Everything old is new again. revisiting hypophysectomy for the treatment of refractory cancer-related pain: a systematic review.

Cancer-related pain is a common and debilitating condition that can significantly affect the quality of life of patients. Opioids, NSAIDs, and antidepressants are among the first-line therapies, but their efficacy is limited or their use can be restricted due to serious side effects. Neuromodulation and lesioning techniques have also proven to be a valuable instrument for managing refractory pain. For patients who have exhausted all standard treatment options, hypophysectomy may be an effective alternative treatment. We conducted a comprehensive systematic review of the available literature on PubMed and Scielo databases on using hypophysectomy to treat refractory cancer-related pain. Data extraction from included studies included study design, treatment model, number of treated patients, sex, age, Karnofsky Performance Status (KPS) score, primary cancer site, lead time from diagnosis to treatment, alcohol injection volume, treatment data, and clinical outcomes. Statistical analysis was reported using counts (N, %) and means (range). The study included data from 735 patients from 24 papers treated with hypophysectomy for refractory cancer-related pain. 329 cancer-related pain patients were treated with NALP, 216 with TSS, 66 with RF, 55 with Y90 brachytherapy, 51 with Gamma Knife radiosurgery (GK), and 18 with cryoablation. The median age was 58.5 years. The average follow-up time was 8.97 months. Good pain relief was observed in 557 out of 735 patients, with complete pain relief in 108 out of 268 patients. Pain improvement onset was observed 24 h after TSS, a few days after NALP or cryoablation, and a few days to 4 weeks after GK. Complications varied among treatment modalities, with diabetes insipidus (DI) being the most common complication. Although mostly forgotten in modern neurosurgical practice, hypophysectomy is an attractive option for treating refractory cancer-related pain after failure of traditional therapies. Radiosurgery is a promising treatment modality due to its high success rate and reduced risk of complications.

Motor cortex stimulation for chronic neuropathic pain: results of a double-blind randomized study.

Motor cortex stimulation via surgically implanted electrodes has been used as an off-label treatment for chronic neuropathic pain, but its efficacy has not been fully established. We aimed to objectively study the efficacy of motor cortex stimulation and characterize potential predictors of response. In this randomized, double-blind, sham-controlled, single centre trial, we recruited 18 patients with chronic neuropathic pain who did not adequately respond to conventional treatment and had a numerical pain rating scale (NRS) score ≥6. Patients were initially assigned to receive 3 months of active ('on') or sham ('off') stimulation in a double-blind cross-over phase. This was followed by a 3-month single-blind phase, and 6 months of open-label follow-up. A meaningful response in our trial was defined as a ≥30% or 2-point reduction in NRS scores during active stimulation. Using Bayesian statistics, we found a 41.4% probability of response towards on versus off motor cortex stimulation. The probability of improvement during active stimulation (double-blind, single-blind and open-label phases) compared to baseline was 47.2-68.5%. Thirty nine per cent of the patients were considered long-term responders, 71.4% of whom had facial pain, phantom limb pain or complex regional pain syndrome. In contrast, 72.7% of non-responders had either post-stroke pain or pain associated with brachial plexus avulsion. Thirty-nine per cent of patients had a substantial postoperative analgesic effect after electrode insertion in the absence of stimulation. Individuals with diagnoses associated with a good postoperative outcome or those who developed an insertional effect had a near 100% probability of response to motor cortex stimulation. In summary, we found that ∼40% of patients responded to motor cortex stimulation, particularly those who developed an insertional effect or had specific clinical conditions that seemed to predict an appropriate postoperative response.

Computer-assisted craniometric evaluation for diagnosis and follow-up of craniofacial asymmetries: SymMetric v. 1.0.

PURPOSE: The current assessment of patients with craniofacial asymmetries is accomplished by physical examination, anamnesis and radiological imaging. We propose a semi-automated, computer-assisted craniofacial evaluation (SymMetric v 1.0) based on orthogonal photography of the patient's head in 3 positions. The system is simple, low-cost, no-radiation or special resources needed. Although it does not substitute CT in cases of doubt between craniosynostosis and positional plagiocephaly, multiple numeric evaluations indicate regional deformities and severity of the asymmetry, which can help in the clinical decision of indicating or not the orthosis in positional deformities, determining treatment duration or evaluating surgical outcomes after correction. METHODS: A Matlab-based tool was developed for digital processing of photographs taken in 3 positions (anterior, superior and lateral). The software guides the user to select visible and reproducible landmarks in each photograph acquisition and calculates multiple indexes and metrics, generating a set of comprehensive plots to offer the user an overview of head and facial symmetry across the orthogonal views. For purposes of demonstration, we evaluated 2 patients (one control and one with non-sinostotic deformity). RESULTS: The results show a clear differentiation of the control and plagiocephalic patient metrics mainly in the superior view, showing potential for diagnosis of the condition, and also detected the clinical improvement during helmet treatment in the follow-up, 3 and 5 months after orthosis' use. CONCLUSION: We presented a proof-of-concept for a low cost, no radiation evaluation system for craniofacial asymmetries, that can be useful in a clinical context for diagnosis and follow-up of patients.

Pediatric intrinsic brainstem lesions: clinical, imaging, histological characterization, and predictors of survival.

PURPOSE: Brainstem lesions comprise 10-20% of all pediatric brain tumors. Over the past years, the benefits of stereotactic biopsy versus the use alone of MRI features to guide treatment have been controversial. METHODS: Retrospective study with pediatric patients submitted to stereotactic brainstem biopsies between 2008 and 2018. Demographic, clinical, imaging, and surgical characteristics were recorded, as well as the histological diagnosis, complications, and survival. Predictors of survival were evaluated through Cox regression models after multivariate adjustment. RESULTS: Twenty-six patients (mean age of 8.8 ± 4.3 years and 14 female). Diagnosis was reached on 84.6% (95% CI 65.1-95.6%) of the patients. Glioma was diagnosed on 20 cases (11 high-grade and 9 low-grade lesions). There was no association between age and gender and the dichotomized histological diagnosis. Contrast enhancement, diffuse distribution, invasion of adjacent structures, and remote injury were present on 62.5%, 75.0%, 62.5%, and 25.0% of the cases. Hydrocephalus at admission was present on almost half of the patients (46.2%). Only radiological invasion of adjacent structures had a possible association with high-grade lesions (p = 0.057). Surgical trajectory was trans-cerebellar in most of the cases (79.9%). There were no major complications and only two minor/transitory complications. Poorer survival was independently associated with high-grade lesions (HR 32.14, 95% CI 1.40-735.98, p = 0.030) and contrast enhancement at MRI (HR 36.54, 95% CI 1.40-952.26, p = 0.031). CONCLUSIONS: Stereotactic biopsy was safe and allows successful tissue sampling for a definite diagnosis. Poorer survival was independently associated with high-grade and contrast-enhancing lesions.

Traumatic Brain Injury in the Setting of Fahr Syndrome.

Fahr syndrome, or bilateral striatopallidodentate calcinosis, is a rare syndrome that can confound interpretation of traumatic brain injury seen on computed tomography of the head (CTH). Understanding that this syndrome presents with diffuse calcified lesions will assist clinicians unfamiliar with Fahr syndrome when evaluating diffuse hyperdensities seen on CTH in the setting of trauma between traumatic acute blood versus calcification. We present a unique image that demonstrates how a traumatic brain injury patient can present with traumatic acute hemorrhage and Fahr syndrome. We highlight 2 methods within the CTH images that can be used to assist in these diagnoses, which will better inform neurosurgeons and other clinicians when encountering this unique and rare presentation for the first time.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Related to Autosomal Dominant Polycystic Kidney Disease.

Autosomal dominant polycystic kidney disease (ADPKD) is a connective tissue disease with vascular abnormalities involving multiple organs. The prevalence of ADPKD associated with a spontaneous subdural hematoma (SDH) is very low, with less than 10 cases reported in the literature to date. Symptomatic chronic SDH is classically treated with a twist drill, burr holes, or craniotomy. Recently, middle meningeal artery (MMA) embolization has emerged as an ancillary modality. We present the first case in the literature of a bilateral SDH in a young ADPKD patient successfully managed with MMA embolization. Moreover, we discuss the role of different treatment modalities on this subset of patients.

Navigated Dorsal Root Ganglion Stimulation (DRGS) for the Treatment of Chronic Refractory Coccygodynia: A Case Report.

Sacral stimulation is a well-established therapy for urologic neuromodulation. After the advent of dorsal root ganglion (DRG) stimulation, pain surgeons have started to reach this target mostly for pelvic and sacral pain. For those without good surgical experience, sacral foramen puncture, especially S3 and S4, can be a challenge, due to its entry angle and limited C-arm image resolution. In this report, we describe a new technique to utilize sacral navigation using the O-arm approach to guide DRG stimulation implants. We discuss a case of a 53-year-old male patient with refractory coccygodynia, who underwent sacral DRG implantation using neuronavigation. Punctures could be done without the need for multiple attempts to reach the foramen in this patient.

Unusual Intraventricular Bullet Migration During Operation: A Case Report on Treatment Strategies.

Gunshot head injuries are increasingly prevalent in the urban setting and carry complex technical and clinical decision-making challenges to practicing neurosurgeons. Here, we present a unique case of a patient who suffered a gunshot injury and presented to the emergency department with an intraventricular bullet lodgment without significant neurological deficits. The patient was rushed to the operating room to remove the bullet after neuroimaging demonstrated its migration inside the ventricular system. The patient showed a favorable outcome postoperatively. This case report highlights the importance of prompt diagnosis and tailored management strategies in cases of intraventricular bullet lodgment.

Robotic-Assisted Stereoelectroencephalography: A Systematic Review and Meta-Analysis of Safety, Outcomes, and Precision in Refractory Epilepsy Patients.

Robotic assistance in stereoelectroencephalography (SEEG) holds promising potential for enhancing accuracy, efficiency, and safety during electrode placement and surgical procedures. This systematic review and meta-analysis, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and International Prospective Register of Systematic Reviews (PROSPERO) registration, delves into the latest advancements and implications of robotic systems in SEEG, while meticulously evaluating outcomes and safety measures. Among 855 patients suffering from medication-refractory epilepsy who underwent SEEG in 29 studies, averaging 24.6 years in age, the most prevalent robots employed were robotic surgical assistant (ROSA) (450 patients), Neuromate (207), Sinovation (140), and ISys1 (58). A total of 8,184 electrodes were successfully implanted, with an average operative time of 157.2 minutes per procedure and 15.1 minutes per electrode, resulting in an overall mean operative time of 157.7 minutes across all studies. Notably, the mean target point error (TPE) stood at 2.13 mm, the mean entry point error (EPE) at 1.48 mm, and postoperative complications occurred in 7.69% of robotically assisted (RA) SEEG cases (60), with 85% of these complications being asymptomatic. This comprehensive analysis underscores the safety and efficacy of RA-SEEG in patients with medication-refractory epilepsy, characterized by low complication rates, reduced operative time, and precise electrode placement, supporting its widespread adoption in clinical practice, with no discernible differences noted among the various robotic systems.

Burr Hole Hematoma Evacuation of Large Subdural Component Using Recombinant Tissue-Type Plasminogen Activator and a Novel Catheter: Case Report.

The large acute component in a chronic subdural hematoma (cSDH) typically requires a craniotomy. Open surgery can be associated with increased morbidity and is not always possible due to systemic conditions. We present the case of a 58-year-old patient who presented with a Glasgow Coma Scale (GCS) of three fixed pupils, but remaining brainstem reflexes were present. Brain CT showed a large mixed subdural left chronic hematoma, with a predominant acute component, with a 26mm midline shift. The patient was hemodynamically unstable and coagulopathic; thus, emergency bedside burr hole evacuation was done. An "anti-thrombotic catheter" was left in the subdural space as a postoperative drain. Postoperatively, GCS improved, and CT presented a residual 12.7mm midline shift due to the acute bleeding component. Recombinant tissue-type plasminogen activator (r-tPA) solution was repeatedly administered using the catheter for two days, and it continued to drain for 10 more days with no additional dose. The patient presented clinical and radiological improvement with the dissolution of the acute component. This case is the first description of local subdural use of r-tPA to treat the acute component of cSDH with success associated with an anti-thrombotic catheter.

Pain Relief in CRPS-II after Spinal Cord and Motor Cortex Simultaneous Dual Stimulation.

UNLABELLED: We describe a case of a 30-year-old woman who suffered a traumatic injury of the right brachial plexus, developing severe complex regional pain syndrome type II (CRPS-II). After clinical treatment failure, spinal cord stimulation (SCS) was indicated with initial positive pain control. However, after 2 years her pain progressively returned to almost baseline intensity before SCS. Additional motor cortex electrode implant was then proposed as a rescue therapy and connected to the same pulse generator. This method allowed simultaneous stimulation of the motor cortex and SCS in cycling mode with independent stimulation parameters in each site. At 2 years follow-up, the patient reported sustained improvement in pain with dual stimulation, reduction of painful crises, and improvement in quality of life. The encouraging results in this case suggests that this can be an option as add-on therapy over SCS as a possible rescue therapy in the management of CRPS-II. However, comparative studies must be performed in order to determine the effectiveness of this therapy. KEY WORDS: Chronic neuropathic pain, Complex regional pain syndrome Type II, brachial plexus injury, motor cortex stimulation, spinal cord stimulation.

Immediate ischemic preconditioning based on somatosensory evoked potentials seems to prevent spinal cord injury following descending thoracic aorta cross-clamping.

OBJECTIVE: Delayed ischemic preconditioning has demonstrated neuroprotective effects in spinal cord ischemia. We investigated the effects of immediate ischemic preconditioning based on somatosensory evoked potentials monitoring in a model of spinal cord injury due descending thoracic aorta occlusion in dogs. METHODS: Twenty-one dogs were submitted to spinal cord ischemia induced by descending thoracic aorta cross-clamping for 45 min. Control group underwent only the aortic cross-clamping (n=7), group A underwent one cycle of ischemic preconditioning (n=7) and group B underwent three equal cycles of ischemic preconditioning (n=7), immediately before the aortic cross-clamping. Ischemic preconditioning cycles were determined by somatosensory evoked potentials monitoring. Neurologic evaluation was performed according to the Tarlov score at 72 h of follow-up. The animals were then sacrificed and the spinal cord harvested for histopathology. RESULTS: Aortic pressures before and after the occluded segment were similar in the three groups. Ischemic preconditioning periods corresponded to a mean ischemic time of 3+/-1 min and a mean recovery time of 7+/-2 min. Severe paraplegia was observed in three animals in Control group, in four in group A and in none in group B. Tarlov scores of group B were significantly better in comparison to the Control group (P=0.036). Histopathologic examination showed severe neuronal necrosis in the thoracic and lumbar gray matter in animals who presented paraplegia. CONCLUSIONS: Immediate repetitive ischemic preconditioning based on somatosensory evoked potentials monitoring seems to protect spinal cord during descending aorta cross-clamping, reducing paraplegia incidence.

Frame-based stereotactic neurosurgery in children under the age of seven: Freiburg University's experience from 99 consecutive cases.

INTRODUCTION: Stereotactic frame-based procedures proved to be precise, safe and are of widespread use among adult patients. Regarding pediatric patients few data is available, therefore the use of the stereotactic frame remains controversial in this population. This motivated us to report our experience in stereotactic procedures in the youngest patients and review the literature concerning this subject. METHODS: All frame-based procedures performed in patients younger than seven years in the University of Freiburg during the last 10 years were retrospectively analyzed and discussed under the light of the current literature. RESULTS: The studied population was composed of 72 patients under the age of seven (mean 3.4±2.1 years-old), in whom 99 stereotactic procedures were performed. Brain tumor was present in 60 patients, hydrocephalus in five, cystic lesions in three, intracranial abscess in three and epilepsy in one patient. Stereotactic surgery was performed in 36 cases for brachytherapy, in 29 for biopsy, in 20 cases for cyst puncture, in eight for stereotactically guided endoscopic ventriculostomy, in five for catheter placement and in one case for depth electrode insertion. The overall complication rate was 5%. There were three cases of pin penetration through the skull, one case of frame dislocation after extensive cyst drainage and two skull fractures. Neurologic deficit related to frame fixation was observed in none of the cases. In disagreement with other authors, no case of pin related infection, air embolism, hematoma or CSF leak was observed. CONCLUSION: Frame-based stereotactic neurosurgery is a safe technique also in the youngest patients. Rather than the simple use of torque-limiting devices training and experience in the manual adjustment of the stereotactic frame in children have been proven to be crucial factors that contribute to reducing pin related complications.