Effectiveness and reliability of hypnosis in stereotaxy: a randomized study.

BACKGROUND: Patients suffering from Parkinson's disease (PD) may experience pain during stereotactic frame (SF) fixation in deep brain stimulation (DBS). We assessed the role of hypnosis during the SF fixation in PD patients undergoing awake bilateral subthalamic nucleus (STN) DBS. METHODS: N = 19 patients were included (N = 13 males, mean age 63 years; N = 10 allocated to the hypnosis and N = 9 allocated to the control groups). Patients were randomly assigned to the interventional (hypnosis and local anesthesia) or non-interventional (local anesthesia only) groups. The primary outcome was the pain perceived (the visual analogue scale (VAS)). Secondary outcomes were stress, anxiety, and depression, as measured by the perceived stress scale (PSS) and hospital anxiety and depression scale (HADS). Procedural distress was measured using the peritraumatic distress inventory (PDI-13). RESULTS: In the hypnosis group, VASmean was 5.6 ± 2.1, versus 6.4 ± 1.2 in the control group (p = 0.31). Intervention and control groups reported similar VASmax scores (7.6 ± 2.1 versus 8.6 ± 1.6 (p = 0.28), respectively). Both groups had similar HADS scores (6.2 ± 4.3 versus 6.7 ± 1.92, p = 0.72 (HADSa) and 6.7 ± 4.2 versus 7.7 ± 3, p = 0.58 (HADSd)), so were the PSS scores (26.1 ± 6.3 versus 25.1 ± 7, p = 0.75). Evolutions of VASmean (R2 = 0.93, 95% CI [0.2245, 1.825], p = 0.03) and PDI-13 scores (R2 = 0.94, 95% CI [1.006, 6.279], p = 0.02) significantly differ over follow-up with patients in the hypnosis groups showing lower scores. CONCLUSION: In this unblinded, randomized study, hypnosis does not influence pain, anxiety, and distress during awake SF fixation but modulates pain memory over time and may prevent the integration of awake painful procedures as a bad experience into the autobiographical memory of patients suffering from PD. A randomized controlled study with more data is necessary to confirm our findings.

Successful MRI-Guided Focused Ultrasound Thalamotomy after Ipsilateral Gamma Knife Radiosurgery for Essential Tremor: A Case Report with Video.

We report the case of a 67-year-old left-handed female patient with disabling medically refractory essential tremor who underwent successful right-sided magnetic resonance-guided focused ultrasound (MRgFUS) of the ventral intermediate nucleus after ipsilateral gamma knife radiosurgery (GKRS) thalamotomy performed 3 years earlier. The GKRS had a partial effect on her postural tremor without side effects, but there was no reduction of her kinetic tremor or improvement in her quality of life (QoL). The patient subsequently underwent a MRgFUS thalamotomy, which induced an immediate and marked reduction in both the postural and kinetic tremor components, with minor complications (left upper lip hypesthesia, dysmetria in her left hand, and slight gait ataxia). The MRgFUS-induced lesion was centered more medially than the GKRS-induced lesion and extended more posteriorly and inferiorly. The MRgFUS-induced lesion interrupted remaining fibers of the dentatorubrothalamic tract (DRTT). The functional improvement 1-year post-MRgFUS was significant due to a marked reduction of the patient's kinetic tremor. The QoL score (Quality of Life in Essential Tremor) improved by 88% and her Clinical Rating Scale for Tremor left hand score by 62%. The side effects persisted but were minor, with no impact on her QoL. The explanation for the superior efficacy of MRgFUS compared to GKRS in our patient could be due to either a poor response to the GKRS or to a better localization of the MRgFUS lesion with a more extensive interruption of DRTT fibers. In conclusion, MRgFUS can be a valuable therapeutic option after unsatisfactory GKRS, especially because MRgFUS has immediate clinical effectiveness, allowing intra-procedural test lesions and possible readjustment of the target if necessary.

A combined cognitive and gait quantification to identify normal pressure hydrocephalus from its mimics: The Geneva's protocol.

OBJECTIVES: Idiopathic normal pressure hydrocephalus (iNPH) is very prevalent in aging, underdiagnosed, and represents a rare cause of reversible neurological condition. The clinical triad of iNPH - gait, cognitive and urinary symptoms - and its neuroradiological features (i.e. ventriculomegaly) are not specific and found a various neurodegenerative and/or vascular conditions. We present our iNPH standardized protocol at the Geneva University Hospitals involving a multispecialty team of behavioral neurologists, neurosurgeons, neuropsychologists, engineers, and physical therapists. Based on a pragmatic approach, the goal of this protocol is to improve the identification of older patients with iNPH from its mimics (i.e. vascular dementia or other parkinsonian syndromes). PATIENTS AND METHODS: We used a novel standardized paradigm with a simultaneous quantification of cognition and gait (dual task gait assessment and mental imagery of locomotion) before and 24h after CSF tapping. RESULTS: We assessed 125 patients with suspicion of iNPH (age: 75.9±7.4years; 34.4% female) in 5 years: 54.4% of probable/possible iNPH and 45.6% of mimics. Among the mimics, vascular dementia (24.6%) and patients with multifactorial conditions (19.9%) were the two most common diagnoses. A total of 27 patients with iNPH (39.7%) accepted the neurosurgical shunt procedure. CONCLUSION: This report shows that a quantified gait and cognitive assessment - using dual-task paradigms - before and after CSF tapping is feasible among older adults with suspicion of iNPH and that this multidisciplinary approach contributes to the identification of patients with iNPH from its mimics.

[Operative and perioperative aspects of deep brain stimulation]. / Aspects opératoires et péri-opératoires de la stimulation cérébrale profonde.

Deep brain stimulation (DBS) requires the surgical implantation of a system including brain electrodes and impulsion generator(s). The nuclei targeted by the stereotaxic implantation methodology have to be visualized at best by high resolution imaging. The surgical procedure for implanting the electrodes is performed if possible under local anaesthesia to make electro-physiological measurements and to test intra-operatively the effect of the stimulation, in order to optimize the position of the definitive electrode. In a second step, the impulsion generator(s) are implanted under general anaesthesia. DBS for movement disorders has a very good efficacy and a low albeit non-zero risk of serious complications. Complications related to the material are the most common.

Normal pressure hydrocephalus and cerebral blood flow: a PET study of baseline values.

Regional cerebral blood flow (CBF) was studied with O(15)-water positron emission tomography and anatomic region-of-interest analysis on co-registered magnetic resonance in patients with idiopathic (n = 12) and secondary (n = 5) normal pressure hydrocephalus (NPH). Mean CBF was compared with values obtained from healthy volunteers (n = 12) and with clinical parameters. Mean CBF was significantly decreased in the cerebrum and cerebellum of patients with NPH. The regional analysis demonstrated that CBF was reduced in the basal ganglia and the thalamus but not in white matter regions. The results suggest that the role of the basal ganglia and thalamus in NPH may be more prominent than currently appreciated. The implications for theories regarding the pathogenesis of NPH are discussed.