An initial experience with intraoperative O-Arm for deep brain stimulation surgery: can it replace post-operative MRI?

Deep brain stimulation (DBS) is used to treat movement disorders, severe psychiatric disorders, and neuropathic pain, among other diseases. Advanced neuroimaging techniques allow direct or indirect localization of the target site, which is verified in many centers by the intraoperative recording of unitary neuronal activity. Intraoperative image acquisition technology (e.g., O-Arm) is increasingly used for accurate electrode positioning throughout the surgery. The aim of our study is to analyze the initial experience of our team in the utilization of O-Arm for planning DBS and monitoring its precision and accuracy throughout the procedure. The study included 13 patients with movement disorders. All underwent DBS with the intraoperative O-arm image acquisition system (iCT) and Medtronic StealthStation S7 cranial planning system, placing a total of 25 electrodes. For each patient, we calculated the difference between real and theoretic x, y, z coordinates, using the paired Student's t test to evaluate absolute and directional differences and the one-sample Student's t test to analyze differences in Euclidean distances. No statistically significant differences were found in absolute, directional, or Euclidean distances between intended and actual x, y, and z coordinates, based on iCT scan. Our experience confirms that utilization of the O-Arm system in DBS provides accurate and precise verification of electrode placements throughout the procedure. Recent studies found no significant differences between iCT and postoperative MRI, the current gold standard. Further prospective studies are warranted to test the elimination of postoperative MRI when this system is used.

[Bilateral acute subdural haematoma without subarachnoid haemorrhage secondary to rupture of an anterior communicating aneurysm. A case report and review of the literature]. / Hematoma subdural agudo bilateral sin hemorragia subaracnoidea secundario a ruptura de aneurisma comunicante anterior. Presentacion de un caso y revision de la bibliografia.

INTRODUCTION: Pure acute subdural haematomas caused by aneurysmal rupture are a highly infrequent event, with only 51 cases published in the literature to date, with only six cases due to the rupture of anterior communicating artery aneurysm. AIM: To describe a case of an acute subdural haematoma not associated with subarachnoid haemorrhage due to ruptured of an anterior communicating cerebral artery aneurysm. CASE REPORT: A 55-year-old woman without a traumatic history, who is found at home with a level of consciousness of 4 points on the Glasgow Coma Scale and a bilateral arreactive mydriasis, which are reversed with medical measures. Cranial CT shows an acute bi-hemispherical convexity and interhemispheric subdural haematoma with no evidence of associated subarachnoid haemorrhage. The angio-CT reveals an anterior communicating artery aneurysm. We proceed to urgent embolization of the aneurysm. The patient was admitted to the Intensive Care Unit, where intracranial pressure is monitored and controlled initially with medical treatment. Patient outcome was unfavorable, confirming in the control CT scan coincident with an increase of uncontrolled medically intracranial hypertension, established ischemic infarctions areas, which made any surgical treatment non-viable. CONCLUSION: In the case of an acute subdural haematoma without subarachnoid haemorrhage nor traumatic brain injury or its external stigmas, we must consider the rupture of a cerebral aneurysm as a possible cause. Likewise, the initial management of the acute subdural haematoma in patients with poor neurological condition should be priority and surgical.

TITLE: Hematoma subdural agudo bilateral sin hemorragia subaracnoidea secundario a ruptura de aneurisma comunicante anterior. Presentacion de un caso y revision de la bibliografia.Introduccion. Los hematomas subdurales agudos de causa aneurismatica son muy infrecuentes, con solo 51 casos publicados en la bibliografia hasta la fecha, y unicamente seis de ellos por un aneurisma de la arteria comunicante anterior. Objetivo. Describir un caso de hematoma subdural agudo no asociado a hemorragia subaracnoidea, debido a la rotura de un aneurisma de la arteria comunicante anterior. Caso clinico. Mujer de 55 años sin antecedente traumatico, con un nivel de conciencia de 4 puntos en la escala de coma de Glasgow y midriasis bilateral arreactiva, que posteriormente revierte con medidas medicas. La tomografia computarizada craneal evidencia hematoma subdural agudo, de convexidad bihemisferica e interhemisferico izquierdo, sin hemorragia subaracnoidea asociada. En la angiotomografia se observa un aneurisma de la arteria comunicante anterior. De forma urgente, se procede a su embolizacion. En la unidad de cuidados intensivos se instauran medidas medicas para el control y la monitorizacion de la presion intracraneal. La evolucion de la paciente no es favorable, y en la tomografia computarizada de control, ante un episodio de aumento de la presion intracraneal refractario al tratamiento medico, se constatan areas de infartos isquemicos establecidos en multiples localizaciones. Ante estos hallazgos se desestima el tratamiento quirurgico y la paciente fallece en los siguientes dias. Conclusion. Ante un hematoma subdural agudo sin hemorragia subaracnoidea, en ausencia de traumatismo craneoencefalico o de sus estigmas externos, debemos considerar la rotura de un aneurisma cerebral como posible causa. El tratamiento inicial del hematoma subdural agudo en pacientes con deterioro neurologico ha de ser quirurgico y prioritario.