Rescue procedure for isolated dystonia after the secondary failure of globus pallidus internus deep brain stimulation.

Introduction: Globus pallidus internus (GPi) deep brain stimulation (DBS) is widely used in patients with dystonia. However, 10-20% of patients receive insufficient benefits. The objectives of this study are to evaluate the effectiveness of bilateral subthalamic nucleus (STN) DBS along with unilateral posteroventral pallidotomy (PVP) in patients with dystonia who experienced unsatisfactory GPi-DBS and to address the reported rescue procedures after suboptimal DBS or lesion surgery in dystonia patients. Methods: Six patients with isolated dystonia who had previously undergone bilateral GPi-DBS with suboptimal improvement were included. Standardized assessments of dystonia using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and quality of life using SF-36 were evaluated before surgery and 1, 6 months, and last follow-up (LFU) after surgery. STN bilateral OFF (bi-OFF), unilateral ON (uni-ON), and bilateral ON (bi-ON) states were recorded at LFU. Specific items were used to find publications published before 10 April 2022 regarding rescue procedures after suboptimal DBS or lesion surgery in patients with dystonia for reference. Eleven original studies including case reports/series were identified for discussion. Results: Substantial clinical benefits were achieved in all six patients. Significant amelioration was achieved during the 1-month (6.5 ± 7.45; p = 0.0049), 6-month (5.67 ± 6.3; p = 0.0056) follow-ups, and at LFU (4.67 ± 4.72; p = 0.0094) when compared with the baseline (LFU of GPi DBS with on status) (17.33 ± 11.79) assessed by BFMDRS. The percentage of improvement reached 70.6, 74.67, and 77.05%, respectively. At LFU, significant differences were found between the stimulation bi-OFF and uni-ON (11.08 ± 8.38 vs. 9 ± 8.52, p = 0.0191), and between the stimulation bi-OFF and bi-ON (11.08 ± 8.38 vs. 4.67 ± 4.72, p = 0.0164). Trends depicting a better improvement in stimulation bi-ON compared with uni-ON (4.67 ± 4.72 vs. 9 ± 8.52, p = 0.0538) were observed. Conclusion: Our results suggest that bilateral STN-DBS plus unilateral PVP may be an effective rescue procedure for patients with isolated dystonia who experienced suboptimal movement improvement following GPi-DBS. However, given the heterogeneity of patients and the small sample size, these findings should be interpreted with caution.

Forefoot Replantation in a 3-Year-Old Boy: Case Report.

Few reports about successful forefoot replantation in children have been published. In this article, we present a case of a 3-year-old boy with severe complete amputation of the left forefoot from a crushed and degloved injury in a motorcycle accident. The replantation was successfully performed, even though total ischemia time lasted 8 hours, of which 4 hours was cold ischemia time. The child was able to walk without significant difficulties from 4 months postoperatively and led a normal life in school at 2 years of follow-up. In this case, we present the replantation of a high-velocity traumatic partial foot amputation in a child with excellent function and cosmetic outcome.

Elderly Patients with Frontobasal and Suprasellar Meningiomas: Safety and Efficacy of Tumor Removal via Frontolateral Approach.

OBJECTIVE: Many neurosurgeons prefer conservative treatments in the elderly because of higher rates of mortality and morbidity after surgery. We aim to evaluate safety and efficacy of surgery in elderly patients with frontobasal and suprasellar meningiomas with a simple operative procedure, the frontolateral approach. METHODS: Retrospective analysis was made in consecutive patients with meningiomas operated via frontolateral approach. They were divided into 2 groups: elderly group (age ≥ 65 years) and young group (age < 65 years). Multivariate logistic regression analysis was performed for postoperative complications and Karnofsky Performance Scale score (KPS). RESULTS: The study comprises 128 patients operated over a 19-year period, of which 35 patients were in the elderly group and 93 patients were in the young group. More elderly patients presented with American Society of Anesthesiology (ASA) class II and III (57.1% vs. 43%). Gross resection was achieved in 31 cases in the elderly and 85 cases in young group (88.6% vs. 90.3%, P = 0.17). Postoperative KPS in both groups was improved (85.7% vs. 91.4%, P = 0.18). One death occurred in elderly group (2.9%, P = 0.27). Approach-related and medical morbidity in the elderly group was slightly higher than in the young group without significant difference (respectively, 11.4% and 14.3% vs. 9.7% and 8.6%, P = 0.18). Multivariate logistic regression showed increasing age was not associated with approach-related morbidity (odds ratio [OR]: 1.39, P = 0.53), medical morbidity (OR: 1.94, P = 0.88), and improvement of KPS (OR: 0.32, P = 0.25). CONCLUSIONS: Frontobasal and suprasellar meningiomas in elderly patients can be treated surgically with acceptably low morbidity and mortality rates via the frontolateral approach. Preoperative KPS score ≤60 and ASA classification ≥III predict an unfavorable postoperative outcome.