebellar and hypothetical transfrontal trajectories were reconstructed and transferred into a common MR space for further comparison with anatomical atlases.
RESULTS
Robot-assisted, transcerebellar biopsies demonstrated a high diagnostic yield (96.2%) while exerting no surgical mortality and no permanent morbidity in both pediatric and adult patients. Only 3.8% of cases involved a transient neurological deterioration. Transcerebellar trajectories had a length of 48.4 ± 7.3 mm using a wide stereotactic corridor via crus I or II of the cerebellum and the middle cerebellar peduncle. The mean STS time was 49.5 ± 23.7 minutes and differed significantly between the robotic systems (p = 0.017). The TFA was characterized by longer trajectories (107.4 ± 11.8 mm, p < 0.001) and affected multiple eloquent structures. Transfrontal target points were located significantly more medial (−3.4 ± 7.2 mm, p = 0.042) and anterior (−3.9 ± 8.4 mm, p = 0.048) in comparison with the transcerebellar trajectories.
CONCLUSIONS
Robot-assisted, transcerebellar stereotaxy can improve the risk-benefit ratio of brainstem biopsies by avoiding the restrictions of a TFA and conventional frame-based stereotaxy. Profound registration and anatomical-functional trajectory selection were essential to reduce mortality and morbidity.
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Affiliation(s)
- Kathrin Machetanz
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen
- Institute for Neuromodulation and Neurotechnology, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Florian Grimm
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen
- Institute for Neuromodulation and Neurotechnology, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Sophie Wang
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen
| | - Martin U. Schuhmann
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen
| | - Marcos Tatagiba
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen
| | - Alireza Gharabaghi
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen
- Institute for Neuromodulation and Neurotechnology, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Georgios Naros
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen
- Institute for Neuromodulation and Neurotechnology, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
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14
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Drexler R, Ben-Haim S, Bien CG, Borger V, Cardinale F, Carpentier A, Cendes F, Chandra S, Clusmann H, Colon A, de Curtis M, Delev D, Didato G, Dührsen L, Farah JO, Guenot M, Ghatan S, Haegelen C, Hamer H, Hauptmann JS, Jeffree RL, Kalbhenn T, Kegele J, Krayenbühl N, Lang J, Mathon B, Naros G, Onken J, Panov F, Raftopoulos C, Ricklefs FL, Rijkers K, Rizzi M, Rössler K, Schijns O, Schneider UC, Spyrantis A, Strzelczyk A, Stodieck S, Tripathi M, Vadera S, Alonso-Vanegas MA, Vaz JGR, Wellmer J, Wehner T, Westphal M, Sauvigny T. Enhancing Safety in Epilepsy Surgery (EASINESS): Study Protocol for a Retrospective, Multicenter, Open Registry. Front Neurol 2021; 12:782666. [PMID: 34966349 PMCID: PMC8710656 DOI: 10.3389/fneur.2021.782666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/05/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction: Optimizing patient safety and quality improvement is increasingly important in surgery. Benchmarks and clinical quality registries are being developed to assess the best achievable results for several surgical procedures and reduce unwarranted variation between different centers. However, there is no clinical database from international centers for establishing standardized reference values of patients undergoing surgery for mesial temporal lobe epilepsy. Design: The Enhancing Safety in Epilepsy Surgery (EASINESS) study is a retrospectively conducted, multicenter, open registry. All patients undergoing mesial temporal lobe epilepsy surgery in participating centers between January 2015 and December 2019 are included in this study. The patient characteristics, preoperative diagnostic tools, surgical data, postoperative complications, and long-term seizure outcomes are recorded. Outcomes: The collected data will be used for establishing standardized reference values (“benchmarks”) for this type of surgical procedure. The primary endpoints include seizure outcomes according to the International League Against Epilepsy (ILAE) classification and defined postoperative complications. Discussion: The EASINESS will define robust and standardized outcome references after amygdalohippocampectomy for temporal lobe epilepsy. After the successful definition of benchmarks from an international cohort of renowned centers, these data will serve as reference values for the evaluation of novel surgical techniques and comparisons among centers for future clinical trials. Clinical trial registration: This study is indexed at clinicaltrials.gov (NT 04952298).
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Affiliation(s)
- Richard Drexler
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sharona Ben-Haim
- Department of Neurosurgery, University of California San Diego, San Diego, CA, United States
| | | | - Valeri Borger
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | | | | | - Fernando Cendes
- Department of Neurology, University of Campinas, Campinas, Brazil
| | | | - Hans Clusmann
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Albert Colon
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (UM), Maastricht, Netherlands
| | - Marco de Curtis
- Epilepsy Unit, IRCCS "C. Besta" Neurological Institute Foundation, Milan, Italy
| | - Daniel Delev
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Giuseppe Didato
- Epilepsy Unit, IRCCS "C. Besta" Neurological Institute Foundation, Milan, Italy
| | - Lasse Dührsen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Marc Guenot
- Department of Functional Neurosurgery, P. Wertheimer Hospital, Hospices Civils de Lyon, Lyon, France.,Department for Neurosurgery, University of Lyon, Lyon, France
| | - Saadi Ghatan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Claire Haegelen
- Department of Functional Neurosurgery, P. Wertheimer Hospital, Hospices Civils de Lyon, Lyon, France.,Department for Neurosurgery, University of Lyon, Lyon, France
| | - Hajo Hamer
- Epilepsy Center, Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Jason S Hauptmann
- Department of Neurosurgery, University of Washington, Seattle, WA, United States
| | - Rosalind L Jeffree
- Department of Neurosurgery, Royal Brisbane and Womens Hospital, Brisbane, QLD, Australia.,Herston Clinical School, University of Queensland, Brisbane, QLD, Australia
| | - Thilo Kalbhenn
- Department of Neurosurgery (Evangelisches Klinikum Bethel), Bielefeld University, Medical School, Bielefeld, Germany
| | - Josua Kegele
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tubingen, Tubingen, Germany
| | - Niklaus Krayenbühl
- Division of Pediatric Neurosurgery, University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Johannes Lang
- Epilepsy Center, Department of Neurology, University of Erlangen-Nürnberg, Erlangen, Germany
| | - Bertrand Mathon
- Department of Neurosurgery, Pitié-Salpêtrière Hospital, Paris, France
| | - Georgios Naros
- Department of Neurology and Epileptology, Hertie Institute of Clinical Brain Research, University of Tubingen, Tubingen, Germany
| | - Julia Onken
- Department of Neurosurgery, Universitätsmedizin Charité-Berlin, Berlin, Germany
| | - Fedor Panov
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Christian Raftopoulos
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Franz L Ricklefs
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kim Rijkers
- Department of Neurosurgery, Academic Center for Epileptology UMC Maastricht, Maastricht, Netherlands
| | - Michele Rizzi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Karl Rössler
- Department of Neurosurgery, Medical University Vienna, Vienna, Austria
| | - Olaf Schijns
- Department of Neurosurgery, Academic Center for Epileptology UMC Maastricht, Maastricht, Netherlands.,School for Mental Health and Neuroscience (MHeNS), University Maastricht (UM), Maastricht, Netherlands
| | - Ulf C Schneider
- Department of Neurosurgery, Universitätsmedizin Charité-Berlin, Berlin, Germany
| | - Andrea Spyrantis
- Department of Neurosurgery and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Frankfurt, Germany
| | - Adam Strzelczyk
- Department of Neurosurgery and Epilepsy Center Frankfurt Rhine-Main, Center of Neurology and Neurosurgery, Goethe-University Frankfurt, Frankfurt, Germany
| | - Stefan Stodieck
- Hamburg Epilepsy Center, Protestant Hospital Alsterdorf, Department of Neurology and Epileptology, Hamburg, Germany
| | | | - Sumeet Vadera
- Department of Neurological Surgery, University of California Irvine, Irvine, CA, United States
| | - Mario A Alonso-Vanegas
- National Institute of Neurology and Neurosurgery, Manuel Velasco Suarez, Mexico City, Mexico
| | - José Géraldo Ribero Vaz
- Department of Neurosurgery, University Hospital St-Luc, Université Catholique de Louvain (UCL), Brussels, Belgium
| | - Jörg Wellmer
- Ruhr - Epileptology, Department of Neurology, University Hospital Knappschafts-Krankenhaus, Ruhr - University Bochum, Bochum, Germany
| | - Tim Wehner
- Ruhr - Epileptology, Department of Neurology, University Hospital Knappschafts-Krankenhaus, Ruhr - University Bochum, Bochum, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Sauvigny
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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15
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Machetanz K, Wiesinger L, Leao MT, Liebsch M, Trakolis L, Wang S, Gharabaghi A, Tatagiba M, Naros G. Interhemispheric differences in time-frequency representation of motor evoked potentials in brain tumor patients. Clin Neurophysiol 2021; 132:2780-2788. [PMID: 34583121 DOI: 10.1016/j.clinph.2021.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 07/10/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Conventional time-series parameters are unreliable descriptors of motor-evoked potentials (MEPs) in brain tumor patients. Frequency domain analysis is suggested to provide additional information about the status of the cortico-spinal motor system. Aim of the present study was to describe the time-frequency representation of MEPs and its relation to the motor performance. METHODS This study enrolled 17 consecutive brain tumor patients with impaired dexterity. After brain mapping of the affected (AH) and non-affected (NAH) hemisphere, TMS was applied to the hotspots of the abductor pollicis brevis muscles (APB). Using a Morlet wavelet approach, event-related spectral perturbation (ERSP) and inter-trial coherence (ITC) of the MEPs were calculated and compared to the Grooved Pegboard Test (GPT). Additionally, inter- and intra-subject reliability was assessed by the intraclass correlation coefficient (ICC). RESULTS MEPs were projecting to a frequency band between 30 and 400 Hz with a local maximum between 100 and 150 Hz. There was a significant ERSP and ITC reduction of the AH in comparison to the NAH. In contrast, no interhemispheric differences were depicted in the conventional time-series analysis. ERSP and ITC values correlated significantly with GPT results (r = 0.35 and r = 0.50). Time-frequency MEP description had good inter-and intra-subject reliability (ICC = 0.63). CONCLUSIONS Brain tumors affect corticospinal transmission resulting in a reduction of temporal and spectral MEP synchronization correlating with the dexterity performance. SIGNIFICANCE Time-frequency representation of MEPs provide additional information beyond conventional time-domain features.
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Affiliation(s)
- Kathrin Machetanz
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany; Institute for Neuromodulation and Neurotechnology, Department of Neurosurgery and Neurotechnology, Eberhard Karls University Tuebingen, Germany
| | - Lasse Wiesinger
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Maria Teresa Leao
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Marina Liebsch
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Leonidas Trakolis
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Sophie Wang
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Alireza Gharabaghi
- Institute for Neuromodulation and Neurotechnology, Department of Neurosurgery and Neurotechnology, Eberhard Karls University Tuebingen, Germany
| | - Marcos Tatagiba
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Georgios Naros
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany; Institute for Neuromodulation and Neurotechnology, Department of Neurosurgery and Neurotechnology, Eberhard Karls University Tuebingen, Germany.
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16
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Abstract
Abstract
Purpose of Review
Management of vestibular schwannomas (VSs) is multimodal and include watchful observation, radiation treatment, and surgery. Over the past decades, a shift in treatment strategy toward radiation treatment has gradually displaced surgery from the main treatment option for VS. In recent years, however, surgery has been further refined by developments of microsurgical and endoscopic techniques and advances in intraoperative application of neuroprotective drugs. This article presents outcomes of modern surgical treatment of VS in the era of radiosurgery and reviews recent published advancements relevant to VS management.
Recent Findings
Following VS surgery, excellent tumor resection rates and cranial nerve outcomes were achieved in a consecutive series of 572 adult patients with mean postoperative follow up of 4 years. Innovations in surgical technique include endoscopic technique as additional tool to microsurgery, exploration of semi-sitting position for large tumors, and intraoperative use of vasoactive agents as neuroprotective strategy.
Summary
Despite great developments in radiation treatment of VS, surgery remains the key solution for the majority of the cases in order to achieve cure of the disease, long-term tumor control, and preservation of cranial nerve function at long-term.
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17
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Machetanz K, Grimm F, Wang S, Bender B, Tatagiba M, Gharabaghi A, Naros G. Patient-to-robot registration: The fate of robot-assisted stereotaxy. Int J Med Robot 2021; 17:e2288. [PMID: 34036749 DOI: 10.1002/rcs.2288] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 05/22/2021] [Accepted: 05/22/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Robot-assisted stereotaxy (RAS) promises higher stereotactic accuracy (SA) and time efficiency (TE) than frame-based stereotaxy. However, both aspects are attributed to the problem of patient-to-robot registration. OBJECTIVE To examine different registration techniques regarding their SA and TE. METHODS This study enrolled 57 patients undergoing RAS with bone fiducial registration (BFR) or laser surface registration (LSR). SA was measured by the entry point error (EPE). Additionally, predictors of SA (registration error [RegE], distance-to-registration plane [DTC]) and TE (imaging, skin-to-skin) were assessed. RESULTS The mean SA was 1.0 ± 0.8 mm. BFR increased SA by reducing RegE and DTC. In LSR, EPE depended on DTC (face and forehead) with highest accuracy for DTC ≤100 mm. CT-based LSR exerted a higher SA than MR-based LSR. In BFR, TE was confined by the additional imaging. CONCLUSION Every registration technique counteracts one of the promises of RAS. New solutions are needed to increase the acceptance of RAS in neurosurgery.
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Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery and Neurotechnology, Neurosurgical Clinic, Eberhard Karls University, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Florian Grimm
- Department of Neurosurgery and Neurotechnology, Neurosurgical Clinic, Eberhard Karls University, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Sophie Wang
- Department of Neurosurgery and Neurotechnology, Neurosurgical Clinic, Eberhard Karls University, Tuebingen, Germany
| | - Benjamin Bender
- Department of Neuroradiology, Eberhard Karls University, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery and Neurotechnology, Neurosurgical Clinic, Eberhard Karls University, Tuebingen, Germany
| | - Alireza Gharabaghi
- Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Georgios Naros
- Department of Neurosurgery and Neurotechnology, Neurosurgical Clinic, Eberhard Karls University, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
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18
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Grimm F, Kraugmann J, Naros G, Gharabaghi A. Clinical validation of kinematic assessments of post-stroke upper limb movements with a multi-joint arm exoskeleton. J Neuroeng Rehabil 2021; 18:92. [PMID: 34078400 PMCID: PMC8170809 DOI: 10.1186/s12984-021-00875-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 04/30/2021] [Indexed: 11/10/2022] Open
Abstract
Background The clinical evaluation of the upper limb of severely impaired stroke patient is challenging. Sensor-based assessments may allow for an objective evaluation of this patient population. This study investigated the validity of a device-assisted approach in comparison to the clinical outcome that it is supposed to reflect. Methods In nineteen severely impaired chronic stroke patients, we applied a gravity-compensating, multi-joint arm exoskeleton (Armeo Spring) and compared this sensor-based assessment with the clinical outcome measure Upper Extremity Fugl-Meyer Assessment (UE-FMA) scale. Specifically, we assessed separately and subsequently the range of motion in joint space for four single joints (i.e., wrist, elbow and shoulder flexion/extension (FE), and shoulder internal/external rotation (IER)), and the closing and opening of the hand with a pressure sensor placed in the handle. Results Within the kinematic parameters, a strong correlation was observed between wrist and elbow FE (r > 0.7, p < 0.003; Bonferroni corrected). The UE-FMA was significantly predicted by a multiple regression model (F (5, 13) = 12.22, p < 0.0005, adj. R2 = 0.83). Both shoulder IER and grip pressure added significantly (p < 0.05) to the prediction with the standardized coefficients β of 0.55 and 0.38, respectively. Conclusions By applying an exoskeleton-based self-contained evaluation of single-joint movements, a clinically valid assessment of the upper limb range of motion in severely impaired stroke patients is feasible. Shoulder IER contributed most relevantly to the prediction of the clinical status. These findings need to be confirmed in a large, independent patient cohort.
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Affiliation(s)
- Florian Grimm
- Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Otfried-Mueller-Str. 45, 72076, Tübingen, Germany.
| | - Jelena Kraugmann
- Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Otfried-Mueller-Str. 45, 72076, Tübingen, Germany
| | - Georgios Naros
- Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Otfried-Mueller-Str. 45, 72076, Tübingen, Germany
| | - Alireza Gharabaghi
- Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, University Hospital and University of Tübingen, Otfried-Mueller-Str. 45, 72076, Tübingen, Germany.
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19
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Naros G, Machetanz K, Grimm F, Roser F, Gharabaghi A, Tatagiba M. Framed and non-framed robotics in neurosurgery: A 10-year single-center experience. Int J Med Robot 2021; 17:e2282. [PMID: 34030218 DOI: 10.1002/rcs.2282] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/15/2021] [Accepted: 05/11/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Safety, efficacy and efficiency of neurosurgical robots are defined by their design (i.e., framed and non-framed) and procedural workflow (PW) (from image to surgery). The present study describes the quality indicators of three different robots in brain and spine surgery. METHODS This single-centre study enrolled 252 patients over a 10-year period. Safety (complication rate) and efficacy (diagnostic yield, pedicle screw placement) were determined. Predictors of workflow efficiency (e.g., skin-to-skin) were evaluated and compared to conventional techniques (neuronavigation, stereotaxy). RESULTS All robots showed excellent reliability (97.5%-100%) with low complication rates (4.5%-5.3%) and high efficacy (94.7%-97.7%). Robotics demonstrated a better time-efficiency than neuronavigation. However, there was no shortening of surgery time compared to conventional stereotaxy. Time-efficiency differed significantly between framed and non-framed workflows. CONCLUSION While all neurosurgical robots were reliable, safe and efficacious, there were significant differences in time-efficiency. PWs should be improved to increase the acceptance of robotics in neurosurgery.
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Affiliation(s)
- Georgios Naros
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University Tuebingen, Germany
| | - Kathrin Machetanz
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University Tuebingen, Germany
| | - Florian Grimm
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University Tuebingen, Germany
| | - Florian Roser
- Department of Neurosurgery, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Alireza Gharabaghi
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University Tuebingen, Germany
| | - Marcos Tatagiba
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
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20
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Machetanz K, Grimm F, Wuttke TV, Kegele J, Lerche H, Tatagiba M, Rona S, Gharabaghi A, Honegger J, Naros G. Frame-based and robot-assisted insular stereo-electroencephalography via an anterior or posterior oblique approach. J Neurosurg 2021:1-10. [PMID: 33930861 DOI: 10.3171/2020.10.jns201843] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/21/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is an increasing interest in stereo-electroencephalography (SEEG) for invasive evaluation of insular epilepsy. The implantation of insular SEEG electrodes, however, is still challenging due to the anatomical location and complex functional segmentation in both an anteroposterior and ventrodorsal (i.e., superoinferior) direction. While the orthogonal approach (OA) is the shortest trajectory to the insula, it might insufficiently cover these networks. In contrast, the anterior approach (AOA) or posterior oblique approach (POA) has the potential for full insular coverage, with fewer electrodes bearing a risk of being more inaccurate due to the longer trajectory. Here, the authors evaluated the implantation accuracy and the detection of epilepsy-related SEEG activity with AOA and POA insular trajectories. METHODS This retrospective study evaluated the accuracy of 220 SEEG electrodes in 27 patients. Twelve patients underwent a stereotactic frame-based procedure (frame group), and 15 patients underwent a frameless robot-assisted surgery (robot group). In total, 55 insular electrodes were implanted using the AOA or POA considering the insular anteroposterior and ventrodorsal functional organization. The entry point error (EPE) and target point error (TPE) were related to the implantation technique (frame vs robot), the length of the trajectory, and the location of the target (insular vs noninsular). Finally, the spatial distribution of epilepsy-related SEEG activity within the insula is described. RESULTS There were no significant differences in EPE (mean 0.9 ± 0.6 for the nonsinsular electrodes and 1.1 ± 0.7 mm for the insular electrodes) and TPE (1.5 ± 0.8 and 1.6 ± 0.9 mm, respectively), although the length of trajectories differed significantly (34.1 ± 10.9 and 70.1 ± 9.0 mm, repsectively). There was a significantly larger EPE in the frame group than in the robot group (1.5 ± 0.6 vs 0.7 ± 0.5 mm). However, there was no group difference in the TPE (1.5 ± 0.8 vs 1.6 ± 0.8 mm). Epilepsy-related SEEG activity was detected in 42% (23/55) of the insular electrodes. Spatial distribution of this activity showed a clustering in both anteroposterior and ventrodorsal directions. In purely insular onset cases, subsequent insular lesionectomy resulted in a good seizure outcome. CONCLUSIONS The implantation of insular electrodes via the AOA or POA is safe and efficient for SEEG implantation covering both anteroposterior and ventrodorsal functional organization with few electrodes. In this series, there was no decrease in accuracy due to the longer trajectory of insular SEEG electrodes in comparison with noninsular SEEG electrodes. The results of frame-based and robot-assisted implantations were comparable.
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Affiliation(s)
- Kathrin Machetanz
- 1Department of Neurosurgery.,2Division of Functional and Restorative Neurosurgery, Department of Neurosurgery; and
| | - Florian Grimm
- 1Department of Neurosurgery.,2Division of Functional and Restorative Neurosurgery, Department of Neurosurgery; and
| | - Thomas V Wuttke
- 1Department of Neurosurgery.,3Department of Epileptology, Eberhardt Karls University, Tuebingen, Germany
| | - Josua Kegele
- 3Department of Epileptology, Eberhardt Karls University, Tuebingen, Germany
| | - Holger Lerche
- 3Department of Epileptology, Eberhardt Karls University, Tuebingen, Germany
| | | | | | - Alireza Gharabaghi
- 1Department of Neurosurgery.,2Division of Functional and Restorative Neurosurgery, Department of Neurosurgery; and
| | | | - Georgios Naros
- 1Department of Neurosurgery.,2Division of Functional and Restorative Neurosurgery, Department of Neurosurgery; and
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21
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Trakolis L, Bender B, Ebner FH, Ernemann U, Tatagiba M, Naros G. Cortical and subcortical gray matter changes in patients with chronic tinnitus sustaining after vestibular schwannoma surgery. Sci Rep 2021; 11:8411. [PMID: 33863965 PMCID: PMC8052351 DOI: 10.1038/s41598-021-87915-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 04/06/2021] [Indexed: 02/07/2023] Open
Abstract
Tinnitus is attributed to partial sensory deafferentation resulting in a central maladaptive neuroplasticity. Unfortunately, the agent of deafferentation is usually unknown or irreversible. In patients with unilateral vestibular schwannoma (VS), however, the auditory nerve is affected by a benign tumor. Hence, removal of the tumor can cease the tinnitus. In turn, sustaining complaints after surgery indicate cortical neuroplasticity. The present study is a cross sectional study which aims to track cortical structural changes by surface-based morphometry in 46 VS patients with sustained (i.e. centralized) or ceased (i.e. peripheral) tinnitus after surgery. A volumetric analysis of cortical and subcortical gray matter (GM) anatomy was performed on preoperative high-resolution MRI and related to the presence of hearing impairment, pre- and/or postoperative tinnitus. Patients with sustained (i.e. chronic) tinnitus showed an increased GM volume of the bilateral caudate nucleus, the contralateral superior colliculus, the middle frontal and middle temporal gyrus, the fusiform gyrus as well as the ipsilateral pars orbitalis when compared to those patients in whom tinnitus ceased postoperatively. Chronic tinnitus in VS patients is associated with characteristic structural changes in frontal, temporal and subcortical areas. Notably, a significant GM change of the caudate nucleus was detected providing further support for the striatal gaiting model of tinnitus.
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Affiliation(s)
- Leonidas Trakolis
- grid.411544.10000 0001 0196 8249Department of Neurosurgery and Neurotechnology, Eberhard Karls University Hospital, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany
| | - Benjamin Bender
- grid.411544.10000 0001 0196 8249Department of Diagnostic and Interventional Neuroradiology, Eberhardt Karls University Hospital, Tuebingen, Germany
| | - Florian H. Ebner
- grid.476313.4Department of Neurosurgery, Alfried Krupp Hospital, Essen, Germany
| | - Ulrike Ernemann
- grid.411544.10000 0001 0196 8249Department of Diagnostic and Interventional Neuroradiology, Eberhardt Karls University Hospital, Tuebingen, Germany
| | - Marcos Tatagiba
- grid.411544.10000 0001 0196 8249Department of Neurosurgery and Neurotechnology, Eberhard Karls University Hospital, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany
| | - Georgios Naros
- grid.411544.10000 0001 0196 8249Department of Neurosurgery and Neurotechnology, Eberhard Karls University Hospital, Hoppe-Seyler-Straße 3, 72076 Tuebingen, Germany
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22
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Leao MT, Machetanz K, Sandritter J, Liebsch M, Stengel A, Tatagiba M, Naros G. Repetitive Transcranial Magnetic Stimulation for Tinnitus Treatment in Vestibular Schwannoma: A Pilot Study. Front Neurol 2021; 12:646014. [PMID: 33912127 PMCID: PMC8072380 DOI: 10.3389/fneur.2021.646014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 02/23/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Vestibular schwannomas (VS) are brain tumors affecting the vestibulocochlear nerve. Thus, VS patients suffer from tinnitus (TN). While the pathophysiology is mainly unclear, there is an increasing interest in repetitive transcranial magnetic stimulation (rTMS) for TN treatment. However, the results have been divergent. In addition to the methodological aspects, the heterogeneity of the patients might affect the outcome. Yet, there is no study evaluating rTMS exclusively in VS-associated tinnitus. Thus, the present pilot study evaluates low-frequency rTMS to the right dorsolateral pre-frontal cortex (DLPFC) in a VS-associated tinnitus. Methods: This prospective pilot study enrolled nine patients with a monoaural VS-associated tinnitus ipsilateral to the tumor. Patients were treated with a 10-day rTMS regime (1 Hz, 100% RMT, 1,200 pulses, right DLPFC). The primary endpoint of the study was the reduction of TN distress (according to the Tinnitus Handicap Inventory, THI). The secondary endpoint was a reduction of TN intensity (according to the Tinnitus Matching Test, TMT) and the evaluation of factors predicting tinnitus outcome (i.e., hearing impairment, TN duration, type of tinnitus). Results: No complications or side effects occurred. There was one drop-out due to a non-responsiveness of the complaint. There was a significant acute effect of rTMS on the THI and TMT. However, there was no significant long-term effect after 4 weeks. While the THI failed to detect any clinically relevant acute effect of rTMS in 56% of the patients, TMT revealed a reduction of TN intensity for more than 20 in 89% and for more than 50 in 56% of the patients. Notably, the acute effect of rTMS was influenced by the TN type and duration. In general, patients with a tonal TN and shorter TN duration showed a better response to the rTMS therapy. Conclusion: The present pilot study is the first one to exclusively evaluate the effect of low-frequency rTMS to the right DLPFC in a VS-associated tinnitus. Our results prove the feasibility and the efficacy of rTMS in this patient cohort. There is a significant acute but a limited long-term effect. In addition, there is evidence that patients with a tonal tinnitus and shorter tinnitus duration might have the strongest benefit. A larger, randomized controlled study is necessary to prove these initial findings.
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Affiliation(s)
- Maria Teresa Leao
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany.,Section Psychooncology, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany
| | - Kathrin Machetanz
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Joey Sandritter
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Marina Liebsch
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Andreas Stengel
- Section Psychooncology, Comprehensive Cancer Center Tuebingen-Stuttgart, University Hospital Tuebingen, Tuebingen, Germany.,Department of Psychosomatic Medicine and Psychotherapy, University Hospital Tuebingen, Tuebingen, Germany.,Charité Center for Internal Medicine and Dermatology, Department for Psychosomatic Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
| | - Georgios Naros
- Department of Neurosurgery and Neurotechnology, Eberhard Karls University, Tuebingen, Germany
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Naros G, Lehnertz T, Leão MT, Ziemann U, Gharabaghi A. Brain State-dependent Gain Modulation of Corticospinal Output in the Active Motor System. Cereb Cortex 2021; 30:371-381. [PMID: 31204431 DOI: 10.1093/cercor/bhz093] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 03/18/2019] [Accepted: 04/10/2019] [Indexed: 01/17/2023] Open
Abstract
The communication through coherence hypothesis suggests that only coherently oscillating neuronal groups can interact effectively and predicts an intrinsic response modulation along the oscillatory rhythm. For the motor cortex (MC) at rest, the oscillatory cycle has been shown to determine the brain's responsiveness to external stimuli. For the active MC, however, the demonstration of such a phase-specific modulation of corticospinal excitability (CSE) along the rhythm cycle is still missing. Motor evoked potentials in response to transcranial magnetic stimulation (TMS) over the MC were used to probe the effect of cortical oscillations on CSE during several motor conditions. A brain-machine interface (BMI) with a robotic hand orthosis allowed investigating effects of cortical activity on CSE without the confounding effects of voluntary muscle activation. Only this BMI approach (and not active or passive hand opening alone) revealed a frequency- and phase-specific cortical modulation of CSE by sensorimotor beta-band activity that peaked once per oscillatory cycle and was independent of muscle activity. The active MC follows an intrinsic response modulation in accordance with the communication through coherence hypothesis. Furthermore, the BMI approach may facilitate and strengthen effective corticospinal communication in a therapeutic context, for example, when voluntary hand opening is no longer possible after stroke.
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Affiliation(s)
- Georgios Naros
- Division of Functional and Restorative Neurosurgery, and Tuebingen NeuroCampus, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Tobias Lehnertz
- Division of Functional and Restorative Neurosurgery, and Tuebingen NeuroCampus, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Maria Teresa Leão
- Division of Functional and Restorative Neurosurgery, and Tuebingen NeuroCampus, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Ulf Ziemann
- Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
| | - Alireza Gharabaghi
- Division of Functional and Restorative Neurosurgery, and Tuebingen NeuroCampus, Eberhard Karls University Tuebingen, 72076 Tuebingen, Germany
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Trakolis L, Naros G, Vougioukas V, Tatagiba M. Herpes simplex meningitis after vestibular schwannoma surgery: illustrative case. Journal of Neurosurgery: Case Lessons 2021; 1:CASE20146. [PMID: 36045937 PMCID: PMC9394175 DOI: 10.3171/case20146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 12/13/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND Herpes is the most common cause of viral encephalitis in the young population. Herpes meningitis following brain surgery is very rare, however. Only a few cases are reported in the literature, and only one concerned an infection after vestibular schwannoma surgery. OBSERVATIONS The authors report a case of a 44-year-old patient who developed severe herpes meningitis a few days after removal of a large cystic vestibular schwannoma. LESSONS Herpes simplex virus meningitis following a posterior fossa surgery must be considered when patients develop atypical symptoms a few days after surgery.
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Affiliation(s)
- Leonidas Trakolis
- Department of Neurosurgery, Eberhardt Karls University, Tuebingen, Germany; and
| | - Georgios Naros
- Department of Neurosurgery, Eberhardt Karls University, Tuebingen, Germany; and
| | | | - Marcos Tatagiba
- Department of Neurosurgery, Eberhardt Karls University, Tuebingen, Germany; and
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25
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Machetanz K, Gallotti AL, Leao Tatagiba MT, Liebsch M, Trakolis L, Wang S, Tatagiba M, Gharabaghi A, Naros G. Time-Frequency Representation of Motor Evoked Potentials in Brain Tumor Patients. Front Neurol 2021; 11:633224. [PMID: 33613426 PMCID: PMC7894199 DOI: 10.3389/fneur.2020.633224] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/21/2020] [Indexed: 12/27/2022] Open
Abstract
Background: The integrity of the motor system can be examined by applying navigated transcranial magnetic stimulation (nTMS) to the cortex. The corresponding motor-evoked potentials (MEPs) in the target muscles are mirroring the status of the human motor system, far beyond corticospinal integrity. Commonly used time domain features of MEPs (e.g., peak-to-peak amplitudes and onset latencies) exert a high inter-subject and intra-subject variability. Frequency domain analysis might help to resolve or quantify disease-related MEP changes, e.g., in brain tumor patients. The aim of the present study was to describe the time-frequency representation of MEPs in brain tumor patients, its relation to clinical and imaging findings, and the differences to healthy subject. Methods: This prospective study compared 12 healthy subjects with 12 consecutive brain tumor patients (with and without a paresis) applying nTMS mapping. Resulting MEPs were evaluated in the time series domain (i.e., amplitudes and latencies). After transformation into the frequency domain using a Morlet wavelet approach, event-related spectral perturbation (ERSP), and inter-trial coherence (ITC) were calculated and compared to diffusion tensor imaging (DTI) results. Results: There were no significant differences in the time series characteristics between groups. MEPs were projecting to a frequency band between 30 and 300 Hz with a local maximum around 100 Hz for both healthy subjects and patients. However, there was ERSP reduction for higher frequencies (>100 Hz) in patients in contrast to healthy subjects. This deceleration was mirrored in an increase of the inter-peak MEP latencies. Patients with a paresis showed an additional disturbance in ITC in these frequencies. There was no correlation between the CST integrity (as measured by DTI) and the MEP parameters. Conclusion: Time-frequency analysis may provide additional information above and beyond classical MEP time domain features and the status of the corticospinal system in brain tumor patients. This first evaluation indicates that brain tumors might affect cortical physiology and the responsiveness of the cortex to TMS resulting in a temporal dispersion of the corticospinal transmission.
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Affiliation(s)
- Kathrin Machetanz
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tuebingen, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Alberto L Gallotti
- Department of Neurosurgery and Stereotactic Radiosurgery, Vita-Salute University, Milan, Italy
| | - Maria Teresa Leao Tatagiba
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Marina Liebsch
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Leonidas Trakolis
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Sophie Wang
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Marcos Tatagiba
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Alireza Gharabaghi
- Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
| | - Georgios Naros
- Neurosurgical Clinic, Department of Neurosurgery and Neurotechnology, Eberhard Karls University of Tuebingen, Tuebingen, Germany.,Department of Neurosurgery and Neurotechnology, Institute for Neuromodulation and Neurotechnology, Eberhard Karls University of Tuebingen, Tuebingen, Germany
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26
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Cenzato M, Colistra D, Iacopino G, Raftopoulos C, Sure U, Tatagiba M, Spetzler RF, Konovalov AN, Smolanka A, Smolanka V, Stefini R, Bortolotti C, Ferroli P, Pinna G, Franzini A, Dammann P, Naros G, Boeris D, Mantovani P, Lizio D, Piano M, Fava E. Holmes tremor: a delayed complication after resection of brainstem cavernomas. J Neurosurg 2020:1-11. [PMID: 33307533 DOI: 10.3171/2020.7.jns201352] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this paper, the authors aimed to illustrate how Holmes tremor (HT) can occur as a delayed complication after brainstem cavernoma resection despite strict adherence to the safe entry zones (SEZs). METHODS After operating on 2 patients with brainstem cavernoma at the Great Metropolitan Hospital Niguarda in Milan and noticing a similar pathological pattern postoperatively, the authors asked 10 different neurosurgery centers around the world to identify similar cases, and a total of 20 were gathered from among 1274 cases of brainstem cavernomas. They evaluated the tremor, cavernoma location, surgical approach, and SEZ for every case. For the 2 cases at their center, they also performed electromyographic and accelerometric recordings of the tremor and evaluated the post-operative tractographic representation of the neuronal pathways involved in the tremorigenesis. After gathering data on all 1274 brainstem cavernomas, they performed a statistical analysis to determine if the location of the cavernoma is a potential predicting factor for the onset of HT. RESULTS From the analysis of all 20 cases with HT, it emerged that this highly debilitating tremor can occur as a delayed complication in patients whose postoperative clinical course has been excellent and in whom surgical access has strictly adhered to the SEZs. Three of the patients were subsequently effectively treated with deep brain stimulation (DBS), which resulted in complete or almost complete tremor regression. From the statistical analysis of all 1274 brainstem cavernomas, it was determined that a cavernoma location in the midbrain was significantly associated with the onset of HT (p < 0.0005). CONCLUSIONS Despite strict adherence to SEZs, the use of intraoperative neurophysiological monitoring, and the immediate success of a resective surgery, HT, a severe neurological disorder, can occur as a delayed complication after resection of brainstem cavernomas. A cavernoma location in the midbrain is a significant predictive factor for the onset of HT. Further anatomical and neurophysiological studies will be necessary to find clues to prevent this complication.
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Affiliation(s)
- Marco Cenzato
- 1Neurosurgery, Great Metropolitan Hospital Niguarda, Milan
| | | | - Giorgia Iacopino
- 2Neurosurgery, Department of Human Neurosciences, Sapienza University, Rome, Italy
| | - Christian Raftopoulos
- 3Department of Neurosurgery, Saint-Luc University Clinic, Catholic University of Louvain, Brussels, Belgium
| | - Ulrich Sure
- 4Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Marcos Tatagiba
- 5Department of Neurosurgery, University Hospital Tübingen, Germany
| | | | | | | | | | | | - Carlo Bortolotti
- 10Department of Neurologic Surgery, Bellaria Hospital, Institute of Neurological Sciences of Bologna
| | - Paolo Ferroli
- 11Department of Neurosurgery, Carlo Besta Neurological Institute, Milan
| | | | - Angelo Franzini
- 11Department of Neurosurgery, Carlo Besta Neurological Institute, Milan
| | - Philipp Dammann
- 4Department of Neurosurgery, University Hospital Essen, University of Duisburg-Essen
| | - Georgios Naros
- 5Department of Neurosurgery, University Hospital Tübingen, Germany
| | - Davide Boeris
- 1Neurosurgery, Great Metropolitan Hospital Niguarda, Milan
| | - Paolo Mantovani
- 10Department of Neurologic Surgery, Bellaria Hospital, Institute of Neurological Sciences of Bologna
| | | | - Mariangela Piano
- 14Neuroradiology, Great Metropolitan Hospital Niguarda, Milan; and
| | - Enrica Fava
- 1Neurosurgery, Great Metropolitan Hospital Niguarda, Milan.,15Department of Medical Biotechnologies and Translational Medicine, University of Milan, Italy
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Machetanz K, Leuze F, Mounts K, Trakolis L, Gugel I, Grimm F, Tatagiba M, Naros G. Occurrence and management of postoperative pneumocephalus using the semi-sitting position in vestibular schwannoma surgery. Acta Neurochir (Wien) 2020; 162:2629-2636. [PMID: 32712719 PMCID: PMC7550361 DOI: 10.1007/s00701-020-04504-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/17/2020] [Indexed: 11/25/2022]
Abstract
Background The semi-sitting position in neurosurgical procedures is still under debate due to possible complications such as venous air embolism (VAE) or postoperative pneumocephalus (PP). Studies reporting a high frequency of the latter raise the question about the clinical relevance (i.e., the incidence of tension pneumocephalus) and the efficacy of a treatment by an air replacement procedure. Methods This retrospective study enrolled 540 patients harboring vestibular schwannomas who underwent posterior fossa surgery in a supine (n = 111) or semi-sitting (n = 429) position. The extent of the PP was evaluated by voxel-based volumetry (VBV) and related to clinical predictive factors (i.e., age, gender, position, duration of surgery, and tumor size). Results PP with a mean volume of 32 ± 33 ml (range: 0–179.1 ml) was detected in 517/540 (96%) patients. The semi-sitting position was associated with a significantly higher PP volume than the supine position (40.3 ± 33.0 ml [0–179.1] and 0.8 ± 1.4 [0–10.2], p < 0.001). Tension pneumocephalus was observed in only 14/429 (3.3%) of the semi-sitting cases, while no tension pneumocephalus occurred in the supine position. Positive predictors for PP were higher age, male gender, and longer surgery duration, while large (T4) tumor size was established as a negative predictor. Air exchange via a twist-drill was only necessary in 14 cases with an intracranial air volume > 60 ml. Air replacement procedures did not add any complications or prolong the ICU stay. Conclusion Although pneumocephalus is frequently observed following posterior fossa surgery in semi-sitting position, relevant clinical symptoms (i.e., a tension pneumocephalus) occur in only very few cases. These cases are well-treated by an air evacuation procedure. This study indicates that the risk of postoperative pneumocephalus is not a contraindication for semi-sitting positioning.
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Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
| | - Felix Leuze
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Kristin Mounts
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Leonidas Trakolis
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Isabel Gugel
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Florian Grimm
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Georgios Naros
- Department of Neurosurgery, Eberhardt Karls University, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany.
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Gallotti AL, Machetanz K, Trakolis L, Tatagiba M, Naros G. The involvement of the cortifugal fibers in hearing impairment related to a pontine capillary telangiectasia: a connectome-based analysis: Brainstem connectome analysis in pontine capillary teleangiectasia. Clin Neurol Neurosurg 2020; 199:106241. [PMID: 33053457 DOI: 10.1016/j.clineuro.2020.106241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/13/2020] [Accepted: 09/14/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Alberto L Gallotti
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany; Department of Neurosurgery and Stereotactic Radiosurgery, Vita-Salute University, Milan, Italy
| | - Kathrin Machetanz
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Leonidas Trakolis
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany
| | - Georgios Naros
- Department of Neurosurgery, University of Tuebingen, Tuebingen, Germany.
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Machetanz K, Grimm F, Schuhmann M, Tatagiba M, Gharabaghi A, Naros G. Time Efficiency in Stereotactic Robot-Assisted Surgery: An Appraisal of the Surgical Procedure and Surgeon's Learning Curve. Stereotact Funct Neurosurg 2020; 99:25-33. [PMID: 33017833 DOI: 10.1159/000510107] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 07/11/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Frame-based stereotactic procedures are still the gold standard in neurosurgery. However, there is an increasing interest in robot-assisted technologies. Introducing these increasingly complex tools in the clinical setting raises the question about the time efficiency of the system and the essential learning curve of the surgeon. METHODS This retrospective study enrolled a consecutive series of patients undergoing a robot-assisted procedure after first system installation at one institution. All procedures were performed by the same neurosurgeon to capture the learning curve. The objective read-out were the surgical procedure time (SPT), the skin-to-skin time, and the intraoperative registration time (IRT) after laser surface registration (LSR), bone fiducial registration (BFR), and skin fiducial registration (SFR), as well as the quality of the registration (as measured by the fiducial registration error [FRE]). The time measures were compared to those for a patient group undergoing classic frame-based stereotaxy. RESULTS In the first 7 months, we performed 31 robot-assisted surgeries (26 biopsies, 3 stereotactic electroencephalography [SEEG] implantations, and 2 endoscopic procedures). The SPT was depending on the actual type of surgery (biopsies: 85.0 ± 36.1 min; SEEG: 154.9 ± 75.9 min; endoscopy: 105.5 ± 1.1 min; p = 0.036). For the robot-assisted biopsies, there was a significant reduction in SPT within the evaluation period, reaching the level of frame-based surgeries (58.1 ± 17.9 min; p < 0.001). The IRT was depending on the applied registration method (LSR: 16.7 ± 2.3 min; BFR: 3.5 ± 1.1 min; SFR: 3.5 ± 1.6 min; p < 0.001). In contrast to BFR and SFR, there was a significant reduction in LSR time during that period (p = 0.038). The FRE differed between the applied registration methods (LSR: 0.60 ± 0.17 mm; BFR: 0.42 ± 0.15 mm; SFR: 2.17 ± 0.78 mm; p < 0.001). There was a significant improvement in LSR quality during the evaluation period (p = 0.035). CONCLUSION Introducing stereotactic, robot-assisted surgery in an established clinical setting initially necessitates a prolonged intraoperative preparation time. However, there is a steep learning curve during the first cases, reaching the time level of classic frame-based stereotaxy. Thus, a stereotactic robot can be integrated into daily routine within a decent period of time, thereby expanding the neurosurgeons' armamentarium, especially for procedures with multiple trajectories.
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Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery, Eberhardt Karls University of Tübingen, Tübingen, Germany.,Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Florian Grimm
- Department of Neurosurgery, Eberhardt Karls University of Tübingen, Tübingen, Germany.,Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Martin Schuhmann
- Department of Neurosurgery, Eberhardt Karls University of Tübingen, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, Eberhardt Karls University of Tübingen, Tübingen, Germany
| | - Alireza Gharabaghi
- Department of Neurosurgery, Eberhardt Karls University of Tübingen, Tübingen, Germany.,Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Georgios Naros
- Department of Neurosurgery, Eberhardt Karls University of Tübingen, Tübingen, Germany, .,Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany,
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Scherer M, Milosevic L, Guggenberger R, Maus V, Naros G, Grimm F, Bucurenciu I, Steinhoff BJ, Weber YG, Lerche H, Weiss D, Rona S, Gharabaghi A. Desynchronization of temporal lobe theta-band activity during effective anterior thalamus deep brain stimulation in epilepsy. Neuroimage 2020; 218:116967. [PMID: 32445879 DOI: 10.1016/j.neuroimage.2020.116967] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 05/04/2020] [Accepted: 05/13/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Bilateral cyclic high frequency deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) reduces the seizure count in a subset of patients with epilepsy. Detecting stimulation-induced alterations of pathological brain networks may help to unravel the underlying physiological mechanisms related to effective stimulation delivery and optimize target engagement. METHODS We acquired 64-channel electroencephalography during ten ANT-DBS cycles (145 Hz, 90 μs, 3-5 V) of 1-min ON followed by 5-min OFF stimulation to detect changes in cortical activity related to seizure reduction. The study included 14 subjects (three responders, four non-responders, and seven healthy controls). Mixed-model ANOVA tests were used to compare differences in cortical activity between subgroups both ON and OFF stimulation, while investigating frequency-specific effects for the seizure onset zones. RESULTS ANT-DBS had a widespread desynchronization effect on cortical theta and alpha band activity in responders, but not in non-responders. Time domain analysis showed that the stimulation induced reduction in theta-band activity was temporally linked to the stimulation period. Moreover, stimulation induced theta-band desynchronization in the temporal lobe channels correlated significantly with the therapeutic response. Responders to ANT-DBS and healthy-controls had an overall lower level of theta-band activity compared to non-responders. CONCLUSION This study demonstrated that temporal lobe channel theta-band desynchronization may be a predictive physiological hallmark of therapeutic response to ANT-DBS and may be used to improve the functional precision of this intervention by verifying implantation sites, calibrating stimulation contacts, and possibly identifying treatment responders prior to implantation.
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Affiliation(s)
- Maximillian Scherer
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, And Tübingen NeuroCampus, University of Tübingen, 72076, Tübingen, Germany
| | - Luka Milosevic
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, And Tübingen NeuroCampus, University of Tübingen, 72076, Tübingen, Germany
| | - Robert Guggenberger
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, And Tübingen NeuroCampus, University of Tübingen, 72076, Tübingen, Germany
| | - Volker Maus
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, And Tübingen NeuroCampus, University of Tübingen, 72076, Tübingen, Germany
| | - Georgios Naros
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, And Tübingen NeuroCampus, University of Tübingen, 72076, Tübingen, Germany
| | - Florian Grimm
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, And Tübingen NeuroCampus, University of Tübingen, 72076, Tübingen, Germany
| | | | | | - Yvonne G Weber
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany; Epilepsy Unit, Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Holger Lerche
- Department of Neurology and Epileptology, Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
| | - Daniel Weiss
- Department for Neurodegenerative Diseases, Hertie Institute for Clinical Brain Research, And German Centre of Neurodegenerative Diseases (DZNE), University Tübingen, Tübingen, Germany
| | - Sabine Rona
- Epilepsy Unit, Department of Neurosurgery, University of Tübingen, Tübingen, Germany
| | - Alireza Gharabaghi
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, And Tübingen NeuroCampus, University of Tübingen, 72076, Tübingen, Germany.
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Milosevic L, Scherer M, Cebi I, Guggenberger R, Machetanz K, Naros G, Weiss D, Gharabaghi A. Online Mapping With the Deep Brain Stimulation Lead: A Novel Targeting Tool in Parkinson's Disease. Mov Disord 2020; 35:1574-1586. [PMID: 32424887 DOI: 10.1002/mds.28093] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 04/16/2020] [Accepted: 04/17/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Beta-frequency oscillations (13-30 Hz) are a subthalamic hallmark in patients with Parkinson's disease, and there is increased interest in their utility as an intraoperative marker. OBJECTIVES The objectives of this study were to assess whether beta activity measured directly from macrocontacts of deep brain stimulation leads could be used (a) as an intraoperative electrophysiological approach for guiding lead placements and (b) for physiologically informed stimulation delivery. METHODS Every millimeter along the surgical trajectory, local field-potential data were collected from each macrocontact, and power spectral densities were calculated and visualized (n = 39 patients). This was done for online intraoperative functional mapping and post hoc statistical analyses using 2 methods: generating distributions of spectral activity along surgical trajectories and direct delineation (presence versus lack) of beta peaks. In a subset of patients, this approach was corroborated by microelectrode recordings. Furthermore, the match rate between beta peaks at the final target position and the clinically determined best stimulation site were assessed. RESULTS Subthalamic recording sites were delineated by both methods of reconstructing functional topographies of spectral activity along surgical trajectories at the group level (P < 0.0001). Beta peaks were detected when any portion of the 1.5 mm macrocontact was within the microelectrode-defined subthalamic border. The highest beta peak at the final implantation site corresponded to the site of active stimulation in 73.3% of hemispheres (P < 0.0001). In 93.3% of hemispheres, active stimulation corresponded to the first-highest or second-highest beta peak. CONCLUSIONS Online measures of beta activity with the deep brain stimulation macroelectrode can be used to inform surgical lead placement and contribute to optimization of stimulation programming procedures. © 2020 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Luka Milosevic
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, and Tübingen NeuroCampus, University of Tübingen, Tübingen, Germany
| | - Maximilian Scherer
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, and Tübingen NeuroCampus, University of Tübingen, Tübingen, Germany
| | - Idil Cebi
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, and Tübingen NeuroCampus, University of Tübingen, Tübingen, Germany.,Centre for Neurology, Department for Neurodegenerative Diseases, and Hertie Institute for Clinical Brain Research, University Tübingen, Tübingen, Germany
| | - Robert Guggenberger
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, and Tübingen NeuroCampus, University of Tübingen, Tübingen, Germany
| | - Kathrin Machetanz
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, and Tübingen NeuroCampus, University of Tübingen, Tübingen, Germany
| | - Georgios Naros
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, and Tübingen NeuroCampus, University of Tübingen, Tübingen, Germany
| | - Daniel Weiss
- Centre for Neurology, Department for Neurodegenerative Diseases, and Hertie Institute for Clinical Brain Research, University Tübingen, Tübingen, Germany
| | - Alireza Gharabaghi
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, and Tübingen NeuroCampus, University of Tübingen, Tübingen, Germany
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Leão MT, Naros G, Gharabaghi A. Detecting poststroke cortical motor maps with biphasic single- and monophasic paired-pulse TMS. Brain Stimul 2020; 13:1102-1104. [PMID: 32418913 DOI: 10.1016/j.brs.2020.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/05/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Residual corticospinal connections are the precondition for poststroke motor recovery and necessary for targeted interventions. In severely affected patients, standard transcranial magnetic stimulation (TMS) may lead to false negative findings. OBJECTIVE Detecting the cortical representation of paralyzed forearm muscles by applying different stimulation techniques and maps beyond the hotspot. METHODS In seventeen chronic stroke patients with severe motor deficits, navigated biphasic single (SP) and monophasic paired-pulse (PP) TMS was applied at 100% stimulator output to an extended cortical area in the ipsilesional hemisphere, while recording surface EMG of the extensor carpi radialis muscle. RESULTS In eleven patients, residual connectivity to the paralyzed forearm was detected with either mapping technique (five SP and PP, four PP only, two SP only). In five patients, connections originated from non-primary motor areas. CONCLUSION These results could be instrumental for identifying candidates and stimulation targets for novel neuromodulation interventions in the context of neurorehabilitation.
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Affiliation(s)
- Maria Teresa Leão
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, And Tuebingen NeuroCampus, University of Tuebingen, Germany
| | - Georgios Naros
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, And Tuebingen NeuroCampus, University of Tuebingen, Germany
| | - Alireza Gharabaghi
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, And Tuebingen NeuroCampus, University of Tuebingen, Germany.
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Dias Leao MT, Wiesinger L, Ziemann U, Tatagiba M, Naros G. Rapid motor cortical reorganization following subacute spinal cord dysfunction. Brain Stimul 2020; 13:783-785. [PMID: 32289708 DOI: 10.1016/j.brs.2020.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 01/20/2020] [Accepted: 01/21/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE Damage to the spinal cord is known to be associated with a posterior shift of the motor cortical upper limb representation, i.e. towards the somatosensory cortex. Due to missing pre-traumatic data, knowledge resulted from comparing findings between patients and healthy subjects. Here, we present a case of transient spinal cord injury resulting in a left-sided hemiparesis for 4 weeks. By chance, this patient had a pre-lesional navigated transcranial magnetic stimulation (nTMS) motor mapping 2 years before. Hence, nTMS mapping was repeated during the acute (after 1 day), sub-acute (after 10 days) and chronic (after 2 years) phase to trace the cortical reorganization following this incident. METHODS Acute clinical work-up included magnetic resonance imaging and navigated transcranial magnetic stimulation (nTMS). Motor mapping was performed with 110% of the abductor pollicis brevis muscle (APB) resting motor threshold (rMT). Amplitudes and latencies of the motor-evoked potential (MEPs) were recorded and analyzed. In addition, motor function was evaluated by the Medical Research Council (MRC) scale, a standard Purdue Pegboard test and by a reaction time (RT) task. RESULTS MRI revealed no aberrant findings. nTMS mapping, however, showed a posterior shift of the APB representation from the anatomical hand knob towards the somatosensory cortex in the acute in comparison to the pre-lesional phase. Concomitantly, there was an increase of rMT (6%). Within 10 days, there was an incomplete reversal of the posterior shift in parallel with improvement of the clinical motor function. Long-term follow-up revealed a complete restitution of nTMS cortical mapping and motor function. CONCLUSION The present case report thoroughly documents a rapid cortical reorganization within a few days after a transient spinal shock. Our data adds further evidence to the literature suggesting a posterior shift of motor cortical representation following spinal cord injury. For the first time, 52 cortical reorganization was shown idiosyncratically in a single patient arising from the fortuitous fact of having a pre - lesional nTMS map.
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Affiliation(s)
- M T Dias Leao
- Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany.
| | - L Wiesinger
- Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - U Ziemann
- Department of Neurology & Stroke, And Hertie-Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - M Tatagiba
- Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - G Naros
- Department of Neurosurgery, Eberhard Karls University of Tübingen, Tübingen, Germany
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Machetanz K, Trakolis L, Leão MT, Liebsch M, Mounts K, Bender B, Ernemann U, Gharabaghi A, Tatagiba M, Naros G. Neurophysiology-Driven Parameter Selection in nTMS-Based DTI Tractography: A Multidimensional Mathematical Model. Front Neurosci 2019; 13:1373. [PMID: 31920523 PMCID: PMC6930230 DOI: 10.3389/fnins.2019.01373] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/04/2019] [Indexed: 01/08/2023] Open
Abstract
Object: There is an increasing interest in preoperative diffusion tensor imaging-based fiber tracking (DTI-FT) to preserve function during surgeries in motor eloquent brain regions. However, DTI tractography is challenged by inherent presumptions during particular tracking steps [e.g., deterministic vs. probabilistic DTI, fractional anisotropy (FA) and fiber length (FL) thresholding] and the missing "ground truth" information. In the present study, we intended to establish an objective, neurophysiology-driven approach for parameter selection during DTI-FT of the corticospinal tract integrating both imaging and neurophysiological information. Methods: In ten patients with lesions in eloquent motor areas, preoperative navigated transcranial magnetic stimulation (nTMS) was performed, followed by individual deterministic DTI-FT from a grid of cortical seed points. We investigated over 300 combinations of FA and FL thresholds and applied subsequently a multidimensional mathematical modeling of this empirical data. Optimal DTI parameters were determined by the relationship between DTI-FT (i.e., number of fibers, NoF) and nTMS (i.e., amplitudes of motor-evoked potentials) results. Finally, neurophysiological DTI parameters and the resulting tractography were compared to the current standard approaches of deterministic DTI fiber tracking with a 75% and 50% FA and a FL threshold of 110 mm as well as with intraoperative direct cortical and subcortical stimulation. Results: There was a good goodness-of-fit for the mathematical model (r 2 = 0.68 ± 0 13; range: 0.59-0.97; n = 8) except of two cases. Neurophysiology-driven parameter selection showed a high correlation between DTI-FT and nTMS results (r = 0.73 ± 0.16; range: 0.38-0.93). In comparison to the standard approach, the mathematically calculated thresholds resulted in a higher NoF in 75% of patients. In 50% of patients this approach helped to clarify the exact tract location or to detect additional functional tracts, which were not identified by the standard approach. This was confirmed by direct cortical or subcortical stimulation. Conclusion: The present study evaluates a novel user-independent method to extract objective DTI-FT parameters that were completely based on neurophysiological data. The findings suggest that this method may improve the specificity and sensitivity of DTI-FT and thereby overcome the disadvantages of current approaches.
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Affiliation(s)
- Kathrin Machetanz
- Department of Neurosurgery, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Leonidas Trakolis
- Department of Neurosurgery, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Maria Teresa Leão
- Department of Neurosurgery, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Marina Liebsch
- Department of Neurosurgery, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Kristin Mounts
- Department of Neurosurgery, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Benjamin Bender
- Department of Neuroradiology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Ulrike Ernemann
- Department of Neuroradiology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Alireza Gharabaghi
- Department of Neurosurgery, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Georgios Naros
- Department of Neurosurgery, Eberhard Karls Universität Tübingen, Tübingen, Germany
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Machetanz K, Naros G, Grimm F, Weiß D, Gharabaghi A. FV 53 DTI-based analysis of cortical projections between the STN, SN and different motor cortical areas in PD patients. Clin Neurophysiol 2019. [DOI: 10.1016/j.clinph.2019.04.656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Naros G, Grimm F, Weiß D, Gharabaghi A. FV 52 Subtype-specific communication between subdivision of the STN and different motor cortical areas in tremor and non-tremor PD patients. Clin Neurophysiol 2019. [DOI: 10.1016/j.clinph.2019.04.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Scherer M, Milosevic L, Guggenberger R, Volker M, Naros G, Grimm F, Bucurenciu I, Steinhoff B, Weber Y, Lerche H, Weiss D, Rona S, Gharabaghi A. FV 25 Cortical α-activity identifies responders to anterior thalamic deep brain stimulation for epilepsy. Clin Neurophysiol 2019. [DOI: 10.1016/j.clinph.2019.04.634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Naros G, Grimm F, Weiß D, Gharabaghi A. P21 Evaluation of thalamo-cortical networks during Deep Brain Stimulation. Clin Neurophysiol 2019. [DOI: 10.1016/j.clinph.2019.04.675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Grimm F, Maurus R, Beschorner R, Naros G, Stanojevic M, Gugel I, Giese S, Bier G, Bender B, Honegger J. Ki-67 labeling index and expression of p53 are non-predictive for invasiveness and tumor size in functional and nonfunctional pituitary adenomas. Acta Neurochir (Wien) 2019; 161:1149-1156. [PMID: 31037500 DOI: 10.1007/s00701-019-03879-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/20/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND It is still controversial whether an increased proliferation index is correlated with the tumor invasiveness of pituitary adenomas. A homogeneous large monocentric series of pituitary adenomas was retrospectively analyzed. The correlation between the proliferation indices (Ki-67 and p53 expression levels) and invasiveness and size of pituitary adenomas was investigated in primary operated and recurrent adenomas. METHOD Four hundred thirty-nine patients after resection of pituitary adenomas were retrospectively included (43 recurrent tumors, 196 null cell adenomas, 86 somatotroph adenomas, 55 corticotroph adenomas, 55 prolactinomas, 4 thyreotroph adenomas). The maximum tumor diameter and tumor invasiveness in Knosp grading were assessed and Ki-67 and p53 immunostaining was performed. The role of invasiveness was evaluated using a cumulative odds ordinal logistic regression. For calculating the effect of tumor size, a one-way analysis of variance (ANOVA) was conducted. RESULTS Overall and in the subgroups, no significant correlation between proliferation indices and mean tumor diameter was found. No significant predictive expression value of Ki-67 and p53 on tumor invasiveness and in recurrent tumors could be demonstrated. There was a tendency that Ki-67 LI and p53 LI are higher in recurrent corticotroph adenomas and lactotroph adenomas but values did not reach the significant level. CONCLUSION Invasive character of pituitary adenomas is neither correlated with increased Ki-67 LI nor with increased p53 expression. Proliferation parameters are independent from adenoma size at initial presentation. The partly elevated expression of Ki-67 in recurrent tumors underlines the clinical importance of the marker.
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Affiliation(s)
- Florian Grimm
- Department for Neurosurgery, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany.
| | - Roland Maurus
- Department for Neurosurgery, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Rudi Beschorner
- Institute of Pathology and Neuropathology, Department of Neuropathology, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Georgios Naros
- Department for Neurosurgery, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Milan Stanojevic
- Department for Neurosurgery, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Isabel Gugel
- Department for Neurosurgery, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Sabrina Giese
- Department for Neurosurgery, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Georg Bier
- Department for Neuroradiology, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Benjamin Bender
- Department for Neuroradiology, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
| | - Jürgen Honegger
- Department for Neurosurgery, University Hospital Tübingen, Hoppe-Seyler-Strasse 3, 72076, Tübingen, Germany
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Naros G, Grimm F, Weiss D, Gharabaghi A. Directional communication during movement execution interferes with tremor in Parkinson's disease. Mov Disord 2019; 33:251-261. [PMID: 29427344 DOI: 10.1002/mds.27221] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 08/15/2017] [Accepted: 09/08/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Both the cerebello-thalamo-cortical circuit and the basal ganglia/cortical motor loop have been postulated to be generators of tremor in PD. The recent suggestion that the basal ganglia trigger tremor episodes and the cerebello-thalamo-cortical circuitry modulates tremor amplitude combines both competing hypotheses. However, the role of the STN in tremor generation and the impact of proprioceptive feedback on tremor suppression during voluntary movements have not been considered in this model yet. OBJECTIVES The objective of this study was to evaluate the role of the STN and proprioceptive feedback in PD tremor generation during movement execution. METHODS Local-field potentials of the STN as well as electromyographical and electroencephalographical rhythms were recorded in tremor-dominant and nontremor PD patients while performing voluntary movements of the contralateral hand during DBS surgery. Effective connectivity between these electrophysiological signals were analyzed and compared to electromyographical tremor activity. RESULTS There was an intensified information flow between the STN and the muscle in the tremor frequencies (5-8 Hz) for tremor-dominant, in comparison to nontremor, patients. In both subtypes, active movement was associated with an increase of afferent interaction between the muscle and the cortex in the β- and γ-frequencies. The γ-frequency (30-40 Hz) of this communication between muscle and cortex correlated inversely with electromyographical tremor activity. CONCLUSIONS Our results indicate an involvement of the STN in propagation of tremor-related activity to the muscle. Furthermore, we provide evidence that increased proprioceptive information flow during voluntary movement interferes with central tremor generation. © 2018 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Georgios Naros
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, and Centre for Integrative Neuroscience, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Florian Grimm
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, and Centre for Integrative Neuroscience, Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Daniel Weiss
- Department for Neurodegenerative Diseases and Hertie Institute for Clinical Brain Research, and German Centre of Neurodegenerative Diseases (DZNE), Eberhard Karls University Tuebingen, Tuebingen, Germany
| | - Alireza Gharabaghi
- Division of Functional and Restorative Neurosurgery, Department of Neurosurgery, and Centre for Integrative Neuroscience, Eberhard Karls University Tuebingen, Tuebingen, Germany
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Belardinelli P, Azodi-Avval R, Ortiz E, Naros G, Grimm F, Weiss D, Gharabaghi A. Intraoperative localization of spatially and spectrally distinct resting-state networks in Parkinson's disease. J Neurosurg 2019; 132:1234-1242. [PMID: 30835693 DOI: 10.3171/2018.11.jns181684] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 11/21/2018] [Indexed: 11/06/2022]
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective treatment for symptomatic Parkinson's disease (PD); the clinical benefit may not only mirror modulation of local STN activity but also reflect consecutive network effects on cortical oscillatory activity. Moreover, STN-DBS selectively suppresses spatially and spectrally distinct patterns of synchronous oscillatory activity within cortical-subcortical loops. These STN-cortical circuits have been described in PD patients using magnetoencephalography after surgery. This network information, however, is currently not available during surgery to inform the implantation strategy.The authors recorded spontaneous brain activity in 3 awake patients with PD (mean age 67 ± 14 years; mean disease duration 13 ± 7 years) during implantation of DBS electrodes into the STN after overnight withdrawal of dopaminergic medication. Intraoperative propofol was discontinued at least 30 minutes prior to the electrophysiological recordings. The authors used a novel approach for performing simultaneous recordings of STN local field potentials (LFPs) and multichannel electroencephalography (EEG) at rest. Coherent oscillations between LFP and EEG sensors were computed, and subsequent dynamic imaging of coherent sources was performed.The authors identified coherent activity in the upper beta range (21-35 Hz) between the STN and the ipsilateral mesial (pre)motor area. Coherence in the theta range (4-6 Hz) was detected in the ipsilateral prefrontal area.These findings demonstrate the feasibility of detecting frequency-specific and spatially distinct synchronization between the STN and cortex during DBS surgery. Mapping the STN with this technique may disentangle different functional loops relevant for refined targeting during DBS implantation.
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Affiliation(s)
- Paolo Belardinelli
- 1Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience.,2Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research; and
| | - Ramin Azodi-Avval
- 1Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience
| | - Erick Ortiz
- 1Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience
| | - Georgios Naros
- 1Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience
| | - Florian Grimm
- 1Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience
| | - Daniel Weiss
- 3Department for Neurodegenerative Diseases, and Hertie Institute for Clinical Brain Research, and German Centre of Neurodegenerative Diseases (DZNE), Eberhard Karls University Tübingen, Germany
| | - Alireza Gharabaghi
- 1Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience
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Guggenberger R, Kraus D, Naros G, Leão MT, Ziemann U, Gharabaghi A. Extended enhancement of corticospinal connectivity with concurrent cortical and peripheral stimulation controlled by sensorimotor desynchronization. Brain Stimul 2018; 11:1331-1335. [DOI: 10.1016/j.brs.2018.08.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/17/2018] [Accepted: 08/19/2018] [Indexed: 12/27/2022] Open
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Naros A, Weise H, Tilsen F, Hoefert S, Naros G, Krimmel M, Reinert S, Polligkeit J. Three-dimensional accuracy of mandibular reconstruction by patient-specific pre-bent reconstruction plates using an "in-house" 3D-printer. J Craniomaxillofac Surg 2018; 46:1645-1651. [PMID: 29983306 DOI: 10.1016/j.jcms.2018.05.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 04/13/2018] [Accepted: 05/25/2018] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The purpose of this study was to compare the three-dimensional accuracy of mandibular reconstruction following mandible continuity resection in patients treated with patient-specific, pre-bent reconstruction plates, using an 'in-house' 3D printer, with that in patients treated with conventional, intraoperatively bent plates. PATIENTS AND METHODS We retrospectively analyzed 42 alloplastic mandibular reconstructions following continuity resection. 21 patients received patient-specific, pre-bent reconstruction plates using an in-house 3D printer. The control group consisted of 21 patients provided with intraoperatively bent reconstruction plates. Distances between corresponding anatomical landmarks on the mandibular angle and condyle (A-A', BB', CC', BC'), as well as the intercondylar angle (ICA), were measured and compared on the pre- and postoperative CT scans. RESULTS Multivariate analysis of variance (MANOVA) showed significant multivariate main effect of group (F(5, 36) = 5.58, p = 0.001; Wilks lambda 0.564; partial η2 = 0.436), indicating more accurate postoperative results for the pre-bent group. Post-hoc comparison revealed significantly larger postoperative deviation in the distances between the mandibular angle and the intercondylar angle (ICA) for the intraoperatively bent group in comparison with the pre-bent group. However, there was no significant effect on the distance between the condyles. CONCLUSIONS Mandibular reconstructions employing patient-specific, pre-bent reconstruction plates made using an in-house 3D printer show significantly better three-dimensional accuracy compared with intraoperatively bent plates. The described method prevents rotational error of the mandibular angle and improves restoration of the physiological intercondylar angle in mandible reconstruction after continuity resection.
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Affiliation(s)
- Andreas Naros
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Siegmar Reinert, M.D., D.M.D., Ph.D.), University Hospital Tuebingen, Osianderstrasse 2-8, 72076, Tuebingen, Germany.
| | - Hannes Weise
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Siegmar Reinert, M.D., D.M.D., Ph.D.), University Hospital Tuebingen, Osianderstrasse 2-8, 72076, Tuebingen, Germany
| | - Felix Tilsen
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Siegmar Reinert, M.D., D.M.D., Ph.D.), University Hospital Tuebingen, Osianderstrasse 2-8, 72076, Tuebingen, Germany
| | - Sebastian Hoefert
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Siegmar Reinert, M.D., D.M.D., Ph.D.), University Hospital Tuebingen, Osianderstrasse 2-8, 72076, Tuebingen, Germany
| | - Georgios Naros
- Department of Neurosurgery, University Hospital Tuebingen, Hoppe-Seyler-Straße 3, 72076, Tuebingen, Germany
| | - Michael Krimmel
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Siegmar Reinert, M.D., D.M.D., Ph.D.), University Hospital Tuebingen, Osianderstrasse 2-8, 72076, Tuebingen, Germany
| | - Siegmar Reinert
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Siegmar Reinert, M.D., D.M.D., Ph.D.), University Hospital Tuebingen, Osianderstrasse 2-8, 72076, Tuebingen, Germany
| | - Joachim Polligkeit
- Department of Oral and Maxillofacial Surgery (Head: Prof. Dr. Dr. Siegmar Reinert, M.D., D.M.D., Ph.D.), University Hospital Tuebingen, Osianderstrasse 2-8, 72076, Tuebingen, Germany
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Trakolis L, Ebner FH, Machetanz K, Sandritter J, Tatagiba M, Naros G. Postoperative Tinnitus After Vestibular Schwannoma Surgery Depends on Preoperative Tinnitus and Both Pre- and Postoperative Hearing Function. Front Neurol 2018; 9:136. [PMID: 29593635 PMCID: PMC5857542 DOI: 10.3389/fneur.2018.00136] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 02/26/2018] [Indexed: 11/13/2022] Open
Abstract
Objective Tinnitus is one of the most common symptoms before and/or after the surgical removal of a vestibular schwannoma (VS) affecting almost half of the patients. Although there is increasing evidence for the association of hearing impairment and VS-associated tinnitus, the effect of hearing deterioration due to surgery and its relation to the postoperative tinnitus (postTN) is poorly investigated. This knowledge, however, might (i) enlighten the pathophysiology of VS-associated tinnitus (i.e., peripheral or central origin) and (ii) improve preoperative patient counseling. The aim of this study was to understand the predisposition factors for a postTN in relation to hearing outcome after surgery. Methods This retrospective study analyzed the presence of tinnitus in 208 patients with unilateral VS before and after surgical removal. A binomial logistic regression was performed to ascertain the effect of pre- and postoperative hearing as well as age, gender, tumor side, and size, and intraoperative cochlear nerve resection (CNR) on the likelihood of postoperative VS-associated tinnitus. Results Preoperative tinnitus was the strongest predictor of postTN. In addition, deterioration of functional hearing was increasing, while functional deafferentation (i.e., postoperative hearing loss) of non-functional hearing was reducing the risk of postTN. At the same time, patients with no preoperative tinnitus but complete hearing loss had the lowest risk to suffer from postTN. Patient age, gender, tumor side, and size as well as CNR played a subordinate role. Conclusion While the presence of preoperative tinnitus was the strongest predictor of postTN, there is a distinct relationship between hearing outcome and postTN depending on the preoperative situation. Functional or anatomical deafferentation due to surgical tumor removal does not prevent postTN per se.
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Affiliation(s)
- Leonidas Trakolis
- Department of Neurosurgery, Eberhardt Karls University, Tuebingen, Germany
| | - Florian H Ebner
- Department of Neurosurgery, Eberhardt Karls University, Tuebingen, Germany
| | - Kathrin Machetanz
- Department of Neurosurgery, Eberhardt Karls University, Tuebingen, Germany
| | - Joey Sandritter
- Department of Neurosurgery, Eberhardt Karls University, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, Eberhardt Karls University, Tuebingen, Germany
| | - Georgios Naros
- Department of Neurosurgery, Eberhardt Karls University, Tuebingen, Germany
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Naros G, Sandritter J, Liebsch M, Ofori A, Rizk AR, Del Moro G, Ebner F, Tatagiba M. Predictors of Preoperative Tinnitus in Unilateral Sporadic Vestibular Schwannoma. Front Neurol 2017; 8:378. [PMID: 28824535 PMCID: PMC5541055 DOI: 10.3389/fneur.2017.00378] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 07/17/2017] [Indexed: 12/12/2022] Open
Abstract
Objective Nearly two-thirds of patients with vestibular schwannoma (VS) are reporting a significantly impaired quality of life due to tinnitus. VS-associated tinnitus is attributed to an anatomical and physiological damage of the hearing nerve by displacing growth of the tumor. In contrast, the current pathophysiological concept of non-VS tinnitus hypothesizes a maladaptive neuroplasticity of the central nervous system to a (hidden) hearing impairment resulting in a subjective misperception. However, it is unclear whether this concept fits to VS-associated tinnitus. This study aims to determine the clinical predictors of VS-associated tinnitus to ascertain the compatibility of both pathophysiological concepts. Methods This retrospective study includes a group of 478 neurosurgical patients with unilateral sporadic VS evaluated preoperatively regarding the occurrence of ipsilateral tinnitus depending on different clinical factors, i.e., age, gender, tumor side, tumor size (T1–T4 according to the Hannover classification), and hearing impairment (Gardner–Robertson classification, GR1–5), using a binary logistic regression. Results 61.8% of patients complain about a preoperative tinnitus. The binary logistic regression analysis identified male gender [OR 1.90 (1.25–2.75); p = 0.002] and hearing impairment GR3 [OR 1.90 (1.08–3.35); p = 0.026] and GR4 [OR 8.21 (2.29–29.50); p = 0.001] as positive predictors. In contrast, patients with large T4 tumors [OR 0.33 (0.13–0.86); p = 0.024] and complete hearing loss GR5 [OR 0.36 (0.15–0.84); p = 0.017] were less likely to develop a tinnitus. Yet, 60% of the patients with good clinical hearing (GR1) and 25% of patients with complete hearing loss (GR5) suffered from tinnitus. Conclusion These data are good accordance with literature about non-VS tinnitus indicating hearing impairment as main risk factor. In contrast, complete hearing loss appears a negative predictor for tinnitus. For the first time, these findings indicate a non-linear relationship between hearing impairment and tinnitus in unilateral sporadic VS. Our results suggest a similar pathophysiology in VS-associated and non-VS tinnitus.
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Affiliation(s)
- Georgios Naros
- Department of Neurosurgery, Eberhard Karls University, Tuebingen, Germany
| | - Joey Sandritter
- Department of Neurosurgery, Eberhard Karls University, Tuebingen, Germany
| | - Marina Liebsch
- Department of Neurosurgery, Eberhard Karls University, Tuebingen, Germany
| | - Alex Ofori
- Department of Neurosurgery, Eberhard Karls University, Tuebingen, Germany
| | - Ahmed R Rizk
- Department of Neurosurgery, Eberhard Karls University, Tuebingen, Germany
| | - Giulia Del Moro
- Department of Neurosurgery, Eberhard Karls University, Tuebingen, Germany.,Department of Neurosurgery, University of Padova, Padova, Italy
| | - Florian Ebner
- Department of Neurosurgery, Eberhard Karls University, Tuebingen, Germany
| | - Marcos Tatagiba
- Department of Neurosurgery, Eberhard Karls University, Tuebingen, Germany
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Naros G, Gharabaghi A. Physiological and behavioral effects of β-tACS on brain self-regulation in chronic stroke. Brain Stimul 2017; 10:251-259. [DOI: 10.1016/j.brs.2016.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/04/2016] [Accepted: 11/07/2016] [Indexed: 12/21/2022] Open
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Grimm F, Naros G, Gharabaghi A. Closed-Loop Task Difficulty Adaptation during Virtual Reality Reach-to-Grasp Training Assisted with an Exoskeleton for Stroke Rehabilitation. Front Neurosci 2016; 10:518. [PMID: 27895550 PMCID: PMC5108796 DOI: 10.3389/fnins.2016.00518] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2015] [Accepted: 10/26/2016] [Indexed: 11/23/2022] Open
Abstract
Stroke patients with severe motor deficits of the upper extremity may practice rehabilitation exercises with the assistance of a multi-joint exoskeleton. Although this technology enables intensive task-oriented training, it may also lead to slacking when the assistance is too supportive. Preserving the engagement of the patients while providing “assistance-as-needed” during the exercises, therefore remains an ongoing challenge. We applied a commercially available seven degree-of-freedom arm exoskeleton to provide passive gravity compensation during task-oriented training in a virtual environment. During this 4-week pilot study, five severely affected chronic stroke patients performed reach-to-grasp exercises resembling activities of daily living. The subjects received virtual reality feedback from their three-dimensional movements. The level of difficulty for the exercise was adjusted by a performance-dependent real-time adaptation algorithm. The goal of this algorithm was the automated improvement of the range of motion. In the course of 20 training and feedback sessions, this unsupervised adaptive training concept led to a progressive increase of the virtual training space (p < 0.001) in accordance with the subjects' abilities. This learning curve was paralleled by a concurrent improvement of real world kinematic parameters, i.e., range of motion (p = 0.008), accuracy of movement (p = 0.01), and movement velocity (p < 0.001). Notably, these kinematic gains were paralleled by motor improvements such as increased elbow movement (p = 0.001), grip force (p < 0.001), and upper extremity Fugl-Meyer-Assessment score from 14.3 ± 5 to 16.9 ± 6.1 (p = 0.026). Combining gravity-compensating assistance with adaptive closed-loop feedback in virtual reality provides customized rehabilitation environments for severely affected stroke patients. This approach may facilitate motor learning by progressively challenging the subject in accordance with the individual capacity for functional restoration. It might be necessary to apply concurrent restorative interventions to translate these improvements into relevant functional gains of severely motor impaired patients in activities of daily living.
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Affiliation(s)
- Florian Grimm
- Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience, Eberhard Karls University of Tuebingen Tuebingen, Germany
| | - Georgios Naros
- Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience, Eberhard Karls University of Tuebingen Tuebingen, Germany
| | - Alireza Gharabaghi
- Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience, Eberhard Karls University of Tuebingen Tuebingen, Germany
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Naros G, Moro G, Leao T, Sandritter J, Rizk A, Liebsch M, Ebner F, Tatagiba M. Electrophysiological Evidence for Central Neuroplasticity of the Contralesional Ear in Patients with Unilateral Vestibular Schwannoma. Skull Base Surg 2016. [DOI: 10.1055/s-0036-1592485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Grimm F, Walter A, Spüler M, Naros G, Rosenstiel W, Gharabaghi A. Hybrid Neuroprosthesis for the Upper Limb: Combining Brain-Controlled Neuromuscular Stimulation with a Multi-Joint Arm Exoskeleton. Front Neurosci 2016; 10:367. [PMID: 27555805 PMCID: PMC4977295 DOI: 10.3389/fnins.2016.00367] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 07/25/2016] [Indexed: 11/13/2022] Open
Abstract
Brain-machine interface-controlled (BMI) neurofeedback training aims to modulate cortical physiology and is applied during neurorehabilitation to increase the responsiveness of the brain to subsequent physiotherapy. In a parallel line of research, robotic exoskeletons are used in goal-oriented rehabilitation exercises for patients with severe motor impairment to extend their range of motion (ROM) and the intensity of training. Furthermore, neuromuscular electrical stimulation (NMES) is applied in neurologically impaired patients to restore muscle strength by closing the sensorimotor loop. In this proof-of-principle study, we explored an integrated approach for providing assistance as needed to amplify the task-related ROM and the movement-related brain modulation during rehabilitation exercises of severely impaired patients. For this purpose, we combined these three approaches (BMI, NMES, and exoskeleton) in an integrated neuroprosthesis and studied the feasibility of this device in seven severely affected chronic stroke patients who performed wrist flexion and extension exercises while receiving feedback via a virtual environment. They were assisted by a gravity-compensating, seven degree-of-freedom exoskeleton which was attached to the paretic arm. NMES was applied to the wrist extensor and flexor muscles during the exercises and was controlled by a hybrid BMI based on both sensorimotor cortical desynchronization (ERD) and electromyography (EMG) activity. The stimulation intensity was individualized for each targeted muscle and remained subthreshold, i.e., induced no overt support. The hybrid BMI controlled the stimulation significantly better than the offline analyzed ERD (p = 0.028) or EMG (p = 0.021) modality alone. Neuromuscular stimulation could be well integrated into the exoskeleton-based training and amplified both the task-related ROM (p = 0.009) and the movement-related brain modulation (p = 0.019). Combining a hybrid BMI with neuromuscular stimulation and antigravity assistance augments upper limb function and brain activity during rehabilitation exercises and may thus provide a novel restorative framework for severely affected stroke patients.
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Affiliation(s)
- Florian Grimm
- Division of Functional and Restorative Neurosurgery, Centre for Integrative Neuroscience, Eberhard Karls University Tuebingen Tuebingen, Germany
| | - Armin Walter
- Department of Computer Engineering, Wilhelm Schickard Institute for Computer Science, Eberhard Karls University Tuebingen Tuebingen, Germany
| | - Martin Spüler
- Department of Computer Engineering, Wilhelm Schickard Institute for Computer Science, Eberhard Karls University Tuebingen Tuebingen, Germany
| | - Georgios Naros
- Division of Functional and Restorative Neurosurgery, Centre for Integrative Neuroscience, Eberhard Karls University Tuebingen Tuebingen, Germany
| | - Wolfgang Rosenstiel
- Department of Computer Engineering, Wilhelm Schickard Institute for Computer Science, Eberhard Karls University Tuebingen Tuebingen, Germany
| | - Alireza Gharabaghi
- Division of Functional and Restorative Neurosurgery, Centre for Integrative Neuroscience, Eberhard Karls University Tuebingen Tuebingen, Germany
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Grimm F, Naros G, Gharabaghi A. Compensation or Restoration: Closed-Loop Feedback of Movement Quality for Assisted Reach-to-Grasp Exercises with a Multi-Joint Arm Exoskeleton. Front Neurosci 2016; 10:280. [PMID: 27445655 PMCID: PMC4914560 DOI: 10.3389/fnins.2016.00280] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 06/06/2016] [Indexed: 11/13/2022] Open
Abstract
Assistive technology allows for intensive practice and kinematic measurements during rehabilitation exercises. More recent approaches attach a gravity-compensating multi-joint exoskeleton to the upper extremity to facilitate task-oriented training in three-dimensional space with virtual reality feedback. The movement quality, however, is mostly captured through end-point measures that lack information on proximal inter-joint coordination. This limits the differentiation between compensation strategies and genuine restoration both during the exercise and in the course of rehabilitation. We extended in this proof-of-concept study a commercially available seven degree-of-freedom arm exoskeleton by using the real-time sensor data to display a three-dimensional multi-joint visualization of the user's arm. Ten healthy subjects and three severely affected chronic stroke patients performed reach-to-grasp exercises resembling activities of daily living assisted by the attached exoskeleton and received closed-loop online feedback of the three-dimensional movement in virtual reality. Patients in this pilot study differed significantly with regard to motor performance (accuracy, temporal efficiency, range of motion) and movement quality (proximal inter-joint coordination) from the healthy control group. In the course of 20 training and feedback sessions over 4 weeks, these pathological measures improved significantly toward the reference parameters of healthy participants. It was moreover feasible to capture the evolution of movement pattern kinematics of the shoulder and elbow and to quantify the individual degree of natural movement restoration for each patient. The virtual reality visualization and closed-loop feedback of joint-specific movement kinematics makes it possible to detect compensation strategies and may provide a tool to achieve the rehabilitation goals in accordance with the individual capacity for genuine functional restoration; a proposal that warrants further investigation in controlled studies with a larger cohort of stroke patients.
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Affiliation(s)
- Florian Grimm
- Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience, Eberhard Karls University Tuebingen, Germany
| | - Georgios Naros
- Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience, Eberhard Karls University Tuebingen, Germany
| | - Alireza Gharabaghi
- Division of Functional and Restorative Neurosurgery, and Centre for Integrative Neuroscience, Eberhard Karls University Tuebingen, Germany
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