1
|
Hoyningen A, Koster KL, Neidert MC, Bozinov O, Lauber A, Kim OCH, Hundsberger T, Krüger MT. Laser Interstitial Thermal Therapy in a Large Thalamic Glioma with Long-Term Remission: A Case Report. Oncol Res Treat 2023; 47:42-48. [PMID: 38147831 DOI: 10.1159/000535991] [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: 09/05/2023] [Accepted: 12/19/2023] [Indexed: 12/28/2023]
Abstract
INTRODUCTION Thalamic gliomas pose a particular therapeutic challenge as complete resection is rarely achieved due to the deep and eloquent location. Laser interstitial thermal therapy (LITT) may provide a valuable management option for deep-seated gliomas that are not accessible with open surgery. CASE PRESENTATION A 57-year-old woman presented with a rapidly progressive large thalamic glioblastoma. Opting for full ablation, we selected a challenging trajectory to maximize the possibility of full ablation. At 2.4 cm in diameter, the tumour was larger than recommended for LITT; nevertheless, three laser ablations along a single trajectory resulted in macroscopic ablation without complications. Adjuvant radio-chemotherapy was started soon after surgery without radiological recurrence 1.5 years after the initial surgery. CONCLUSION This case demonstrates the potential when thalamic tumours are managed with timely LITT treatment and meticulous trajectory planning. Moreover, it highlights the need for close interdisciplinary management with neurosurgeons, neuropathologists, neuroradiologists, and neurooncologists.
Collapse
Affiliation(s)
- Alexander Hoyningen
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
- Department of Basic Neuroscience, University of Geneva, Geneva, Switzerland
| | - Kira-Lee Koster
- Department of Medical Oncology and Hematology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marian C Neidert
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Arno Lauber
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Olaf Chan-Hi Kim
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Thomas Hundsberger
- Department of Medical Oncology and Hematology, Kantonsspital St. Gallen, St. Gallen, Switzerland
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marie T Krüger
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, The National Hospital for Neurology and Neurosurgery, London, UK
- Department of Stereotactic and Functional Neurosurgery, Medical Center of the University of Freiburg, Freiburg, Germany
| |
Collapse
|
2
|
Girges C, Krüger MT, Xu SS, Akram H, Hyam J, Limousin P, Zrinzo L, Foltynie T. Brain Oedema Associated with Deep Brain Stimulation through a Single Directional Contact. Mov Disord Clin Pract 2023; 10:1695-1697. [PMID: 37982107 PMCID: PMC10654822 DOI: 10.1002/mdc3.13871] [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: 06/23/2023] [Revised: 08/02/2023] [Accepted: 08/14/2023] [Indexed: 11/21/2023] Open
Affiliation(s)
- Christine Girges
- Department of Clinical and Movement NeurosciencesUniversity College LondonLondonUK
- UCL Functional Neurosurgery UnitNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Marie T. Krüger
- Department of Clinical and Movement NeurosciencesUniversity College LondonLondonUK
- UCL Functional Neurosurgery UnitNational Hospital for Neurology and NeurosurgeryLondonUK
- Department of Neurosurgery, University Medical Centre Freiburg, Faculty of Medicine, University of FreiburgFreiburg im BreisgauGermany
| | - San San Xu
- Department of Clinical and Movement NeurosciencesUniversity College LondonLondonUK
- UCL Functional Neurosurgery UnitNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Harith Akram
- Department of Clinical and Movement NeurosciencesUniversity College LondonLondonUK
- UCL Functional Neurosurgery UnitNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Jonathan Hyam
- Department of Clinical and Movement NeurosciencesUniversity College LondonLondonUK
- UCL Functional Neurosurgery UnitNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Patricia Limousin
- Department of Clinical and Movement NeurosciencesUniversity College LondonLondonUK
- UCL Functional Neurosurgery UnitNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Ludvic Zrinzo
- Department of Clinical and Movement NeurosciencesUniversity College LondonLondonUK
- UCL Functional Neurosurgery UnitNational Hospital for Neurology and NeurosurgeryLondonUK
| | - Thomas Foltynie
- Department of Clinical and Movement NeurosciencesUniversity College LondonLondonUK
- UCL Functional Neurosurgery UnitNational Hospital for Neurology and NeurosurgeryLondonUK
| |
Collapse
|
3
|
Klingler JH, Hubbe U, Scholz C, Volz F, Roelz R, Beck J, Watzlawick R, Brönner J, Hoedlmoser H, Krüger MT, Hohenhaus M, Naseri Y. The Impact of Implementing a Radiation-Sparing Protocol for Percutaneous Kyphoplasty-A Prospective Dosemetric Study. Global Spine J 2023; 13:1541-1549. [PMID: 34530629 PMCID: PMC10448088 DOI: 10.1177/21925682211039497] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES The purpose of this prospective study was to evaluate a protocol for radiation-sparing kyphoplasty by assessing dosemetrically recorded radiation exposures to both patient and surgeon. METHODS This prospective clinical study examines the radiation exposure to patient and surgeon during single-level kyphoplasty in 32 thoracolumbar osteoporotic vertebral body fractures (12 OF 2, 9 OF 3, 11 OF 4 types) using a radiation aware surgical protocol between May 2017 and November 2019. The radiation exposure was measured at different locations using film, eye lens and ring dosemeters. Dose values are reported under consideration of lower detection limits of each dosemeter type. RESULTS A high proportion of dosemeter readings was below the lower detection limits, especially for the surgeon (>90%). Radiation exposure to the surgeon was highest at the unprotected thyroid gland (0.053 ± 0.047 mSv), however only slightly above the lower detection limit of dosemeters (0.044 mSv). Radiation exposure to the patient was highest at the chest (0.349 ± 0.414 mSv) and the gonad (0.186 ± 0.262 mSv). Fluoroscopy time, dose area product and number of fluoroscopic images were 46.0 ± 17.9 sec, 124 ± 109 cGy×cm2, and 35 ± 13 per kyphoplasty, respectively. Back pain significantly improved from 6.8 ± 1.6 to 2.5 ± 1.7 on the numeric rating scale on the first postoperative day (P < 0.0001). CONCLUSIONS The implementation of a strict intraoperative radiation protection protocol allows for safely performed kyphoplasty with ultra-low radiation exposure for the patient and surgeon without exceeding the annual occupational dose limits. TRIAL REGISTRATION The study was registered in the German Clinical Trials Register (DRKS00011908, registration date 16/05/2017).
Collapse
Affiliation(s)
- Jan-Helge Klingler
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Volz
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralf Watzlawick
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Brönner
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Herbert Hoedlmoser
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Marie T. Krüger
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marc Hohenhaus
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Yashar Naseri
- Department of Neurosurgery, Medical Center–University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| |
Collapse
|
4
|
Krüger MT, Terrapon APR, Hoyningen A, Kim CHO, Lauber A, Bozinov O. Posterior Fossa Approaches Using the Leksell Vantage Frame with a Virtual Planning Approach in a Series of 10 Patients-Feasibility, Accuracy, and Pitfalls. Brain Sci 2022; 12:brainsci12121608. [PMID: 36552068 PMCID: PMC9775269 DOI: 10.3390/brainsci12121608] [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: 11/03/2022] [Revised: 11/16/2022] [Accepted: 11/19/2022] [Indexed: 11/25/2022] Open
Abstract
The open-face design of the Leksell Vantage frame provides many advantages. However, its more rigid, contoured design offers less flexibility than other frames. This is especially true for posterior fossa approaches. This study explores whether these limitations can be overcome by tailored frame placement using a virtual planning approach. The posterior fossa was accessed in ten patients using the Leksell Vantage frame. Frame placement was planned with the Brainlab Elements software, including a phantom-based (virtual) pre-operative planning approach. A biopsy was performed in all patients; in four, additional laser ablation surgery was performed. The accuracy of virtual frame placement was compared to actual frame placement. The posterior approach was feasible in all patients. In one case, the trajectory had to be adjusted; in another, the trajectory was switched from a right- to a left-sided approach. Both cases showed large deviations from the initially planned frame placement. A histopathological diagnosis was achieved in all patients. The new Leksell Vantage frame can be used to safely target the posterior fossa with a high diagnostic success rate and accuracy. Frame placement needs to be well-planned and executed. This can be facilitated using specific software solutions as demonstrated.
Collapse
Affiliation(s)
- Marie T. Krüger
- Department of Neurosurgery, The National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
- Department of Neurosurgery, Cantonal Hospital, 9007 St. Gallen, Switzerland
- Department of Stereotactic and Functional Neurosurgery, University Medical Centre, 79106 Freiburg, Germany
- Correspondence: ; Tel.: +44-7855785271
| | | | | | - Chan-Hi Olaf Kim
- Department of Radiology and Nuclear Medicine, Cantonal Hospital, 9007 St. Gallen, Switzerland
| | - Arno Lauber
- Department of Radiology and Nuclear Medicine, Cantonal Hospital, 9007 St. Gallen, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Cantonal Hospital, 9007 St. Gallen, Switzerland
| |
Collapse
|
5
|
Avecillas-Chasin JM, Honey CR, Heran MKS, Krüger MT. Sweet spots of standard and directional leads in patients with refractory essential tremor: white matter pathways associated with maximal tremor improvement. J Neurosurg 2022; 137:1811-1820. [PMID: 35535840 DOI: 10.3171/2022.3.jns212374] [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: 10/10/2021] [Accepted: 03/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In patients with essential tremor (ET) treated with standard deep brain stimulation (sDBS) whose ET had progressed and who no longer received optimal benefit from sDBS, directional deep brain stimulation (dDBS) may provide better tremor control. Current steering may provide better coverage of subcortical structures related to tremor control in patients with ET and significant progression without optimal response to sDBS. METHODS This study included 6 patients with ET initially treated with sDBS whose tremor later progressed and who then underwent reimplantation with dDBS to optimize their tremor control. To investigate the differences in the local effects of sDBS and dDBS, the authors generated the volume of tissue activation (VTA) to calculate the sweet spots associated with the best possible tremor control with no side effects. Then, to investigate the anatomical structures associated with maximal tremor control, the white matter pathways of the posterior subthalamic areas (PSAs) were generated and their involvement with the sDBS and dDBS sweet spots was calculated. RESULTS Tremor improvement was significantly better with dDBS (68.4%) than with sDBS (48.7%) (p = 0.017). The sDBS sweet spot was located within the ventral intermediate nucleus, whereas the sweet spot of the dDBS was mainly located within the PSA. The sweet spots of both sDBS and dDBS involved a similar portion of the cerebellothalamic pathway. However, the dDBS had greater involvement of the pallidofugal pathways than the sDBS. CONCLUSIONS In patients with ET treated with sDBS who later had ET progression, dDBS provided better tremor control, which was related to directionality and a more ventral position. The involvement of both the cerebellothalamic and pallidofugal pathways obtained with dDBS is associated with additional improvement over the sDBS.
Collapse
Affiliation(s)
- Josue M Avecillas-Chasin
- 1Department of Neurosurgery, University of Nebraska Medical Center, Omaha, Nebraska.,2Department of Neurosurgery, University of California, Los Angeles, California
| | | | - Manraj K S Heran
- 4Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marie T Krüger
- 5Department of Neurosurgery, Cantonal Hospital St. Gallen, Switzerland; and.,6Department of Stereotactic and Functional Neurosurgery, University Medical Center Freiburg, Germany
| |
Collapse
|
6
|
Masalha W, Heiland DH, Steiert C, Krüger MT, Schnell D, Heiland P, Bissolo M, Grosu AL, Schnell O, Beck J, Grauvogel J. Management of Medial Sphenoid Wing Meningioma Involving the Cavernous Sinus: A Single-Center Series of 105 Cases. Cancers (Basel) 2022; 14:2201. [PMID: 35565330 PMCID: PMC9102569 DOI: 10.3390/cancers14092201] [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: 03/15/2022] [Revised: 04/21/2022] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Medial sphenoid wing meningiomas are among the three most common intracranial meningiomas. These tumors pose a challenge to neurosurgeons in terms of surgical treatment, as they may involve critical neurovascular structures and invade the cavernous sinus. In case of the latter, a complete resection may not be achievable. The purpose of this study was to investigate prognostic features affecting recurrence and progression-free survival (PFS) of medial sphenoid wing meningiomas involving the cavernous sinus, focusing on the contribution of surgery and postoperative radiotherapy. METHODS A retrospective analysis was conducted of the database of our institution, and 105 cases of medial sphenoid wing meningioma with invasion of the cavernous sinus, which were treated between 1998 and 2019, were included. Surgical treatment only was performed in 64 cases, and surgical treatment plus postoperative radiotherapy was performed in 41 cases. Kaplan-Meier analysis was conducted to estimate median survival and PFS rates, and Cox regression analysis was applied to determine significant factors that were associated with each therapeutic modality. RESULTS The risk of recurrence was significantly reduced after near-total resection (NTR) (p-value = 0.0011) compared to subtotal resection. Progression-free survival was also significantly prolonged after postoperative radiotherapy (p-value = 0.0002). CONCLUSIONS Maximal safe resection and postoperative stereotactic radiotherapy significantly reduced the recurrence rate of medial sphenoid wing meningiomas with infiltration of the cavernous sinus.
Collapse
Affiliation(s)
- Waseem Masalha
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Christine Steiert
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Marie T. Krüger
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
- Department of Neurosurgery, Cantonal Hospital St. Gallen, 9000 St. Gallen, Switzerland
| | - Daniel Schnell
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
- Department of Radiation Oncology, Medical Centre—University of Freiburg, 79106 Freiburg, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, 79106 Freiburg, Germany
| | - Pamela Heiland
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Marco Bissolo
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Anca-L. Grosu
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
- Department of Radiation Oncology, Medical Centre—University of Freiburg, 79106 Freiburg, Germany
- German Cancer Consortium (DKTK), Partner Site Freiburg, 79106 Freiburg, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Jürgen Beck
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Centre—University of Freiburg, 79106 Freiburg, Germany; (D.H.H.); (C.S.); (M.T.K.); (P.H.); (M.B.); (O.S.); (J.B.); (J.G.)
- Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany; (D.S.); (A.-L.G.)
| |
Collapse
|
7
|
Stieglitz LH, Oertel MF, Accolla EA, Bally J, Bauer R, Baumann CR, Benninger D, Bohlhalter S, Büchele F, Hägele-Link S, Kägi G, Krack P, Krüger MT, Mahendran S, Möller JC, Mylius V, Piroth T, Werner B, Kaelin-Lang A. Consensus Statement on High-Intensity Focused Ultrasound for Functional Neurosurgery in Switzerland. Front Neurol 2021; 12:722762. [PMID: 34630296 PMCID: PMC8493868 DOI: 10.3389/fneur.2021.722762] [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: 06/09/2021] [Accepted: 08/18/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Magnetic resonance-guided high-intensity focused ultrasound (MRgHiFUS) has evolved into a viable ablative treatment option for functional neurosurgery. However, it is not clear yet, how this new technology should be integrated into current and established clinical practice and a consensus should be found about recommended indications, stereotactic targets, patient selection, and outcome measurements. Objective: To sum up and unify current knowledge and clinical experience of Swiss neurological and neurosurgical communities regarding MRgHiFUS interventions for brain disorders to be published as a national consensus paper. Methods: Eighteen experienced neurosurgeons and neurologists practicing in Switzerland in the field of movement disorders and one health physicist representing 15 departments of 12 Swiss clinical centers and 5 medical societies participated in the workshop and contributed to the consensus paper. All experts have experience with current treatment modalities or with MRgHiFUS. They were invited to participate in two workshops and consensus meetings and one online meeting. As part of workshop preparations, a thorough literature review was undertaken and distributed among participants together with a list of relevant discussion topics. Special emphasis was put on current experience and practice, and areas of controversy regarding clinical application of MRgHiFUS for functional neurosurgery. Results: The recommendations addressed lesioning for treatment of brain disorders in general, and with respect to MRgHiFUS indications, stereotactic targets, treatment alternatives, patient selection and management, standardization of reporting and follow-up, and initialization of a national registry for interventional therapies of movement disorders. Good clinical evidence is presently only available for unilateral thalamic lesioning in treating essential tremor or tremor-dominant Parkinson's disease and, to a minor extent, for unilateral subthalamotomy for Parkinson's disease motor features. However, the workgroup unequivocally recommends further exploration and adaptation of MRgHiFUS-based functional lesioning interventions and confirms the need for outcome-based evaluation of these approaches based on a unified registry. MRgHiFUS and DBS should be evaluated by experts familiar with both methods, as they are mutually complementing therapy options to be appreciated for their distinct advantages and potential. Conclusion: This multidisciplinary consensus paper is a representative current recommendation for safe implementation and standardized practice of MRgHiFUS treatments for functional neurosurgery in Switzerland.
Collapse
Affiliation(s)
| | - Markus F Oertel
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Ettore A Accolla
- Neurology Unit, Department of Internal Medicine, Hôpital Fribourgeois (HFR)-Cantonal Hospital Fribourg, University of Fribourg, Fribourg, Switzerland
| | - Julien Bally
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Department of Neurology, Geneva University Hospital and University of Geneva, Geneva, Switzerland
| | - Roland Bauer
- Department of Neurosurgery, Cantonal Hospital Aarau, Aarau, Switzerland
| | | | - David Benninger
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Stephan Bohlhalter
- Neurocenter, Lucerne Cantonal Hospital, University of Zurich, Zurich, Switzerland
| | - Fabian Büchele
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Stefan Hägele-Link
- Department of Neurology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Georg Kägi
- Department of Neurology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Paul Krack
- Department of Neurology, Inselspital, University Bern, Bern, Switzerland
| | - Marie T Krüger
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Sujitha Mahendran
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - J Carsten Möller
- Parkinson Center, Center for Neurological Rehabilitation, Zihlschlacht, Switzerland
| | - Veit Mylius
- Department of Neurology, Center for Neurorehabilitation, Valens, Switzerland
| | - Tobias Piroth
- Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Beat Werner
- Center for Magnetic Resonance (MR) Research, University Children's Hospital Zurich, Zurich, Switzerland
| | - Alain Kaelin-Lang
- Department of Neurology, Inselspital, University Bern, Bern, Switzerland.,Neurocenter of Southern Switzerland Ente Ospedaliero Cantonale (EOC), Regional Hospital Lugano, Lugano, Switzerland.,Faculty of Biomedical Neurosciences, Università Della Svizzera Italiana, Lugano, Switzerland
| |
Collapse
|
8
|
Krüger MT, Avecillas-Chasin JM, Heran MKS, Naseri Y, Sandhu MK, Polyhronopoulos NE, Sarai N, Honey CR. Directional Deep Brain Stimulation Can Target the Thalamic "Sweet Spot" for Improving Neuropathic Dental Pain. Oper Neurosurg (Hagerstown) 2021; 21:81-86. [PMID: 33956987 DOI: 10.1093/ons/opab136] [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: 08/29/2020] [Accepted: 03/12/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Neuropathic dental pain (NDP) is a chronic pain condition that is notoriously difficult to treat. To date, there are no deep brain stimulation (DBS) studies on this specific pain condition and no optimal target or "sweet spot" has ever been defined. OBJECTIVE To determine the optimal thalamic target for improving this condition by utilizing the steering abilities of a directional DBS electrode (Vercise CartesiaTM Model DB-2202-45, Boston Scientific). METHODS A literature search and review of our database identified 3 potential thalamic targets. A directional lead was implanted in a patient with NDP and its current steering used to test the effects in each nucleus. The patient reported her pain after 2 wk of stimulation in a prospective randomized blinded trial of one. Quality of life measurements were performed before and after 3 mo on their best setting. RESULTS We identified 3 potential nuclei: the centromedian (CM), ventral posterior medial (VPM), and anterior pulvinar. The best results were during VPM stimulation (>90% reduction in pain) and CM stimulation (50% reduction). Following 3 mo of VPM-DBS in combination of lateral CM stimulation, their pain disability index dropped (from 25 to 0) and short form 36 improved (from 67.5 to 90). CONCLUSION VPM stimulation in combination with CM stimulation is a promising target for NDP. DBS electrode directionality can be used to test multiple targets and select a patient specific "sweet spot" for NDP treatment.
Collapse
Affiliation(s)
- Marie T Krüger
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Division of Neurosurgery, University of British Columbia, Vancouver, Canada.,Department of Stereotactic and Functional Neurosurgery, Freiburg Medical Center, Freiburg, Germany
| | - Josue M Avecillas-Chasin
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada.,Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Manraj K S Heran
- Division of Neuroradiology, University of British Columbia, Vancouver, Canada
| | - Yashar Naseri
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Stereotactic and Functional Neurosurgery, Freiburg Medical Center, Freiburg, Germany
| | - Mini K Sandhu
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | | | - Natasha Sarai
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | | |
Collapse
|
9
|
Masalha W, Heiland DH, Steiert C, Krüger MT, Schnell D, Scheiwe C, Schnell O, Grosu AL, Beck J, Grauvogel J. Progression-Free Survival, Prognostic Factors, and Surgical Outcome of Spheno-Orbital Meningiomas. Front Oncol 2021; 11:672228. [PMID: 34150637 PMCID: PMC8212033 DOI: 10.3389/fonc.2021.672228] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/28/2021] [Indexed: 11/13/2022] Open
Abstract
Objective Spheno-orbital meningiomas (SOM) are rare intracranial tumors that arise at the sphenoid wing. These tumors can invade important neurovascular structures making radical resection difficult, while residual tumors often lead to recurrence. The purpose of this study was to evaluate prognostic factors influencing the recurrence and progression-free survival (PFS) rates of spheno-orbital meningiomas, with a particular focus on the role of surgery and postoperative radiotherapy. Methods Between 2000 and March 2020, 65 cases of spheno-orbital meningioma were included, of which 50 cases underwent surgical treatment alone, and 15 cases underwent resection and radiotherapy. A Kaplan-Meier analysis was performed to provide median point estimates and PFS rates; further, Cox regression analysis was used to identify significant factors associated with treatment. Results Gross total resection significantly reduced the risk of recurrence (p-value = 0.0062). There was no significant benefit for progression-free survival after postoperative radiotherapy (p-value = 0.42). Additionally, spheno-orbital meningiomas with an invasion of the cavernous sinus and intraconal invasion showed significantly worse PFS compared to other locations (p-value = 0.017). Conclusion The maximal safe resection remains the most important prognostic factor associated with lower recurrence rates and longer PFS in patients with spheno-orbital meningioma. The invasion of the cavernous sinus and intraconal invasion was an independent factor associated with worse PFS. Patients with postoperative high-precision radiotherapy did not show significantly better PFS due to the small number of patients.
Collapse
Affiliation(s)
- Waseem Masalha
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dieter Henrik Heiland
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christine Steiert
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marie T Krüger
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Daniel Schnell
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Radiation Oncology, Medical Center - University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Oliver Schnell
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Anca-L Grosu
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Radiation Oncology, Medical Center - University of Freiburg, Freiburg, Germany.,German Cancer Consortium (DKTK), Partner Site Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
10
|
Klingler JH, Scholz C, Hohenhaus M, Volz F, Naseri Y, Krüger MT, Vasilikos I, Roelz R, Brönner J, Hoedlmoser H, Sircar R, Hubbe U. Radiation Exposure to Scrub Nurse, Assistant Surgeon, and Anesthetist in Minimally Invasive Spinal Fusion Surgery Comparing 2D Conventional Fluoroscopy With 3D Fluoroscopy-based Navigation: A Randomized Controlled Trial. Clin Spine Surg 2021; 34:E211-E215. [PMID: 32991363 DOI: 10.1097/bsd.0000000000001077] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 07/24/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A randomized controlled trial. OBJECTIVE To compare the radiation exposure with the scrub nurse, assistant surgeon, and anesthetist during minimally invasive transforaminal lumbar interbody fusion using conventional 2-dimensional (2D) fluoroscopy or 3D fluoroscopy-based navigation. SUMMARY OF BACKGROUND DATA Minimally invasive spinal fusion techniques are related to higher radiation exposures compared with open techniques. Especially the routinely exposed surgical staff faces the risks of increased radiation exposure. METHODS In total, 41 patients with planned monosegmental minimally invasive transforaminal lumbar interbody fusion were randomized into the intraoperative imaging techniques 2D fluoroscopy or 3D navigation. Eye lens and film dosemeters were attached to defined locations of the scrub nurse, assistant surgeon, and anesthetist. Mann-Whitney U and Wilcoxon-matched pairs signed-rank test were used to compare dosemeter readings. This study was registered with the German Clinical Trials Register (DRKS00004514). RESULTS The radiation exposure per surgery was low for the scrub nurse, assistant surgeon, and anesthetist in both the 2D fluoroscopy and 3D navigation groups. The maximum average value of 0.057±0.031 mSv was measured on the unprotected chest of the assistant surgeon and was thus slightly above the lower detection limit of the dosemeters (0.044 mSv). The annual occupational dose limit would be exceeded at the earliest after 571 operations for the unprotected eye lens of the assistant surgeon. CONCLUSIONS Minimally invasive lumbar fusion surgery is possible with comparatively low radiation exposure to the assisting operating room personnel without exceeding the annual maximum occupational radiation exposure. However, there is no definite dose value below which ionizing radiation poses no risk. Consequently, radiation sparing work routines should be strictly followed.
Collapse
Affiliation(s)
- Jan-Helge Klingler
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Marc Hohenhaus
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Volz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Yashar Naseri
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Marie T Krüger
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Ioannis Vasilikos
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johannes Brönner
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Herbert Hoedlmoser
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Ronen Sircar
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
11
|
Honey CR, Krüger MT, Almeida T, Rammage LA, Tamber MS, Morrison MD, Poologaindran A, Hu A. Thalamic Deep Brain Stimulation for Spasmodic Dysphonia: A Phase I Prospective Randomized Double-Blind Crossover Trial. Neurosurgery 2021; 89:45-52. [PMID: 33862624 PMCID: PMC8223243 DOI: 10.1093/neuros/nyab095] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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: 10/15/2020] [Accepted: 01/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Adductor spasmodic dysphonia (SD) is a dystonia of the vocal folds causing difficulty with speech. The current standard of care is repeated botulinum toxin injections to weaken the adductor muscles. We sought to ameliorate the underlying neurological cause of SD with a novel therapy—deep brain stimulation (DBS). OBJECTIVE To assess the safety of DBS in SD through phase I trial, and to quantify the magnitude of any benefit. METHODS Six patients had left ventral intermediate nucleus (Vim) thalamic DBS and were randomized to 3 mo blinded-DBS “on” or “off” followed by a crossover. Primary outcomes were quality of life and quality of voice during the blinded phase. Patients continued with open-DBS “on.” Secondary outcomes were comparisons of pre- and 1-yr cognitive, mood, and quality of life. This trial was registered with ClinicalTrials.gov (NCT02558634). RESULTS There were no complications. Every patient reported an improvement in quality of life (P = .07) and had an improvement in quality of their voice (P = .06) when their blinded DBS was “on” versus “off.” The trend did not reach statistical significance with the small sample size. Secondary outcomes showed no difference in cognition, an improvement in mood, and quality of life at 1 yr. CONCLUSION This phase I randomized controlled trial confirmed that DBS can be performed safely in patients with SD. Blinded DBS produced a strong trend toward improved quality of life and objective quality of voice despite the small sample size. The cerebellar circuit, not the pallidal circuit, appears to be crucial for motor control of the vocal folds.
Collapse
Affiliation(s)
| | - Marie T Krüger
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Stereotactic and Functional Neurosurgery, University Medical Clinic Freiburg, Freiburg, Germany
| | - Timóteo Almeida
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Linda A Rammage
- Division of Otolaryngology and School of Audiology and Speech Sciences, University of British Columbia, Vancouver, Canada
| | - Mandeep S Tamber
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Murray D Morrison
- Division of Otolaryngology, University of British Columbia, Vancouver, Canada
| | - Anujan Poologaindran
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK.,The Alan Turing Institute, British Library, London, UK
| | - Amanda Hu
- Division of Otolaryngology, University of British Columbia, Vancouver, Canada
| |
Collapse
|
12
|
Masalha W, Daka K, Woerner J, Pompe N, Weber S, Delev D, Krüger MT, Schnell O, Beck J, Heiland DH, Grauvogel J. Metabolic alterations in meningioma reflect the clinical course. BMC Cancer 2021; 21:211. [PMID: 33648471 PMCID: PMC7923818 DOI: 10.1186/s12885-021-07887-5] [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: 09/29/2020] [Accepted: 02/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background Meningiomas are common brain tumours that are usually defined by benign clinical course. However, some meningiomas undergo a malignant transformation and recur within a short time period regardless of their World Health Organization (WHO) grade. The current study aimed to identify potential markers that can discriminate between benign and malignant meningioma courses. Methods We profiled the metabolites from 43 patients with low- and high-grade meningiomas. Tumour specimens were analyzed by nuclear magnetic resonance analysis; 270 metabolites were identified and clustered with the AutoPipe algorithm. Results We observed two distinct clusters marked by alterations in glycine/serine and choline/tryptophan metabolism. Glycine/serine cluster showed significantly lower WHO grades and proliferation rates. Also progression-free survival was significantly longer in the glycine/serine cluster. Conclusion Our findings suggest that alterations in glycine/serine metabolism are associated with lower proliferation and more recurrent tumours. Altered choline/tryptophan metabolism was associated with increases proliferation, and recurrence. Our results suggest that tumour malignancy can be reflected by metabolic alterations, which may support histological classifications to predict the clinical outcome of patients with meningiomas. Supplementary Information The online version contains supplementary material available at 10.1186/s12885-021-07887-5.
Collapse
Affiliation(s)
- Waseem Masalha
- Department of Neurosurgery, University Medical Center Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany. .,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.
| | - Karam Daka
- Department of Neurosurgery, University Medical Center Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jakob Woerner
- Institute of Physical Chemistry, Faculty of Chemistry and Pharmacy, University of Freiburg, Freiburg im Breisgau, Germany
| | - Nils Pompe
- Institute of Physical Chemistry, Faculty of Chemistry and Pharmacy, University of Freiburg, Freiburg im Breisgau, Germany
| | - Stefan Weber
- Institute of Physical Chemistry, Faculty of Chemistry and Pharmacy, University of Freiburg, Freiburg im Breisgau, Germany
| | - Daniel Delev
- Department of Neurosurgery, RWTH University, Aachen, Germany
| | - Marie T Krüger
- Department of Neurosurgery, Cantonal Hospital St.Gallen, st. gallen, Switzerland
| | - Oliver Schnell
- Department of Neurosurgery, University Medical Center Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Jürgen Beck
- Department of Neurosurgery, University Medical Center Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dieter Henrik Heiland
- Department of Neurosurgery, University Medical Center Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Juergen Grauvogel
- Department of Neurosurgery, University Medical Center Freiburg, Breisacher Straße 64, 79106, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| |
Collapse
|
13
|
Klingler JH, Hubbe U, Scholz C, Krüger MT. Facet-Sparing Decompression of Lumbar Spinal Stenosis: The Minimally Invasive Bilateral Crossover Approach. J Neurol Surg A Cent Eur Neurosurg 2021; 82:278-284. [PMID: 33477189 DOI: 10.1055/s-0040-1718521] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND STUDY OBJECTIVE One risk of established decompression techniques for lumbar spinal stenosis is the resection of facet joints, especially if they are steeply configured, promoting destabilization. Minimally invasive bilateral crossover decompression aims to preserve the facet joints and thus stability of the spine. The purpose of this study is to demonstrate the feasibility and early results of this technique. METHODS This retrospective case series includes 10 consecutive patients with lumbar stenosis and steep-angle (<35 degrees) facet joints who were treated with minimally invasive bilateral crossover decompression. Eleven segments were decompressed, most commonly L3/L4 (63.6%), followed by L1/L2 and L2/L3 (18.2% each). The effectiveness of surgical decompression was assessed by self-reporting questionnaires. RESULTS After a follow-up of 10.5 months, the Symptom Severity Scale and Physical Function Scale of the Swiss Spinal Stenosis Questionnaire improved by 0.9 (p < 0.05) and 0.7 points, respectively. The mean Oswestry Disability Index improved from 53.9 to 34.6 (p < 0.05). Local and radiating pain under strain showed statistically significant improvement on the Visual Analog Scale (8.9 vs. 5.0 and 8.4 vs. 4.6, respectively). Maximum walking distance increased from 190 to 1,029 m. Apart from one patient requiring surgical decompression of an adjacent segment, there were no reoperations, neurological deteriorations, or other complications. CONCLUSION The results of this study indicate that minimally invasive bilateral crossover decompression is a promising technique for the treatment of spinal canal stenosis. With its design to spare facet joints, it can potentially reduce the risk of spinal instability, especially in patients with steep facet joints.
Collapse
Affiliation(s)
- Jan Helge Klingler
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Ulrich Hubbe
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Marie T Krüger
- Department of Neurosurgery, Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| |
Collapse
|
14
|
Krüger MT, Naseri Y, Cavalloni F, Reinacher PC, Kägi G, Weber J, Brogle D, Bozinov O, Hägele-Link S, Brugger F. Do directional deep brain stimulation leads rotate after implantation? Acta Neurochir (Wien) 2021; 163:197-203. [PMID: 32915306 DOI: 10.1007/s00701-020-04568-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/02/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The two middle contacts of directional leads (d-leads) for deep brain stimulation are split into three segments, allowing current steering toward desired axial directions. To facilitate programming, their final orientation needs to be reliably determined. However, it is currently unclear whether d-leads rotate after implantation. Our objective was to assess the degree of d-lead rotation after implantation. METHODS We retrospectively analyzed d-lead orientation on intraoperative X-rays, postoperative CT scans (latencies to surgery: 108-189 min postoperatively), and rotational fluoroscopies (4-9 days postoperatively) for a consecutive series of 32 implanted d-leads. For five d-leads, a CT scan with a mean follow-up of 57 days (range 28-182) was available. All d-leads were implanted with the marker facing anterior and the intention to hit an "iron sight" (ISi) on the X-ray, indicating anterior orientation (i.e., 0° ± 6°). RESULTS In nine d-leads, an ISi was visible on the final X-ray; median orientation was 1.5° (range 0.5-6.0°) at the first follow-up CT, confirming anterior orientation. In d-leads without ISi or where ISi was not evaluable, the median rotation was 15.5° (9.5-35.0°) and 26.5° (5.5-62.0°), respectively. The orientation of the initial CT was comparable with the orientation determined by the postoperative rotational fluoroscopy and second CT in all d-lead groups. CONCLUSION D-lead orientation does not change within the first week after implantation. We provide first indications that d-lead orientation remains stable for several weeks after surgery. Determination of lead orientation using marker-based X-ray alone seems too imprecise; adding the ISi method can increase determination of intraoperative orientation.
Collapse
|
15
|
Krüger MT, Avecillas-Chasin JM, Tamber MS, Heran MKS, Sandhu MK, Polyhronopoulos NE, Sarai N, Honey CR. Tremor and Quality of Life in Patients With Advanced Essential Tremor Before and After Replacing Their Standard Deep Brain Stimulation With a Directional System. Neuromodulation 2020; 24:353-360. [PMID: 33098185 DOI: 10.1111/ner.13301] [Citation(s) in RCA: 3] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/07/2020] [Accepted: 10/05/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Patients with essential tremor treated with thalamic deep brain stimulation may experience increased tremor with the progression of their disease. Initially, this can be counteracted with increased stimulation. Eventually, this may cause unwanted side-effects as the circumferential stimulation from a standard ring contact spreads into adjacent regions. Directional leads may offer a solution to this clinical problem. We aimed to compare the ability of a standard and a directional system to reduce tremor without side-effects and to improve the quality of life for patients with advanced essential tremor. MATERIALS AND METHODS Six advanced essential tremor patients with bilateral thalamic deep brain stimulation had their standard system replaced with a directional system. Tremor rating scale scores were prospectively evaluated before and after the replacement surgery. Secondary analyses of quality of life related to tremor, voice, and general health were assessed. RESULTS There was a significantly greater reduction in tremor without side-effects (p = 0.017) when using the directional system. There were improvements in tremor (p = 0.031) and voice (p = 0.037) related quality of life but not in general health for patients using optimized stimulation settings with the directional system compared to the standard system. CONCLUSIONS In this cohort of advanced essential tremor patients who no longer had ideal tremor reduction with a standard system, replacing their deep brain stimulation with a directional system significantly improved their tremor and quality of life. Up-front implantation of directional deep brain stimulation leads may provide better tremor control in those patients who progress at a later time point.
Collapse
Affiliation(s)
- Marie T Krüger
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada.,Department of Neurosurgery, Cantonal Hospital St.Gallen, St.Gallen, Switzerland.,Department of Stereotactic and Functional Neurosurgery, University Medical Clinic Freiburg, Freiburg, Germany
| | - Josue M Avecillas-Chasin
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada.,Department of Neurosurgery, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Mandeep S Tamber
- Department of Surgery, Division of Pediatric Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| | - Manraj K S Heran
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Mini K Sandhu
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| | | | - Natasha Sarai
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| | - Christopher R Honey
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
16
|
Krüger MT, Várkuti B, Achinger J, Coenen VA, Prokop T, Delev D, Blass BI, Piroth T, Reinacher PC. Navigated Deep Brain Stimulation Surgery: Evaluating the Combined Use of a Frame-Based Stereotactic System and a Navigation System. Stereotact Funct Neurosurg 2020; 99:48-54. [PMID: 33075799 DOI: 10.1159/000510528] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Accepted: 07/28/2020] [Indexed: 11/19/2022]
Abstract
Deep brain stimulation (DBS) is a complex surgical procedure that requires detailed anatomical knowledge. In many fields of neurosurgery navigation systems are used to display anatomical structures during an operation to aid performing these surgeries. In frame-based DBS, the advantage of visualization has not yet been evaluated during the procedure itself. In this study, we added live visualization to a frame-based DBS system, using a standard navigation system and investigated its accuracy and potential use in DBS surgery. As a first step, a phantom study was conducted to investigate the accuracy of the navigation system in conjunction with a frame-based approach. As a second step, 5 DBS surgeries were performed with this combined approach. Afterwards, 3 neurosurgeons and 2 neurologists with different levels of experience evaluated the potential use of the system with a questionnaire. Moreover, the additional personnel, costs and required set up time were noted and compared to 5 consecutive standard procedures. In the phantom study, the navigation system showed an inaccuracy of 2.1 mm (mean SD 0.69 mm). In the questionnaire, a mean of 9.4/10 points was awarded for the use of the combined approach as a teaching tool, a mean of 8.4/10 for its advantage in creating a 3-dimensional (3-D) map and a mean of 8/10 points for facilitating group discussions. Especially neurosurgeons and neurologists in training found it useful to better interpret clinical results and side effects (mean 9/10 points) and neurosurgeons appreciated its use to better interpret microelectrode recordings (mean 9/10 points). A mean of 6/10 points was awarded when asked if the benefits were worth the additional efforts. Initially 2 persons, then one additional person was required to set up the system with no relevant added time or costs. Using a navigation system for live visualization during frame-based DBS surgery can improve the understanding of the complex 3-D anatomy and many aspects of the procedure itself. For now, we would regard it as an excellent teaching tool rather than a necessity to perform DBS surgeries.
Collapse
Affiliation(s)
- Marie T Krüger
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Neurosurgery, Cantonal Hospital, St. Gallen, Switzerland
| | | | | | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Basics in Neuromodulation, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Center for Deep Brain Stimulation, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Prokop
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Delev
- Department of Neurosurgery, University Medical Center Aachen, Aachen, Germany
| | - Bianca-Ioana Blass
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Piroth
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Neurology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany, .,Fraunhofer Institute for Laser Technology, Aachen, Germany,
| |
Collapse
|
17
|
Honey CM, Krüger MT, Rheaume AR, Avecillas-Chasin JM, Morrison MD, Honey CR. Concurrent Glossopharyngeal Neuralgia and Hemi-Laryngopharyngeal Spasm (HeLPS): A Case Report and a Review of the Literature. Neurosurgery 2020; 87:E573-E577. [PMID: 31832655 PMCID: PMC8133322 DOI: 10.1093/neuros/nyz546] [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: 07/29/2019] [Accepted: 10/24/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Hemi-laryngopharyngeal spasm (HeLPS) has been recently described but is not yet widely recognized. Patients describe intermittent coughing and choking and can be cured following microvascular decompression of their Xth cranial nerve. This case report and literature review highlight that HeLPS can co-occur with glossopharyngeal neuralgia (GN) and has been previously described (but not recognized) in the neurosurgical literature. CLINICAL PRESENTATION A patient with GN and additional symptoms compatible with HeLPS is presented. The patient reported left-sided, intermittent, swallow-induced, severe electrical pain radiating from her ear to her throat (GN). She also reported intermittent severe coughing, throat contractions causing a sense of suffocation, and dysphonia (HeLPS). All her symptoms resolved following a left microvascular decompression of a loop of the posterior inferior cerebellar artery that was pulsating against both the IXth and Xth cranial nerves. A review of the senior author's database revealed another patient with this combination of symptoms. An international literature review found 27 patients have been previously described with symptoms of GN and the additional (but not recognized at the time) symptoms of HeLPS. CONCLUSION This review highlights that patients with symptoms compatible with HeLPS have been reported since 1926 in at least 4 languages. This additional evidence supports the growing recognition that HeLPS is another neurovascular compression syndrome. Patients with HeLPS continue to be misdiagnosed as conversion disorder. The increased recognition of this new medical condition will require neurosurgical treatment and should alleviate the suffering of these patients.
Collapse
Affiliation(s)
- C Michael Honey
- Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marie T Krüger
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Alan R Rheaume
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | | | - Murray D Morrison
- Division of Otolaryngology, University of British Columbia, Vancouver, Canada
| | | |
Collapse
|
18
|
Krüger MT, Kurtev-Rittstieg R, Kägi G, Naseri Y, Hägele-Link S, Brugger F. Evaluation of Automatic Segmentation of Thalamic Nuclei through Clinical Effects Using Directional Deep Brain Stimulation Leads: A Technical Note. Brain Sci 2020; 10:brainsci10090642. [PMID: 32957437 PMCID: PMC7563258 DOI: 10.3390/brainsci10090642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 08/18/2020] [Revised: 09/15/2020] [Accepted: 09/15/2020] [Indexed: 11/24/2022] Open
Abstract
Automatic anatomical segmentation of patients’ anatomical structures and modeling of the volume of tissue activated (VTA) can potentially facilitate trajectory planning and post-operative programming in deep brain stimulation (DBS). We demonstrate an approach to evaluate the accuracy of such software for the ventral intermediate nucleus (VIM) using directional leads. In an essential tremor patient with asymmetrical brain anatomy, lead placement was adjusted according to the suggested segmentation made by the software (Brainlab). Postoperatively, we used directionality to assess lead placement using side effect testing (internal capsule and sensory thalamus). Clinical effects were then compared to the patient-specific visualization and VTA simulation in the GUIDE™ XT software (Boston Scientific). The patient’s asymmetrical anatomy was correctly recognized by the software and matched the clinical results. VTA models matched best for dysarthria (6 out of 6 cases) and sensory hand side effects (5/6), but least for facial side effects (1/6). Best concordance was observed for the modeled current anterior and back spread of the VTA, worst for the current side spread. Automatic anatomical segmentation and VTA models can be valuable tools for DBS planning and programming. Directional DBS leads allow detailed postoperative assessment of the concordance of such image-based simulation and visualization with clinical effects.
Collapse
Affiliation(s)
- Marie T. Krüger
- Department of Neurosurgery, Cantonal Hospital, 9000 St. Gallen, Switzerland;
- Department of Stereotactic and Functional Neurosurgery, University Medical Center, 79106 Freiburg, Germany
- Correspondence: ; Tel.: +41-71-494-1111
| | | | - Georg Kägi
- Department of Neurology, Cantonal Hospital, 9000 St. Gallen, Switzerland; (G.K.); (S.H.-L.); (F.B.)
| | - Yashar Naseri
- Department of Neurosurgery, Cantonal Hospital, 9000 St. Gallen, Switzerland;
- Department of Stereotactic and Functional Neurosurgery, University Medical Center, 79106 Freiburg, Germany
| | - Stefan Hägele-Link
- Department of Neurology, Cantonal Hospital, 9000 St. Gallen, Switzerland; (G.K.); (S.H.-L.); (F.B.)
| | - Florian Brugger
- Department of Neurology, Cantonal Hospital, 9000 St. Gallen, Switzerland; (G.K.); (S.H.-L.); (F.B.)
| |
Collapse
|
19
|
Naseri Y, Hubbe U, Scholz C, Brönner J, Krüger MT, Klingler JH. Radiation exposure of a mobile 3D C-arm with large flat-panel detector for intraoperative imaging and navigation - an experimental study using an anthropomorphic Alderson phantom. BMC Med Imaging 2020; 20:96. [PMID: 32799805 PMCID: PMC7429709 DOI: 10.1186/s12880-020-00495-y] [Citation(s) in RCA: 3] [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: 04/22/2020] [Accepted: 08/05/2020] [Indexed: 11/16/2022] Open
Abstract
Background Intraoperative 3-dimensional (3D) navigation is increasingly being used for pedicle screw placement. For this purpose, dedicated mobile 3D C-arms are capable of providing intraoperative fluoroscopy-based 3D image data sets. Modern 3D C-arms have a large field of view, which suggests a higher radiation exposure. In this experimental study we therefore investigate the radiation exposure of a new mobile 3D C-arm with large flat-panel detector to a previously reported device with regular flat-panel detector on an Alderson phantom. Methods We measured the radiation exposure of the Vision RFD 3D (large 30 × 30 cm detector) while creating 3D image sets as well as standard fluoroscopic images of the cervical and lumbar spine using an Alderson phantom. The dosemeter readings were then compared with the radiation exposure of the previous model Vision FD Vario 3D (smaller 20 × 20 cm detector), which had been examined identically in advance and published elsewhere. Results The larger 3D C-arm induced lower radiation exposures at all dosemeter sites in cervical 3D scans as well as at the sites of eye lenses and thyroid gland in lumbar 3D scans. At male and especially female gonads in lumbar 3D scans, however, the larger 3D C-arm showed higher radiation exposures compared with the smaller 3D C-arm. In lumbar fluoroscopic images, the dosemeters near/in the radiation field measured a higher radiation exposure using the larger 3D C-arm. Conclusions The larger 3D C-arm offers the possibility to reduce radiation exposures for specific applications despite its larger flat-panel detector with a larger field of view. However, due to the considerably higher radiation exposure of the larger 3D C-arm during lumbar 3D scans, the smaller 3D C-arm is to be recommended for short-distance instrumentations (mono- and bilevel) from a radiation protection point of view. The larger 3D C-arm with its enlarged 3D image set might be used for long instrumentations of the lumbar spine. From a radiation protection perspective, the use of the respective 3D C-arm should be based on the presented data and the respective application.
Collapse
Affiliation(s)
- Yashar Naseri
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.,Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Ulrich Hubbe
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Christoph Scholz
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Johannes Brönner
- Helmholtz Zentrum München, German Research Center for Environmental Health, Individual Monitoring Service, Munich, Germany
| | - Marie T Krüger
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.,Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Jan-Helge Klingler
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany.
| |
Collapse
|
20
|
Klingler JH, Elsheikh S, Doostkam S, Krüger MT, Blaß BI, Steiert C. Spinal paraganglioma as unusual finding in von Hippel-Lindau disease. J Clin Neurosci 2020; 77:217-221. [PMID: 32389544 DOI: 10.1016/j.jocn.2020.05.025] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/04/2020] [Indexed: 11/16/2022]
Abstract
A 20-year-old patient with a history of von Hippel-Lindau disease reported on thoracic back pain radiating to the left shoulder for 10 weeks. Magnetic resonance imaging revealed a progressive contrast-enhancing tumor (14 × 21 × 28 mm) compressing the spinal cord and extending into the left neural foramen at T5/6. After embolization of supplying vessels, the tumor was completely resected via hemilaminectomy of T5. The postoperative course was uneventful without surgery related morbidity. The pathological examination disclosed a paraganglioma WHO grade I. We discuss the differential diagnoses and pitfalls of this unexpected finding in this patient with von Hippel-Lindau disease.
Collapse
Affiliation(s)
- Jan-Helge Klingler
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany.
| | - Samer Elsheikh
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Soroush Doostkam
- Department of Neuropathology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Marie T Krüger
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Bianca-Ioana Blaß
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Christine Steiert
- Department of Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| |
Collapse
|
21
|
Krüger MT, Hu A, Honey CR. Deep Brain Stimulation for Spasmodic Dysphonia: A Blinded Comparison of Unilateral and Bilateral Stimulation in Two Patients. Stereotact Funct Neurosurg 2020; 98:200-205. [PMID: 32316007 DOI: 10.1159/000507058] [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: 12/29/2019] [Accepted: 03/06/2020] [Indexed: 11/19/2022]
Abstract
Deep brain stimulation (DBS) is a promising new therapy for patients with spasmodic dysphonia (SD). The preliminary results from our randomized controlled trial showed good clinical effects with unilateral left thalamic stimulation in 6 right- handed patients. This suggests that the pathological process underpinning SD may have a "hemisphere dominant" pathway. We describe 2 patients with concurrent essential tremor and SD who had previously undergone bilateral thalamic DBS for their limb tremor. Both patients experienced an unanticipated improvement of their SD symptoms. One patient was right-handed, and the other was mixed left-handed. To investigate the amount of SD improvement following DBS therapy in each hemisphere, 4 different settings were tested: both sides on, left side on, right side on, and both sides off. Both patients most improved following bilateral stimulation. There was, however, a powerful unilateral benefit in both patients with only a small additional benefit from bilateral stimulation. The right-handed patient improved most with left-hemisphere stimulation whereas the mixed left-handed patient improved most with right hemisphere stimulation. There was some discrepancy between the two tests applied in the second patient reflecting the known difficulties to evaluate vocal symptom improvement in SD. We discuss the possible correlation of handedness and speech hemisphere dominance as well as the need for more reliable tests to measure SD severity. Ultimately, we recommend a bilateral approach for future studies, using a patient perception test as the primary outcome and functional imaging to further investigate the correlation of handedness and the amount of hemisphere dominance in SD.
Collapse
Affiliation(s)
- Marie T Krüger
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada, .,Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland, .,Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany,
| | - Amanda Hu
- Division of Otolaryngology, Head and Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
22
|
Honey CR, Krüger MT, Morrison MD, Dhaliwal BS, Hu A. Vagus Associated Neurogenic Cough Occurring Due to Unilateral Vascular Encroachment of Its Root: A Case Report and Proof of Concept of VANCOUVER Syndrome. Ann Otol Rhinol Laryngol 2019; 129:523-527. [PMID: 31786948 DOI: 10.1177/0003489419892287] [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] [Indexed: 12/14/2022]
Abstract
OBJECTIVES A patient is presented with neurogenic cough due to a unilateral vascular compression of a vagus nerve rootlet at the brainstem with complete resolution of cough following microvascular decompression of that nerve. This etiology of a neurogenic cough has not been previously reported to our knowledge. The proportion of patients with neurogenic cough refractory to all current therapies and suffering with this treatable condition remains to be defined. We introduce the concept of Vagus Associated Neurogenic Cough Occurring due to Unilateral Vascular Encroachment of its Root (VANCOUVER syndrome) and present the salient features of this condition. METHODS A case review is presented with details of the patient's history, examination, imaging, laryngoscopy, intraoperative findings, and long-term clinical outcome. RESULTS A 60-year-old man presented with a 15-year history of non-productive cough refractory to antibiotics, and anti-reflux medications. Investigations by an allergist, a cardiologist, a gastroenterologist, two pulmonologists, and an otolaryngologist were negative. MRI demonstrated a vascular compression of his left vagus nerve and microvascular decompression of that nerve resolved his symptoms. There were no surgical complications and the patient remains asymptomatic at 1 year. CONCLUSIONS Neurogenic cough has been likened to a vagus nerve neuropathy in a similar way that trigeminal neuralgia is a trigeminal nerve neuropathy. Both cause intermittent sensory phenomena in their distribution and can be ameliorated with neuropathic medications. We demonstrate that neurogenic cough, like trigeminal neuralgia, may be caused by a vascular compression of its nerve root. A proposed mechanism of this type of neurogenic cough is presented along with a potential diagnostic paradigm for these patients.
Collapse
Affiliation(s)
- Christopher R Honey
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Marie T Krüger
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Murray D Morrison
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Baljinder S Dhaliwal
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Amanda Hu
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
23
|
Reinacher PC, Várkuti B, Krüger MT, Piroth T, Egger K, Roelz R, Coenen VA. Automatic Segmentation of the Subthalamic Nucleus: A Viable Option to Support Planning and Visualization of Patient-Specific Targeting in Deep Brain Stimulation. Oper Neurosurg (Hagerstown) 2019; 17:497-502. [PMID: 30860266 DOI: 10.1093/ons/opz015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 04/16/2018] [Accepted: 01/31/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Automatic segmentation is gaining relevancy in image-based targeting of neural structures. OBJECTIVE To evaluate its feasibility, we retrospectively analyzed the concordance of magnetic resonance imaging (MRI)-based automatic segmentation of the subthalamic nucleus (STN) and intraoperative microelectrode recordings (MERs). METHODS Electrodes (n = 60) for deep brain stimulation were implanted in the STN of patients (n = 30; median age 57 yr) with Parkinson disease (n = 29) or rapid-onset dystonia parkinsonism (n = 1). Elements (Brainlab, Munich, Germany) were used to segment the STN, using 2 volumetric T1 (±contrast) and volumetric T2 images as input. The stereotactic computed tomography was coregistered with the imaging, and the original stereotactic coordinates were imported. MERs (0.5-1 mm steps) along the anterior, central, and lateral trajectories were used to determine differences between the image-segmented STN boundary and MER-based STN entry and exit. RESULTS Of 175 trajectories, 105 penetrated or touched (≤0.7 mm) the STN. The overall median deviation between the segmented STN boundary and electrophysiological recordings was 1.1 mm for MER-based STN entry and 2.0 mm for STN exit. Regarding the entry point of the STN, there was no statistically significant difference between MRI-based automatic segmentation and the electrophysiological trajectories analyzed with intraoperative MER. The exit point was significantly different between both methods in the central and lateral trajectories. CONCLUSION MRI-based automatic segmentation of the STN is a viable, patient-specific targeting approach that can be used alongside traditional targeting methods in deep brain stimulation to support preoperative planning and visualization of target structures and aid postoperative optimization of programming.
Collapse
Affiliation(s)
- Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bálint Várkuti
- Department of Functional and Stereotactic Neurosurgery, Brainlab AG, Olof Palme Straße 9, Munich, Germany
| | - Marie T Krüger
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Piroth
- Department of Neurology, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Roland Roelz
- Department of Neurosurgery, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
24
|
Krüger MT, Hirmer TJ, Honey CR. Coughing as a Side Effect of Deep Brain Stimulation due to Peripheral Stimulation of the Vagus Nerve: Case Report. Stereotact Funct Neurosurg 2019; 97:207-211. [PMID: 31600763 DOI: 10.1159/000503364] [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: 07/21/2019] [Accepted: 09/13/2019] [Indexed: 11/19/2022]
Abstract
The authors describe how severe coughing and breathing issues were caused by a deep brain stimulation (DBS) system due to current induction in the adjacent vagus nerve. A 57-year-old man with Parkinson's disease (PD) who received bilateral subthalamic nucleus DBS presented with coughing and breathing difficulty when his DBS system was activated. The intensity of coughing was directly related to the amount of stimulation. When the DBS system was turned off, his cough resolved immediately. A system check revealed no radiographic abnormalities and all electrode impedances were within the normal range. We hypothesize that the coughing was caused by an induced electromagnetic stimulation of the vagus nerve from the extensions, which were running in close proximity to the nerve in the neck. Since the patient could not tolerate the coughing at stimulation settings required to ameliorate his PD symptoms, we ultimately exchanged the extensions and moved them further away from the vagus nerve. This resulted in immediate, complete, and continuous relief of the patient's symptoms.
Collapse
Affiliation(s)
- Marie T Krüger
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada,
| | - Thomas J Hirmer
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
25
|
Krüger MT, Steiert C, Gläsker S, Klingler JH. Minimally invasive resection of spinal hemangioblastoma: feasibility and clinical results in a series of 18 patients. J Neurosurg Spine 2019; 31:1-10. [PMID: 31398701 DOI: 10.3171/2019.5.spine1975] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 01/20/2019] [Accepted: 05/28/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Hemangioblastomas are benign, highly vascularized tumors that can occur sporadically or as part of von Hippel-Lindau (VHL) disease. Traditionally, spinal hemangioblastomas have been surgically treated via an open approach. In recent years, however, minimally invasive techniques using tubular retractors have been increasingly applied in spine surgery. Such procedures involve less tissue trauma but are also particularly demanding for the surgeon, especially in cases of highly vascular tumors such as hemangioblastomas. The object of this study was to evaluate the safety and efficacy of minimally invasive resection of selected spinal hemangioblastomas. METHODS The authors conducted a retrospective single-center study of all patients who, between January 2010 and January 2018, had been operated on for spinal hemangioblastoma via a minimally invasive approach performed at the surgeon's discretion. The surgical technique is described and the pre- and postoperative neurological and imaging results were analyzed descriptively. The primary outcome was the postoperative compared to preoperative neurological condition (McCormick grade). The secondary outcomes were the extent of tumor resection and postoperative complications. RESULTS Eighteen patients, 12 female and 6 male, harboring a total of 19 spinal hemangioblastomas underwent surgery in the study period. Seventeen patients had stable neurological findings with stable or improved McCormick grades (94.5%) at a mean of 4.3 months after surgery. One (5.5%) of the 18 patients developed progressive neurological symptoms with a worsened McCormick grade that did not improve in the long-term follow-up. Sixteen of the 18 patients had VHL disease, whereas 2 patients had sporadic spinal hemangioblastomas. In all patients, postoperative MRI showed complete resection of the tumors. No other surgery-related perioperative or postoperative complications were recorded. CONCLUSIONS A minimally invasive approach for the resection of selected spinal hemangioblastomas is safe and allows complete tumor resection with good clinical results in experienced hands.
Collapse
Affiliation(s)
- Marie T Krüger
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- 2Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada; and
| | - Christine Steiert
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sven Gläsker
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- 3Department of Neurosurgery, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jan-Helge Klingler
- 1Department of Neurosurgery, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
26
|
Reinacher PC, Altenmüller DM, Krüger MT, Schulze-Bonhage A, Urbach H, Trippel M, Coenen VA, Delev D. Simultaneous Frame-assisted Stereotactic Placement of Subdural Grid Electrodes and Intracerebral Depth Electrodes. J Neurol Surg A Cent Eur Neurosurg 2019; 80:353-358. [PMID: 31083743 DOI: 10.1055/s-0039-1685193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND AND STUDY AIMS In complex cases of drug-resistant focal epilepsy, the precise localization of the epileptogenic zone requires simultaneous implantation of depth and subdural grid electrodes. This study describes a new simple frame-assisted method that facilitates the simultaneous placement of both types of intracranial electrodes. MATERIAL AND METHODS Ten consecutive patients were evaluated and divided into two groups. Group A included patients with simultaneous frame-assisted placement of depth and subdural grid electrodes. In group B, depth electrodes were implanted stereotactically; grid electrodes were implanted in a separate surgery. RESULTS The placement of the subdural grid was accurate as individually designed by the epileptologists in all five patients from group A. In group B, one patient showed a slight and another one a significant deviation of the subdural grid position postoperatively. The mean surgical time in group A was shorter (280±62 minutes) compared with the mean duration of the surgical procedures in group B (336±51 minutes). CONCLUSION The frame-assisted placement of subdural grid electrodes facilitates the surgical procedure for invasive video-electroencephalography monitoring in complex cases of drug-resistant focal epilepsy in which a combination of depth electrodes and subdural grid electrodes is needed, by reducing the surgical time and guaranteeing highly accurate electrode localizations.
Collapse
Affiliation(s)
- Peter C Reinacher
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Dirk-Matthias Altenmüller
- Medical Faculty, Freiburg University, Freiburg, Germany.,Department of Epileptology, Freiburg University Medical Center, Freiburg, Germany
| | - Marie T Krüger
- Medical Faculty, Freiburg University, Freiburg, Germany.,Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany
| | - Andreas Schulze-Bonhage
- Medical Faculty, Freiburg University, Freiburg, Germany.,Department of Epileptology, Freiburg University Medical Center, Freiburg, Germany
| | - Horst Urbach
- Medical Faculty, Freiburg University, Freiburg, Germany.,Department of Neuroradiology, Freiburg University Medical Center, Freiburg, Germany
| | - Michael Trippel
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Volker A Coenen
- Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Freiburg, Germany.,Medical Faculty, Freiburg University, Freiburg, Germany
| | - Daniel Delev
- Medical Faculty, Freiburg University, Freiburg, Germany.,Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany
| |
Collapse
|
27
|
Krüger MT, Reinacher PC. AJNR Am J Neuroradiol 2019; 40:757-757. [DOI: 10.3174/ajnr.p0065] [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: 11/07/2022]
|
28
|
Krüger MT, Naseri Y, Hohenhaus M, Hubbe U, Scholz C, Klingler JH. Impact of morbid obesity (BMI > 40 kg/m2) on complication rate and outcome following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). Clin Neurol Neurosurg 2019; 178:82-85. [DOI: 10.1016/j.clineuro.2019.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 11/29/2022]
|
29
|
Krüger MT, Klingler JH, Jilg C, Steiert C, Zschiedrich S, Van Velthoven V, Gläsker S. Polyglobulia in patients with hemangioblastomas is related to tumor size but not to serum erythropoietin. Hered Cancer Clin Pract 2018; 16:15. [PMID: 30214643 PMCID: PMC6131788 DOI: 10.1186/s13053-018-0097-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 11/22/2017] [Accepted: 08/30/2018] [Indexed: 11/10/2022] Open
Abstract
Background Hemangioblastomas are associated with elevated hemoglobin (Hb) levels (polyglobulia), which is associated with a higher risk for cerebral stroke, cardiac infarction and pulmonary embolism. The pathomechanism of polyglobulia remains unclear and different theories have been postulated. Among those are elevated serum erythropoietin (EPO) levels caused by secretion of the tumor or associated tumor cyst. Methods To elucidate the pathomechanism, we systematically investigated the relation between polyglobulia, serum EPO level, size of the solid tumor and associated cyst in hemangioblastomas. We prospectively evaluated hemoglobin and EPO levels in a series of 33 consecutive patients operated on hemangioblastomas in our center. We measured the size of the solid tumor and associated cyst in magnetic resonance imaging. Statistical evaluations were performed using the Fisher's exact test and student's t-test. Results As a result five patients had elevated hemoglobin levels. Only one of these had an elevated serum EPO level. Of 26 patients with normal hemoglobin levels, 4 patients had elevated EPO levels.Patients with low or normal hemoglobin levels (84%) had an average tumor size of 0.8 cm3, which differed significantly from patients with elevated hemoglobin levels (16%), who had an average solid tumor size of 8.0 cm3 (p < 0.05). We did not observe a significant correlation between EPO levels or polyglobulia and associated cysts. Conclusions We therefore conclude that in contrast to previous case reports and interpretations, our data show no correlation between polyglobulia and EPO levels or associated cysts in patients with hemangioblastomas. In fact, it is the size of the solid tumor that correlates with polyglobulia.The study was retrospectively registered in the German Clinical Trial Registry on 10 July 2014; Trial registration: DRKS00006310.
Collapse
Affiliation(s)
- Marie T Krüger
- 1Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany
| | - Jan-Helge Klingler
- 1Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany
| | - Cordula Jilg
- 2Department of Urology, Freiburg University Medical Center, Freiburg, Germany
| | - Christine Steiert
- 1Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany
| | - Stefan Zschiedrich
- 3Department of Internal Medicine, Section for Preventive Medicine, Freiburg University Medical Center, Freiburg, Germany
| | - Vera Van Velthoven
- 4Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium
| | - Sven Gläsker
- 1Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany.,4Department of Neurosurgery, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussel, Belgium
| |
Collapse
|
30
|
Krüger MT, Coenen VA, Jenkner C, Urbach H, Egger K, Reinacher PC. Combination of CT angiography and MRI in surgical planning of deep brain stimulation. Neuroradiology 2018; 60:1151-1158. [DOI: 10.1007/s00234-018-2079-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 08/13/2018] [Indexed: 12/20/2022]
|
31
|
Affiliation(s)
- P C Reinacher
- Department of Stereotactic and Functional Neurosurgery
| | | | - V A Coenen
- Department of Stereotactic and Functional Neurosurgery
| | - M Shah
- Department of Neurosurgery
| | | | | | - K Egger
- Department of Neuroradiology Medical Center, Faculty of Medicine University of Freiburg, Freiburg, Germany
| |
Collapse
|
32
|
Reinacher PC, Krüger MT, Coenen VA, Shah M, Roelz R, Jenkner C, Egger K. Determining the Orientation of Directional Deep Brain Stimulation Electrodes Using 3D Rotational Fluoroscopy. AJNR Am J Neuroradiol 2017; 38:1111-1116. [PMID: 28385887 DOI: 10.3174/ajnr.a5153] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/23/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE New deep brain stimulation leads with electrode contacts that are split along their circumference allow steering of the electrical field in a predefined direction. However, imaging-assisted directional stimulation requires detailed knowledge of the exact orientation of the electrode array. The purpose of this study was to evaluate whether this information can be obtained by rotational 3D fluoroscopy. MATERIALS AND METHODS Two directional leads were inserted into a 3D-printed plaster skull filled with gelatin. The torsion of the lead tip versus the lead at the burr-hole level was investigated. Then, 3 blinded raters evaluated 12 3D fluoroscopies with random lead orientations. They determined the lead orientation considering the x-ray marker only and considering the overlap of the gaps between the contact segments. Intraclass correlation coefficients and an extended version of the Bland-Altman plot were used to determine interrater reliability and agreement of the measurements of the different raters. RESULTS Electrode torsion of up to 35° could be demonstrated. Evaluation of the lead rotation considering the x-ray marker only revealed limits of agreement of ±9.37° and an intraclass correlation coefficient of 0.9975. In addition, taking into account the lines resulting from overlapping of the gaps between the electrode segments, the limits of agreement to the mean were ±2.44° and an intraclass correlation coefficient of 0.9998. CONCLUSIONS In directional deep brain stimulation systems, rotational 3D fluoroscopy combined with the described evaluation method allows for determining the exact orientation of the leads, enabling the full potential of imaging-assisted personalized programming.
Collapse
Affiliation(s)
- P C Reinacher
- From the Departments of Stereotactic and Functional Neurosurgery (P.C.R., V.A.C.)
| | | | - V A Coenen
- From the Departments of Stereotactic and Functional Neurosurgery (P.C.R., V.A.C.)
| | - M Shah
- Neurosurgery (M.T.K., M.S., R.R.)
| | - R Roelz
- Neurosurgery (M.T.K., M.S., R.R.)
| | - C Jenkner
- Clinical Trial Unit (C.J.), Freiburg University Medical Center, Freiburg, Germany
| | | |
Collapse
|
33
|
Gläsker S, Krüger MT, Klingler JH, Wlodarski M, Klompen J, Schatlo B, Hippchen B, Neumann HPH, Van Velthoven V. Hemangioblastomas and neurogenic polyglobulia. Neurosurgery 2014; 72:930-5; discussion 935. [PMID: 23407287 DOI: 10.1227/neu.0b013e31828ba793] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Neurogenic polyglobulia occurs with central nervous system hemangioblastomas. Among the suggested mechanisms are extramedullary hematopoiesis in the tumor tissue and germline mutations of the von Hippel-Lindau (VHL) tumor suppressor gene. OBJECTIVE To determine the frequency and driving mechanisms of polyglobulia in central nervous system hemangioblastomas. METHODS We performed a retrospective analysis of pre- and postoperative (at 3 and 12 months) hemoglobin levels in a consecutive series of patients with hemangioblastomas operated on in our institution from 1996 to 2009. We performed molecular genetic analyses for mutations of the VHL tumor suppressor gene. RESULTS Preoperative hemoglobin levels were available from 164 patients. The average hemoglobin level (15.2 g/dL in males and 13.1 g/dL in females) was within normal range according to our standards. Of 22 patients with increased preoperative hemoglobin levels (>17 g/dL in males and >15 g/dL in females), 8 presented with pathological hemoglobin (>18.5 g/dL in males and >16.5 g/dL in females) according to World Health Organization criteria. Surgical removal of the hemangioblastoma resulted in a permanent cure of polyglobulia in all patients. Six of the 8 patients with pathological hemoglobin elevation carried a germline mutation of the VHL tumor suppressor gene. CONCLUSION Neurogenic polyglobulia occurs in a subset of patients with hemangioblastomas. This phenomenon is mostly observed in VHL mutation carriers, but also occurs in patients with sporadic hemangioblastomas. Removal of the tumor results in the permanent cure of polyglobulia. Our observations suggest that polyglobulia is an effect by the tumor itself, either due to paraneoplasia or extramedullary hematopoiesis.
Collapse
Affiliation(s)
- Sven Gläsker
- Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany.
| | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Klingler JH, Krüger MT, Lemke JR, Jilg C, Van Velthoven V, Zentner J, Neumann HPH, Gläsker S. Sequence variations in the von Hippel-Lindau tumor suppressor gene in patients with intracranial aneurysms. J Stroke Cerebrovasc Dis 2013; 22:437-43. [PMID: 23434161 DOI: 10.1016/j.jstrokecerebrovasdis.2013.01.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 01/23/2013] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The rupture of intracranial aneurysms leads to subarachnoid hemorrhage, which is often associated with poor outcome. Preventive treatment of unruptured intracranial aneurysms is possible and recommended. However, the lack of candidate genes precludes identifying patients at risk by genetic analyses. We observed intracranial aneurysms in 2 patients with von Hippel-Lindau (VHL) disease and the known disease-causing mutation c.292T > C (p.Tyr98His) in the VHL tumor suppressor gene. This study investigates whether the VHL gene is a possible candidate gene for aneurysm formation. METHODS Patients with intracranial aneurysms admitted to our department between 2006 and 2009 were enrolled. The peripheral leukocyte DNA of 200 patients was investigated for sequence variations in the VHL gene using denaturing high performance liquid chromatography. Peripheral leukocyte DNA of 100 randomly sampled probands was investigated as a control group. The allelic frequencies of sequence variations between both groups were compared using the Fisher exact test. RESULTS Fourteen of 200 patients with intracranial aneurysms had sequence variations at 6 different loci in the VHL gene. In contrast, no sequence variations were identified in 100 probands in the control group (P = 0.0062). However, none of the single-sequence variations had a statistically significant difference in the allelic frequencies compared to the control group. CONCLUSIONS There is accumulating evidence for a genetic basis of aneurysm development. Our investigations lead to the conclusion that the VHL gene is potentially involved in the formation of intracranial aneurysms in a subset of patients. Additional candidate genes need to be identified in order to develop sensitive genetic screening for at-risk patients.
Collapse
Affiliation(s)
- Jan-Helge Klingler
- Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany
| | | | | | | | | | | | | | | |
Collapse
|
35
|
Krüger MT, Zhao S, Chai X, Brunne B, Bouché E, Bock HH, Frotscher M. Role for Reelin-induced cofilin phosphorylation in the assembly of sympathetic preganglionic neurons in the murine intermediolateral column. Eur J Neurosci 2010; 32:1611-7. [PMID: 21039973 DOI: 10.1111/j.1460-9568.2010.07433.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Sympathetic preganglionic neurons (SPNs) are located in the intermediolateral column (IMLC) of the spinal cord. This specific localization results from primary and secondary migratory processes during spinal cord development. Thus, following neurogenesis in the neuroepithelium, SPNs migrate first in a ventrolateral direction and then, in a secondary step, dorsolaterally to reach the IMLC. These migratory processes are controlled, at least in part, by the glycoprotein Reelin, which is known to be important for the development of laminated brain structures. In reeler mutants deficient in Reelin, SPNs initially migrate ventrolaterally as normal. However, most of them then migrate medially to become eventually located near the central canal. Here, we provide evidence that in wild-type animals this aberrant medial migration towards the central canal is prevented by Reelin-induced cytoskeletal stabilization, brought about by phosphorylation of cofilin. Cofilin plays an important role in actin depolymerization, a process required for the changes in cell shape during migration. Phosphorylation of cofilin renders it unable to depolymerize F-actin, thereby stabilizing the cytoskeleton. Using immunostaining for phosphorylated cofilin (p-cofilin), we demonstrate that SPNs in wild-type animals, but not in reeler mutants and other mutants of the Reelin signalling cascade, are immunoreactive for p-cofilin. These findings suggest that Reelin near the central canal induces cofilin phosphorylation in SPNs, thereby preventing them from aberrant migration towards the central canal. The results extend our previous studies on cortical neurons in which Reelin in the marginal zone was found to stabilize the leading processes of migrating neurons and terminate the migration process.
Collapse
Affiliation(s)
- Marie T Krüger
- Institut für Anatomie und Zellbiologie, Albert-Ludwigs-Universität Freiburg, Albertstr. 17, Freiburg, Germany
| | | | | | | | | | | | | |
Collapse
|