Dorsal anterior cingulate cortex (ACC) deep brain stimulation (DBS): a promising surgical option for the treatment of refractory thalamic pain syndrome (TPS).

BACKGROUND: Neuroimaging evidences and previous successful case series of cingulotomy for cancer pain have disclosed the key-role of the dorsal anterior cingulate cortex (ACC) in the generation of the empathic and affective dimension of pain. The aim of this study is to assess the effectiveness and safety of ACC neuromodulation for the treatment of the thalamic pain syndrome (TPS), a chronic neuropathic disease often complicated by severe affective and emotional distress in the long term. METHOD: From January 2015 to April 2017, 5 patients with pure drug-refractory TPS underwent ACC deep brain stimulation (DBS) at our institution. Quantitative assessment of pain and health-related quality of life were performed 1 day before surgery and postoperatively at 6 and 18 months by using the numeric rating scale (NRS), the 36-item short-form health survey (SF-36), and the McGill pain and the EuroQol5-domain questionnaires. RESULTS: Mean age at surgery was 56.2 years (range, 47-66). NRS score improved by 37.9% at 6 months (range, - 22.2 to - 80%) and by 35% at 18 months (range, - 11.1 to - 80%). At the last follow-up, one patient reported a relevant pain reduction (NRS 2), only complaining of mild pain poorly interfering with activities of daily living. Concomitant improvements in the McGill and EuroQol5-domain pain questionnaires, SF-36 total and sub-item scores were also noticed at each follow-up. No surgical or stimulation-related complications occurred during the study period. CONCLUSIONS: ACC DBS may be a safe and promising surgical option to alleviate discomfort and improve the overall quality of life in a patient affected by drug-resistant TPS. Further prospective, larger, and randomized studies are needed to validate these findings.

Deep brain stimulation of the ventral striatum/anterior limb of the internal capsule in thalamic pain syndrome: study protocol for a pilot randomized controlled trial.

BACKGROUND: Chronic neuropathic pain in thalamic pain syndrome remains intractable. Its poor response is ascribed to destruction of the integrated neuromatrix in experience of pain. Deep brain stimulation is a promising technique to modulate activity of implicated structures. However, traditional approaches targeting sensori-motor substrates have failed to affect disability. The offending lesion in thalamic pain syndrome that almost invariably destroys sensory pain pathways may render these classical approaches ineffective. Instead, we hypothesize that targeting structures representing emotion and affective behavior-ventral striatum/anterior limb of the internal capsule, may alleviate disability. METHODS/DESIGN: We present the design of our phase I randomized, double-blinded, sham-controlled, crossover trial that examines safety, feasibility and efficacy of our proposed approach. In our ongoing trial, we intend to enroll ten patients with thalamic pain syndrome. Following implantation, patients are randomized to receive active deep brain stimulation to the ventral striatum/anterior limb of the internal capsule or sham for 3 months, after which they are crossed over. The primary endpoint is Pain Disability Index. Other outcomes include visual analog scale, depression and anxiety inventories, quality of life, and functional neuroimaging. DISCUSSION: Designing trials of deep brain stimulation for pain is challenging owing to the ethical-scientific dilemma of introducing a control arm, complicated blinding, heterogeneous etiologies, patient expectations, and inadequate assessment of disability. The quality of evidence in the field is classified as level III (poor) because it mainly includes a multitude of uncontrolled case series reporting variable outcomes, with little regard for the placebo effect related to implantation. Without valid data on efficacy, use of deep brain stimulation for pain remains "off label". We present our trial design to discuss feasibility of conducting sham-controlled phase I studies that may represent significant refinement for the field. Double-blinding would reduce influence of patient expectations and therapeutic confusion amongst investigators. With a cross-over approach, the dilemma regarding including a control group can be mitigated. Use of homogeneous etiology, measurement of disability, depression and quality of life, besides pain perception, all represent strategies to evaluate efficacy rigorously. Functional imaging would serve to define mechanisms underlying observed effects and may help optimize future targeting. TRIAL REGISTRATION: Clinicaltrials.gov NCT01072656.

Tractography-guided stimulation of somatosensory fibers for thalamic pain relief.

BACKGROUND: The spinothalamocortical tract (STC) is seen as a neural tract responsible for or involved in the generation or transmission of thalamic pain. Either the thalamus itself or the posterior limb of the internal capsule (PLIC) are targets for deep brain stimulation (DBS) in patients with thalamic pain, but due to its low contrast, conventional MRI cannot visualize the STC directly. OBJECTIVES: To show the feasibility of integrating diffusion tensor imaging-based tractography into the stereotactic treatment planning for identification of an object-oriented lead trajectory that allows STC-DBS with multiple electrode contacts. METHODS: Diffusion tensor imaging was performed in 4 patients with thalamic pain. The STC was modeled and integrated into the stereotactic treatment planning for DBS. DBS-lead implantation was done according to trajectory planning along the modeled STC at the level of the PLIC. RESULTS: After implantation, electrode stimulation was possible over a length of more than 20 mm with a tractography-based trajectory along the PLIC part of the STC. After a follow-up of 12 months, pain relief of more than 40% was achieved in 3 of 4 patients with rating on a visual analogue scale. In 1 patient, stimulation failed to reach any long-lasting positive effects. CONCLUSIONS: Integrating tractography data into stereotactic planning of DBS in thalamic pain is technically feasible. It can be used to identify a lead trajectory that allows for multiple contact stimulation along the STC at the level of the PLIC. Due to long-lasting positive stimulation effect, tractography-guided stimulation of sensory fibers seems to be beneficial for thalamic pain relief.

Current differential diagnoses and treatment options of vascular occlusions presenting as bilateral thalamic infarcts: a review of the literature.

bilateral thalamic infarctions are rare and usually caused by vascular occlusions. When symptomatic, it is important to make a distinction between different vascular etiologies in order to provide an effective and timely therapeutic response. Clinical presentations may not adequately differentiate between the vascular etiologies alone. It is therefore important to use imaging technologies to distinguish appropriately the origin of the infarct so that proper treatment can be administered. Advanced imaging techniques, such as CT angiography and MR angiography, have proved useful for distinguishing between arterial and venous causes of bithalamic infarctions. Bilateral thalamic venous infarctions can be treated with anticoagulation medication and with thrombolysis in more severe cases. Bilateral thalamic arterial infarctions may be treated with thrombolysis.

Stereotactic aspiration plus subsequent thrombolysis for moderate thalamic hemorrhage.

OBJECTIVE: This study aimed to evaluate the efficacy and safety of stereotactic aspiration combined with subsequent thrombolysis in treating moderate thalamic hemorrhage (TH). METHODS: A total of 105 patients with TH were nonrandomly assigned to the conservative treatment group (n = 60) or to the aspiration group (n = 45). Patients in the aspiration group were treated with stereotactic aspiration plus subsequent thrombolysis for removal for their hematomas. RESULTS: The 30-day mortality in the conservative group was significantly higher than that in the aspiration group (28.3% (17/60) vs. 11.2% (5/45), P = 0.032). The rank of the 30-day Glasgow outcome scale in the conservative group was significantly lower than that in the aspiration group (P = 0.041), and the mean 30-day National Institutes of Health Stroke Scale score of the survivors in the conservative group was significantly higher than that in the aspiration group (16.5 ± 4. 2 vs. 14.2 ± 3.9, P = 0.012). There were a greater reduction in TH volume in the aspiration group than in the conservative group from day 1 to day 3 (-0.24% and 39.28%, respectively, P < 0.0001) and from day 1 to day 7 (26.58% and 63.26%, respectively, P < 0.0001). The rank of 90-day Glasgow outcome scale was significantly lower in the conservative group than that in the aspiration group (P = 0.015). Eighteen of 60 patients (30.0%) had a favorable outcome in the conservative group, whereas 23 of 45 patients (51.1%) had a favorable outcome in the aspiration group, and this difference was significant (P = 0.028). The 90-day cumulative mortality rate in the conservative group was significantly higher than that in the aspiration group (33.3% (20/60)) vs. 15.6% (7/45), P = 0.039). CONCLUSIONS: Stereotactic aspiration plus subsequent thrombolysis is effective and safe for moderate TH.

[Dynamic observation on therapeutic features of thalamic pain by mind calming, blood activating and pain relief acupuncture and carbamazepine].

OBJECTIVE: To observe therapeutic features of thalamic pain by mind Calming, blood activating and pain relief acupuncture and Carbamazepine. METHODS: Crossover trial design was adopted. Eleven patients with confirmed diagnosis of thalamic pain were randomly assigned to two groups according to the minimal unbalance index method, i.e., Group I (Six patients received acupuncture first and then Western medicine.) and Group II (Five patients received Western medicine first and then acupuncture). The therapeutic course for each group was ten days. There was a ten-day elution phase between the two therapeutic methods. The total therapeutic course was thirty days. Eleven patients were enrolled in the two groups for statistical analysis. The therapeutic efficacy was assessed with visual analogue scale (VAS) and the pain assessment scale of Anderson Cancer Center in the USA (MD Pain Evaluation value) respectively. The VAS and MD values of the two groups were recorded every day to get the dynamic curve. RESULTS: The VAS and MD values obviously decreased in the two groups after treatment (P<0.05). The pain curves of the two groups showed a declining trend during the treatment. A gradual and stable descending process was shown in the acupuncture group. But a greater decrease first appeared in the Western medicine group, then a comparatively greater decrease occurred after one platform stage, showing ladder-shaped curve. CONCLUSIONS: Cumulative potency may be the main analgesic effects of acupuncture. Western medicine may possibly play a role by rapid initiate effect.

Glasgow Coma Scale and hematoma volume as criteria for treatment of putaminal and thalamic intracerebral hemorrhage.

BACKGROUND: The decision to administer conservative or surgical treatment for putaminal and thalamic ICH is still a controversial issue. This study was undertaken to examine the decision-making criteria for these 2 treatments. METHODS: In a retrospective study, case records of 400 patients with spontaneous putaminal and thalamic hemorrhage who underwent conservative treatment (n = 201) and surgical treatment (n = 199) over the past 5 years were examined. Conservative treatment included hypertonic solution treatment and hypertension control. Surgical treatments included endoscopic surgery, craniotomy, and stereotactic aspiration. Preoperative GCS score and ICH volume were the major evaluating factors, and comparison of the 30-day mortality rate and 6-month BI score was used for outcome evaluation. RESULTS: In patients with a GCS score of 13 to 15, there was no difference in mortality between conservative and surgical treatments. At a GCS score of 9 to 12 and ICH volume of less than 30 mL, the mortality rate with surgical treatment (10.5%) was lower than that with conservative treatment (20.0%, P < .05). At a GCS score of 3 to 8 and ICH volume of at least 30 mL, surgical treatment was for life saving. Mortality rates were lower for conservative treatment than for surgical treatment when the GCS score was 3 to 12 and ICH volume less than 30 mL. Endoscopic surgery had a better functional outcome compared with craniotomy and stereotactic aspiration when the GCS score was at least 9 (P < .001 and P < .02, respectively). Those in conservative treatment received a better BI score than those in surgical treatment did when the ICH volume was less than 40 mL (P < .001). CONCLUSIONS: Intracerebral hemorrhage volume is probably more important than GCS score in determining treatment. Our nonrandomized data could be interpreted to show that conservative treatment is suggested at GCS score of at least 13 or when ICH volume is less than 30 mL, regardless of GCS score. Surgical treatment could be recommended at GCS score of less than 12 with ICH volume of at least 30 mL for life saving. Endoscopic surgery may improve the functional outcomes because it is less invasive and effectively removes the ICH at GCS score of at least 9.

Familial neurofibromatosis 1 with germinoma involving the basal ganglion and thalamus.

Intracranial germinoma associated with neurofibromatosis 1 (NF-1) has never been documented previously. We report a case of familial NF-1 with a germinoma involving the right basal ganglion and thalamus. A 12-year-old boy presented with multiple café-au-lait spots and a family history of neurofibromatosis in his mother, one of two siblings, and his maternal grandfather. His intracranial lesion was subtotally resected. Histologically, it was a pure germinoma. Serum alpha-feto protein and beta-human chorionic gonadotropin levels were within the normal range. Postoperative myelographic examination and cerebrospinal fluid cytology study showed no evidence of subarachnoid seeding. The patient received postoperative combination chemotherapy resulting in complete response and clearance of the residual tumor. Although this finding of an intracranial germinoma in a patient with familial NF-1 may be coincident, it is suggestive of a potential genetic predisposition. Longitudinal evaluation for the possibility of neoplasm, especially germ cell tumor, in basal ganglion lesions in NF-1 patients is necessary.

[The role of magnetic resonance angiography in the follow-up of intracranial arteriovenous malformations treated by an intravascular approach]. / Rôle de l'Angio-IRM dans la surveillance des malformations artério-veineuses intra-crâniennes traitées par abord endo-vasculaire.

The purpose of our work was to measure the accuracy and reliability of MR-Angiography in the study and follow-up of intracranial arteriovenous malformations, and in particular to evaluate the results of endovascular treatment. Over an 18-month period 4 patients with such malformations were examined by MR-Angiography. There was an angioma of the corpus callosum, a left parieto-rolandic angioma, a posterior thalamic angioma and a cerebellar angioma. All examinations were performed with a Magneton-Impact 1 Tesla machine (Siemens, Erlangen, Germany), using a head coil, MR-Angiography with time-of-flight sequences and differential arterial and venous saturations. Each patient was examined by MR-Angiography first at the beginning of treatment, then when ambulatory after embolization. The morphological study applied to the afferent vessels, the nidus and the efferent veins. MR-Angiography proved to be very good in identifying the arteries feeding the malformation, and this made it easier to evaluate the reduction of their input after treatment, without having recourse to any arteriography. Beside, analysis of the nidus was facilitated by the judicious arrangement of arterial and venous saturations. In fact, the systematic use of MR-Angiography in the follow-up of intracranial arteriovenous malformations makes it possible to measure, with full reliability, the efficacy of the endovascular treatment under conditions of comfort unequalled in these out-patients, and selective angiography sequences need to be performed only during therapeutic phases.

A phase II trial of preirradiation carboplatin in newly diagnosed germinoma of the central nervous system.

BACKGROUND: Central nervous system (CNS) germinomas respond readily to both radiotherapy and chemotherapy. This study was designed to selectively reduce the dose of radiotherapy in those patients expressing a complete response (CR) to neoadjuvant carboplatin. METHODS: A Phase II trial with carboplatin was conducted in 11 newly diagnosed patients with histologically confirmed, radiologically evaluable CNS germinomas before they received radiotherapy. All patients had normal cerebrospinal fluid and serum tumor markers (i.e., human chorionic gonadotropin [HCG] and alpha fetoprotein [AFP]). Seven patients had localized tumors (three pineal, three suprasellar, and one thalamus), and four had multifocal disease. Their median age at diagnosis was 13 years (range, 7-31). One course of carboplatin consisted of 150 mg/m2 weekly for 4 consecutive weeks followed by a 2-week break. Response was evaluated after two courses. If a patient had a CR to chemotherapy, the radiotherapy doses to the involved field and the craniospinal axis were lowered from 50 Gy to 30 Gy and from 36 Gy to 21 Gy, respectively. If less than a CR was observed, two additional courses of chemotherapy were administered, after which the patient's response was reevaluated. Less than a CR required full radiotherapy doses. The radiotherapy volume was determined by the extent of disease at diagnosis (i.e., localized disease was treated with an involved field and craniospinal therapy was used for disseminated disease). RESULTS: Seven patients had a CR to carboplatin (five patients after two courses and two patients after four courses). Three patients had a partial response (one after four courses and two after two courses). The investigators of the latter two patients chose not to give additional chemotherapy. Another patient opted for radiotherapy after receiving only one course of chemotherapy and was not evaluable for response. Ten of 11 patients remain in continuous remission for a median of 25 months. One patient had a recurrence. He presented with a localized pineal germinoma and had a CR after two courses of carboplatin. He received 30 Gy of involved field radiotherapy and suffered a relapse 5 months later in multiple CNS sites. He died 23 months after diagnosis with diffuse CNS and peritoneal metastases. His serum AFP and HCG levels were elevated, consistent with a nongerminoma germ cell tumor. CONCLUSIONS: Carboplatin was highly active in treating newly diagnosed CNS germinomas. Further chemotherapy studies eventually may permit additional dose reductions and/or elimination of radiotherapy for patients with CNS germinomas.

Los síndromes de lesión talámica

En la unidad de Neurología del Centro Hospitalario San Juan de Dios de Bogotá, durante cuatro años (1986 a 1989), se estudiaron en forma consecutiva 25 pacientes con lesiones talámaticas no fatales. Se registraron los hallazgos neurológicos, neurosicológicos y neurooftalmológicos y los diagnósticos se confirmaron por tomografía computarizada (TC). Fueron 14 mujeres y 11 varones con una edad promedio de 52.5 y un rango de 25 a 84 años. La lesión talámica fue de origen vascular en 24 casos, ocho por infarto isquémico, cuatro por infarto hemorrágico y 12 con hematomas parenquimatosos. Diecisiete pacientes tenían hipertensión arterial sistémica y el único factor de riesgo en otros dos era el consumo de cocaína base (basuco). Ocho infartos se presentaron en el tálamo derecho, 12 en el izquierdo y cinco pacientes tuvieron lesiones bilaterales, uno de ellos con un glioma complobado por biopsia. En 5 pacientes con lesiónes bilateral se observó el síndrome del "Tope" de la arteria basilar, por compromiso del pedículo retromamilar; en todos ellos encontramos alteraciones sensitivomotoras, cerebelosas, oculomotoras bilaterales y demencia. Solamente un paciente presentó el clasicó síndrome de hiperpatía (Dejerine-Roussy). En los restantes se observaron asociaciones de síndromes sensitivomotores, cerebelosos, neurooftalmológicos, neuropsicológicos, y del comportamiento motor que remedan con frecuencia los hallazgos clínicos de la alteración cortical frontal, temporal o parietal.

[Cerebral blood flow in patients with thalamic hemorrhage--Part 1: Serial changes of cerebral blood flow in conservatively treated patients].

Serial changes of cerebral blood flow (CBF) in nine patients with thalamic hemorrhage are studied. Measurement of CBF was performed in 3 times (acute, subacute and chronic stage) by the 133 Xe inhalation method using rapidly rotating single photon emission CT (SPECT, Tomomatic 64). The outcome was judged at 16 weeks from onset according to the activities of daily life. All patients divided into two groups (good group and poor group) [Result] 1. Serial changes in mean hemispheric CBF (mCBF) of both hematoma and nonhematoma side between good group and poor group. Between two groups, the significant difference was observed only in hematoma side was 77% CBF in acute stage and it was gradually improved in subacute stage. mCBF of nonhematoma side was normal value in all stage. In poor group, mCBF of hematoma side was 64% CBF in acute stage and it was slightly improved in chronic stage (70% CBF). Slice 2 mCBF of nonhematoma side was 69% CBF in acute stage and it was improved in subacute (74% CBF) and chronic (78% CBF) stage. 2. Serial changes in regional CBF (rCBF)--H (hematoma area).A (anterior area of hematoma).L (lateral area of hematoma).P (posterior area of hematoma) of hematoma side between good group and poor group. Between two groups, the significant differences were observed in rCBF-H.L.P on subacute stage and rCBF-P on chronic stage. Serial changes in rCBF were similar to those in slice 2 mCBF of hematoma side. 3. Serial changes in rCBF-H.A.L.P of nonhematoma side between good group and poor group.(ABSTRACT TRUNCATED AT 250 WORDS)

[A comparison between stereotaxic operation and conservative therapy for thalamic hemorrhage].

The subjects studied in this report included 17 surgical cases which underwent evacuation of hematoma by means of BRW CT stereotaxic system approximately 14 days after its onset, and 11 non-operated cases. The average age was 65.5 years for the operated and 68.7 years for the non-operated groups. The neurological grades on admission were Grade III or above (slight or mild disturbance of consciousness). The evaluation of the cases was made according to (1) laterality of the hematoma on the left or right, (2) neurological grading, (3) maximum anterio-posterior, lateral diameters, and maximum depth of the hematoma, (4) CT classification (Kanaya, 1981) and ADL (5 grades) at 4.5 months after onset. No correlation was found between ADL and the laterality of the lesion in both groups. As for neurological grading I and ADL on admission, 6/8 cases in the operated and 3/8 in the nonoperated groups recovered to ADL grade 2 or above and 2 bed-ridden cases were included in the latter group. In regard to the extent of the hematoma, the mean ADL was 1.83 in the operated group. While 2.75 in the non-operated group where the hematoma was 25 mm or less in its maximum anterio-posterior diameter. On CT, there existed a significant difference in ADL at IIb and 4/5 of the operated and 1/4 of the non-operated groups appeared to be ADL 2 or above. Assessment of the activities (mental change, willingness) as well as the muscle strength was performed within 3 days after surgery in operated group and 88.2% and 35.3% improvements were observed, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Stereotactic mesencephalic tractotomy for thalamic pain.

Forty years after its first reported use, stereotactic mesencephalic tractotomy remains effective in relieving thalamic pain. Twenty seven patients suffering central pain following cerebrovascular accidents were treated by this operation and twenty four were reviewed: sixteen (66.7%) reported long term relief. Fourteen underwent surgery at the original 'superior colliculus' target, nine out of twelve (75%) reporting significant relief. Thirteen had surgery at a revised 'inferior colliculus' target, seven out of twelve (58.3%) obtaining relief. Postoperative disorders of ocular movement were reduced from 83.3% to 20%, and significant problems of binocular vision from 50% to nil. The mortality rate was 7.4%.

Solitary histoplasmoma of the thalamus: case report and literature review.

Only nine cases of solitary thalamic abscess have been reported. All were of bacterial origin, and three were successfully treated by surgical drainage and antibiotic therapy. The authors present the history of a patient with a histoplasmoma of the thalamus. As is often the case with solitary thalamic lesions, this lesion was initially assumed to be a tumor and was first treated with radiotherapy. Despite the sensitive location of the lesion, tissue diagnosis and decompression was safely accomplished with the aid of ultrasonic localization. Appropriate antifungal treatment was given, and the patient made a good recovery.