Continuous Intrathecal Medication Delivery With the IRRA flow Catheter: Pearls and Early Experience

BACKGROUND AND OBJECTIVES

Intrathecal (IT) medications are routinely introduced through catheterization of the intraventricular space or subarachnoid space. There has been sporadic use of IT medications delivered directly to the ventricle either by intermittent injection through an external ventricular drain (EVD) or by an Ommaya reservoir with a ventricular catheter. IT medication delivery through EVD has many drawbacks, including the necessary opening of a sterile system, delivery of medication in a bolus form, and requirements to clamp the EVD after medication delivery. Despite these setbacks, IT medications delivered through EVD have been used across a wide range of applications, including antibiotic delivery treatment of vasospasm with nicardipine and delivery of tissue plasminogen activator.

METHODS

We used a newly developed active fluid exchange device to treat various severe conditions involved in the cerebral ventricles. Here, we present our treatment protocols and advice on the techniques related to successful active fluid exchange therapy.

RESULTS

Seventy patients have been treated with our system with various conditions, including subarachnoid hemorrhage, intraventricular hemorrhage, ventriculitis, and cerebral abscess. Total complication rate was 14% with only 1 catheter occlusion and low rates of hemorrhage, infection, and spinal fluid leak.

CONCLUSION

Current continuous IT medication dosages and protocols are based on reports and consensus statements evaluating intermittent instillation of medication boluses. The pharmacokinetics of continuous dosing and the therapeutic and safety profiles of the medications need to be studied in a prospective manner to evaluate the true optimal dosing standards. Furthermore, the ability to deliver continuous, sterile medications directly through an IT route will open new avenues of pharmacotherapy that were previously closed. This report serves as a basic guide for the safe and effective use of the IRRA flow active fluid exchange catheter to deliver IT medications.

Outpatient Deep Brain Stimulation Surgery Is a Safe Alternative to Inpatient Admission

BACKGROUND

Deep brain stimulation (DBS) is usually performed as an inpatient procedure. The COVID-19 pandemic effected a practice change at our institution with outpatient DBS performed because of limited inpatient and surgical resources. Although this alleviated use of hospital resources, the comparative safety of outpatient DBS surgery is unclear.

OBJECTIVE

To compare the safety and incidence of early postoperative complications in patients undergoing DBS procedures in the outpatient vs inpatient setting.

METHODS

We retrospectively reviewed all outpatient and inpatient DBS procedures performed by a single surgeon between January 2018 and November 2022. The main outcome measures used for comparison between the 2 groups were total complications, length of stay, rate of postoperative infection, postoperative hemorrhage rate, 30-day emergency department (ED) visits and readmissions, and IV antihypertensive requirement.

RESULTS

A total of 44 outpatient DBS surgeries were compared with 70 inpatient DBS surgeries. The outpatient DBS cohort had a shorter mean postoperative stay (4.19 vs 39.59 hours, P = .0015), lower total complication rate (2.3% vs 12.8%, P = .1457), and lower wound infection rate (0% vs 2.9%, P = .52) compared with the inpatient cohort, but the difference in complications was not statistically significant. In the 30-day follow-up period, ED visits were similar between the cohorts (6.8% vs 7.1%, P = .735), but no outpatient DBS patient required readmission, whereas all inpatient DBS patients visiting the ED were readmitted (P = .155).

CONCLUSION

Our study demonstrates that DBS can be safely performed on an outpatient basis with same-day hospital discharge and close continuous monitoring.

Awake Deep Brain Stimulation Surgery Without Intraoperative Imaging Is Accurate and Effective: A Case Series

BACKGROUND

The success of deep brain stimulation (DBS) surgery depends on the accuracy of electrode placement. Several factors can affect this such as brain shift, the quality of preoperative planning, and technical factors. It is crucial to determine whether techniques yield accurate lead placement and effective symptom relief. Many of the studies establishing the accuracy of frameless techniques used intraoperative imaging to further refine lead placement.

OBJECTIVE

To determine whether awake lead placement without intraoperative imaging can achieve similar minimal targeting error while preserving clinical results.

METHODS

Eighty-two trajectories in 47 patients who underwent awake, frameless DBS lead placement with the Fred Haer Corporation STarFix system for essential tremor or Parkinson's disease were analyzed. Neurological testing during lead placement was used to determine appropriate lead locations, and no intraoperative imaging was performed. Accuracy data were compared with previously performed studies.

RESULTS

The Euclidean error for the patient cohort was 1.79 ± 1.02 mm, and the Pythagorean error was 1.40 ± 0.95 mm. The percentage symptom improvement evaluated by the Unified Parkinson's Disease Rating Scale for Parkinson's disease or the Fahn-Tolosa-Marin scale for essential tremor was similar to reported values at 58% ± 17.2% and 67.4% ± 24.7%, respectively. The operative time was 95.0 ± 30.3 minutes for all study patients.

CONCLUSION

Awake, frameless DBS surgery with the Fred Haer Corporation STarFix system does not require intraoperative imaging for stereotactic accuracy or clinical effectiveness.

Neuromodulation Therapies for Spasticity Control: Now and Beyond

Spasticity is a major cause of disability following upper motor neuron (UMN) injury. The diagnosis and treatment of spasticity has been a focus of clinicians and researchers alike. In recent years, there have been significant advances both in strategies for spasticity assessment and in the development of novel treatments. Currently, several well-established spasticity management techniques fall into the major categories of physiotherapy, pharmacotherapy, and surgical management. The majority of recent developments in all of these broad categories have focused more on methods of neuromodulation instead of simple symptomatic treatment, attempting to address the underlying cause of spasticity more directly. The following narrative review briefly discusses the causes and clinical assessment of spasticity and also details the wide variety of current and developing treatment approaches for this often-debilitating condition.