Bilateral Globus Pallidus Externus Deep Brain Stimulation for the Treatment of Refractory Tourette Syndrome: An Open Clinical Trial.

OBJECTIVES: We have previously proposed that Tourette syndrome (TS) is the clinical expression of the hyperactivity of globus pallidus externus (GPe) and various cortical areas. This study was designed to test this hypothesis by verifying the efficacy and safety of bilateral GPe deep brain stimulation (DBS) for treating refractory TS. MATERIALS AND METHODS: In this open clinical trial, 13 patients were operated on. Target coordinates (center of GPe) were obtained by direct visualization. Physiological mapping was performed with macrostimulation and microrecording. Primary and secondary outcome measures were, respectively, responder and improvement rates of TS and comorbidities, according to pre- and postoperative scores on the following assessment instruments: Yale Global Tic Severity Scale, Yale-Brown Obsessive Compulsive Scale, Beck Depression Inventory/Hamilton Depression Rating Scale, Beck Anxiety Inventory/Hamilton Anxiety Rating Scale, and Concentrated Attention test. RESULTS: Intraoperative stimulation (100 Hz/5.0V) did not produce any adverse effects or impact on tics. Microrecording revealed bursting cells discharging synchronously with tics in the central part of the dorsal half of GPe. Patients were followed up for a mean of 61.46±48.50 months. Responder rates were 76.9%, 75%, 71.4%, 71.4%, and 85.7%, respectively, for TS, obsessive-compulsive disorder (OCD), depression, anxiety, and attention deficit hyperactivity disorder. Mean improvements among responders in TS, OCD, depression, and anxiety were 77.4%, 74.7%, 89%, and 84.8%, respectively. After starting stimulation, tic improvement was usually delayed, taking up to ten days to manifest. Afterward, it increased over time, usually reaching its maximum at approximately one year postoperatively. The best stimulation parameters were 2.3V to 3.0V, 90 to 120 µsec, and 100 to 150 Hz, and the most effective contacts were the two dorsal ones. Two complications were registered: reversible impairment of previous depression and transient unilateral bradykinesia. CONCLUSIONS: Bilateral GPe-DBS proved to be low risk and quite effective for treating TS and comorbidities, ratifying the pathophysiological hypothesis that led to this study. Moreover, it compared favorably with DBS of other targets currently in use.

Deep brain stimulation for refractory obsessive-compulsive disorder (OCD): emerging or established therapy?

A consensus has yet to emerge whether deep brain stimulation (DBS) for treatment-refractory obsessive-compulsive disorder (OCD) can be considered an established therapy. In 2014, the World Society for Stereotactic and Functional Neurosurgery (WSSFN) published consensus guidelines stating that a therapy becomes established when "at least two blinded randomized controlled clinical trials from two different groups of researchers are published, both reporting an acceptable risk-benefit ratio, at least comparable with other existing therapies. The clinical trials should be on the same brain area for the same psychiatric indication." The authors have now compiled the available evidence to make a clear statement on whether DBS for OCD is established therapy. Two blinded randomized controlled trials have been published, one with level I evidence (Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score improved 37% during stimulation on), the other with level II evidence (25% improvement). A clinical cohort study (N = 70) showed 40% Y-BOCS score improvement during DBS, and a prospective international multi-center study 42% improvement (N = 30). The WSSFN states that electrical stimulation for otherwise treatment refractory OCD using a multipolar electrode implanted in the ventral anterior capsule region (including bed nucleus of stria terminalis and nucleus accumbens) remains investigational. It represents an emerging, but not yet established therapy. A multidisciplinary team involving psychiatrists and neurosurgeons is a prerequisite for such therapy, and the future of surgical treatment of psychiatric patients remains in the realm of the psychiatrist.

Tectocerebellar dysraphia and occipital encephalocele associated with trisomy X: case report and review of the literature.

INTRODUCTION: Tectocerebellar dysraphia (TCD) is a rare sporadic malformation associated with severe neurodevelopmental morbidity and high infant mortality. The presence of other ciliopathies worsens the prognosis. Joubert syndrome (JS) is a ciliopathy associated with gene mutations, consisting of midbrain and cerebellum malformations, markedly lack fiber decussation at the level of the pontomesencephalic junction. CASE REPORT: We report the case of a child who was born term with occipital encephalocele (OE), diagnosed with TCD and JS spectrum through computed tomography (CT), magnetic resonance (MR), diffuse tensor imaging (DTI), and clinical findings. She had the OE surgically corrected after spontaneous rupture on the second day after delivery. She developed postoperative ventriculitis, meningitis, and hydrocephalus, successfully treated with intravenous antibiotics and cysto-ventriculostomy, cysto-cisternostomy, third ventriculostomy, and choroid plexus coagulation. G-band karyotyping showed 47, XXX, in all analyzed cells (trisomy X). The infant was followed up for 18 months, presenting, so far, a relatively good outcome. CONCLUSION: This is the first case reported in the literature of the association of TCD/OE/JS spectrum (JSS) with trisomy X (XXX).

Our first decade of experience in deep brain stimulation of the brainstem: elucidating the mechanism of action of stimulation of the ventrolateral pontine tegmentum.

The region of the pedunculopontine tegmental nucleus (PPTg) has been proposed as a novel target for deep brain stimulation (DBS) to treat levodopa resistant symptoms in motor disorders. Recently, the anatomical organization of the brainstem has been revised and four new distinct structures have been represented in the ventrolateral pontine tegmentum area in which the PPTg was previously identified. Given this anatomical reassessment, and considering the increasing of our experience, in this paper we revisit the value of DBS applied to that area. The reappraisal of clinical outcomes in the light of this revisitation may also help to understand the consequences of DBS applied to structures located in the ventrolateral pontine tegmentum, apart from the PPTg. The implantation of 39 leads in 32 patients suffering from Parkinson's disease (PD, 27 patients) and progressive supranuclear palsy (PSP, four patients) allowed us to reach two major conclusions. The first is that the results of the advancement of our technique in brainstem DBS matches the revision of brainstem anatomy. The second is that anatomical and functional aspects of our findings may help to explain how DBS acts when applied in the brainstem and to identify the differences when it is applied either in the brainstem or in the subthalamic nucleus. Finally, in this paper we discuss how the loss of neurons in brainstem nuclei occurring in both PD and PSP, the results of intraoperative recording of somatosensory evoked potentials, and the improvement of postural control during DBS point toward the potential role of ascending sensory pathways and/or other structures in mediating the effects of DBS applied in the ventrolateral pontine tegmentum region.

Consensus on guidelines for stereotactic neurosurgery for psychiatric disorders.

BACKGROUND: For patients with psychiatric illnesses remaining refractory to 'standard' therapies, neurosurgical procedures may be considered. Guidelines for safe and ethical conduct of such procedures have previously and independently been proposed by various local and regional expert groups. METHODS: To expand on these earlier documents, representative members of continental and international psychiatric and neurosurgical societies, joined efforts to further elaborate and adopt a pragmatic worldwide set of guidelines. These are intended to address a broad range of neuropsychiatric disorders, brain targets and neurosurgical techniques, taking into account cultural and social heterogeneities of healthcare environments. FINDINGS: The proposed consensus document highlights that, while stereotactic ablative procedures such as cingulotomy and capsulotomy for depression and obsessive-compulsive disorder are considered 'established' in some countries, they still lack level I evidence. Further, it is noted that deep brain stimulation in any brain target hitherto tried, and for any psychiatric or behavioural disorder, still remains at an investigational stage. Researchers are encouraged to design randomised controlled trials, based on scientific and data-driven rationales for disease and brain target selection. Experienced multidisciplinary teams are a mandatory requirement for the safe and ethical conduct of any psychiatric neurosurgery, ensuring documented refractoriness of patients, proper consent procedures that respect patient's capacity and autonomy, multifaceted preoperative as well as postoperative long-term follow-up evaluation, and reporting of effects and side effects for all patients. INTERPRETATION: This consensus document on ethical and scientific conduct of psychiatric surgery worldwide is designed to enhance patient safety.

Striatal somatotopy and motor responses evoked by acute electrical stimulation of the posterior striatum in rats.

INTRODUCTION/OBJECTIVES: Previous experiments suggest that the striatal sensorimotor territory in rats is located in its dorsolateral region, along the rostrocaudal axis, unlike what has been observed in primates. In the present study, electrical stimulation was performed to investigate the degree of participation of the posterior striatum in its motor territory, its somatotopic organization, and the motor responses evoked by stimulation. METHODS: Twenty-five rats were submitted to stereotactic stimulation of the posterior striatum under general anesthesia, receiving consecutively four different current intensities. The motor responses observed in the different body parts were registered for later comparison. We considered as threshold the smallest of these current intensities able to evoke a motor response. RESULTS: The observed motor responses were qualitatively different for each segment: forepaws: ipsilateral, adduction, and contralateral abduction; hindpaws: ipsilateral, flexion, and contralateral, extension/abduction; trunk, rotation/flexion; and tail, rotation/elevation. High-frequency, small-amplitude distal tremor occurred in the ipsilateral forepaw in 95% of the animals. Progressively larger current intensities were necessary for the induction of motor response in the forepaws, hindpaws, and trunk/tail, in that order. CONCLUSIONS: The results allowed us to infer the following posterior striatal somatotopic organization: forepaws, posterolaterally, being the contralateral medial to the ipsilateral; trunk/tail, anteromedially; and hindpaws, in an intermediate position, being the contralateral posterior to the ipsilateral. It is suggested that the tremor and the other observed motor responses derive from the excitation of striatal projection neurons and that the striatum may play an important role in the genesis of essential tremor.

7T Magnetic Resonance Imaging Probabilistic Tractography-Based Evidence of Decussation of the Fibers Between the Lateral Geniculate Nucleus and the Primary Visual Area.

BACKGROUND: Geniculocalcarine fibers are thought to be exclusively ipsilateral. However, recent findings challenged this belief, revealing bilateral recruiting responses in occipitotemporoparietal regions upon unilateral stimulation of the lateral geniculate nucleus (LGN) in humans. This raised the intriguing possibility of bilateral projections to primary visual areas (V1). This study sought to explore the hypothetical decussation of the geniculocalcarine tract. METHODS: 40 healthy individuals' 7T magnetic resonance images from the Human Connectome Project were examined. Employing MRtrix3 software with the constrained spherical deconvolution algorithm, scans were processed. LGN served as the seed region and contralateral regions of interest (splenium of the corpus callosum, posterior commissure, LGN, V1, pulvinar, and superior colliculus) were defined to reconstruct the hypothetical decussated fibers. Tractography included contralateral V1 as the target region in all segmentations, excluding ipsilateral V1 to eliminate fibers leading to or originating from this area. Additionally, a segmentation of the tract originating from LGN and projecting to the ipsilateral V1 was performed. Mean fraction anisotropy and mean diffusivity metrics were extracted from the density maps. RESULTS: Observations revealed a substantial volume of decussated fibers between LGN and contralateral V1 via the splenium of the corpus callosum, albeit much smaller than ipsilateral fibers. The volume of ipsilateral fibers was similar in both sides. Left LGN-originating decussated fibers were more than double those originating from the right LGN. Tract segmentation to other regions of interests yielded no fibers. CONCLUSIONS: This study suggests a partial decussation of the fibers between LGN and V1, likely constituting the geniculocalcarine tract.

Effects of unilateral stereotactic posterior striatotomy on harmaline-induced tremor in rats.

Although long known and the most prevalent movement disorder, pathophysiology of essential tremor (ET) remains controversial. The most accepted hypothesis is that it is caused by a dysfunction of the olivocerebellar system. Vilela Filho et al. [2001; Stereotact Funct Neurosurg 77:149-150], however, reported a patient with unilateral hand ET that was completely relieved after a stroke restricted to the contralateral posterior putamen and suggested that ET could be the clinical manifestation of posterior putamen hyperactivity. The present study was designed to evaluate this hypothesis in the most often used model of ET, harmaline-induced tremor in rats. Fifty-four male Wistar rats were randomly distributed into three groups: experimental (EG), surgical control (SCG), and pharmacological control (PCG) groups. EG animals underwent stereotactic unilateral posterior striatotomy. SCG rats underwent sham lesion at the same target. PCG served exclusively as controls for harmaline effects. All animals received, postoperatively, intraperitoneal harmaline, and the induced tremor was video-recorded for later evaluation by a blind observer. Thirteen animals were excluded from the study. Limb tremor was reduced ipsilaterally to the operation in 20 of 21 rats of EG and in two of nine of SCG, being asymmetric in one of 10 of PCG rats. Comparisons between EG × SCG and EG × PCG were statistically significant, but not between SCG × PCG. Limb tremor reduction was greater in anterior than in posterior paws. Lateral lesions yielded better results than medial lesions. These results suggest that the posterior striatum is involved with harmaline-induced tremor in rats and support the hypothesis presented.

Possible mechanisms involved in subthalamotomy-induced dyskinesia in patients with Parkinson's disease.

BACKGROUND/AIMS: Operation-induced dyskinesia (OID) occurs in approximately 10% of patients submitted to subthalamotomy. The goal of the authors was to determine the possible causes of this feared complication. METHODS: The 54 patients who underwent unilateral subthalamotomy were divided into two groups: the OID group (OIDG), composed of 6 patients who developed dyskinesia following the operation, and the control group (CG), consisting of 48 patients who did not present this complication. The two groups were compared regarding age; sex; presence of levodopa-induced dyskinesia (LID) and/or stimulation-induced dyskinesia (SID); side of the operation; territories of the subthalamic nucleus (STN) involved by the lesion, and degree of lesion extension towards the zona incerta (ZI). RESULTS: The lesion involved the dorsolateral territory of the STN and was almost completely restricted to this nucleus in all patients of the OIDG, while it spread to the ZI in all but 1 patient of the CG. SID was significantly (p < 0.05) more frequent in the OIDG. There was also a strong trend favoring LID (p = 0.055). CONCLUSIONS: Damage to the dorsolateral territory of the STN and sparing of the ZI seem to be essential for the development of OID. SID and, to a lesser extent, LID are apparently significant risk factors for the development of this complication.

Behavioral and motor improvement after deep brain stimulation of the globus pallidus externus in a case of Tourette's syndrome.

OBJECTIVES: The objective of our paper is to show the partial decrease of therapeutic effect with battery exhaustion in a previously successfully treated patient with refractory Tourette's syndrome (TS). MATERIALS AND METHODS: We present a 47-year-old patient diagnosed with TS based on the TS Study Group Criteria and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Surgery was considered based on refractoriness to conservative management. Presurgical evaluation included magnetic resonance imaging (MRI), positron emission tomography scan, and neuropsychologic, neurologic, and psychiatric tests utilizing Yale Brown Obsessive Compulsive Scale, Yale Global Tics Severity Scale, Hamilton Depression Rating Scale, Hamilton Anxiety Rating Scale, Global Assessment of Functioning Scale, and Mini-mental State Examination. Target coordinates were obtained from inversion recovery MRI. Quadripolar deep brain stimulation (DBS) electrodes were implanted bilaterally in the globus pallidus externus (GPe) and connected to the pulse generator in the same procedure. To determine the clinical response to DBS, the scores of the scales obtained preoperatively were compared with those obtained postoperatively. RESULTS: No surgical complications were detected and according to the clinical scales the patient experienced a marked improvement of his symptoms, although he never showed obsessive-compulsive disorder components of any type. The battery was exhausted after two years with the subsequent significant partial loss of therapeutic effect. CONCLUSIONS: GPe seems to be a highly promising target of DBS for the treatment of medically refractory TS. After battery exhaustion, the patient experienced a marked partial decrease in the therapeutic effect, which confirms the beneficial action of this method.

A new strategy for treating drug-resistant focal aware seizures: thalamic specific nuclei deep brain stimulation. Illustrative case.

BACKGROUND: Focal aware seizures (FASs) are relatively common and frequently pharmaco-resistant. If the seizure onset zone (SOZ) is in eloquent cortical areas, making resective surgery risky and inadvisable, deep brain stimulation (DBS) of the anterior nucleus of the thalamus, which is efficacious in less than half of the cases, has been the main alternative. New targets should be searched to address this deficiency. The present study aims to determine if DBS of different thalamic specific nuclei can modulate the abnormal electrical activity of the SOZ located in their respective cortical projection areas. Herein, the authors present the first patient in an ongoing trial. OBSERVATIONS: A 60-year-old female patient presented with 25-year history of pharmaco-resistant focal aware visual seizures frequently evolving to focal impaired awareness seizures. The SOZ was in the right occipital lobe (positron emission tomography-computed tomography/video electroencephalography). Magnetic resonance imaging was normal. She underwent ipsilateral lateral geniculate nucleus (LGN) DBS procedure. After a 24-month follow-up, seizure frequency decreased by 97%, improving quality of life and daily functioning without complications. LESSONS: This is the first time the LGN has been targeted in humans. The results support the hypothesis that led to this study. This strategy represents a paradigm shift in the way of treating pharmaco-resistant FASs not amenable to resective surgery.

Ventral intermediate nucleus deep brain stimulation for treatment-resistant focal aware motor seizures: illustrative case.

BACKGROUND: Resection of the seizure onset zone (SOZ) is considered the gold standard for treating refractory focal aware seizures (FASs). When resective surgery is unadvisable, deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT; ANT-DBS) has been the procedure of choice. However, less than half of patients with FASs respond to ANT-DBS. The need for alternative targets to effectively treat FAS is thus evident. OBSERVATIONS: The authors report the case of a 39-year-old woman presenting with pharmaco-resistant focal aware motor seizures, with the SOZ located in the primary motor cortical area. She had previously undergone unsuccessful resection of the left temporoparietal operculum elsewhere. Considering the risk of new resective surgery, she was offered combined ventral intermediate nucleus (Vim)/ANT-DBS. Vim-DBS proved to be superior to ANT-DBS for seizure control (88% vs 32%), although the association of both provided the best results (97%). LESSONS: This is the first report on the use of the Vim as a target of DBS for the treatment of FAS. The excellent results were presumably obtained by modulation of the SOZ through Vim projections to the motor cortex. This opens a completely new avenue for treating FAS: chronic stimulation of specific thalamic nuclei.

Indicators of correct targeting in stereotactic biopsy of intracranial lesions.

Background: Confirmation of whether a stereotactic biopsy was performed in the correct site is usually dependent on the frozen section or on novel tumor-specific markers that are not widely available. Immediate postoperative computed tomography (CT) or magnetic resonance (MR) is routinely performed in our service after biopsy. In this retrospective study, we have carefully analyzed these images in an attempt to determine the presence of markers that indicate appropriate targeting. Methods: Medical records and neuroimages of patients who underwent stereotactic biopsy of intracranial lesions were reviewed. The following variables were assessed: age, sex, anatomopathology, lesion site, complications, diagnostic accuracy, and the presence of image markers. Results: Twenty-nine patients were included in this case series. About 96.6% of the biopsies were accurate according to the permanent section. Of the 86.2% of patients with intralesional pneumocephalus on the postoperative images, 51.7% additionally presented petechial hemorrhage. In 13.8% of the cases, no image markers were identified. Conclusion: This is the first report of intralesional pneumocephalus and petechial hemorrhage as indicators of appropriate targeting in stereotactic biopsy. In the majority of the cases, an immediate postoperative head CT, which is widely available, can estimate how adequate the targeting is. To use intralesional pneumocephalus/ petechial hemorrhages as not only postoperative but also as intraoperative markers of appropriate targeting, it is advised that the surgical wound should be temporarily closed and dressed after the biopsy so that the patient can undergo a CT/MR scan and be checked for the presence of theses markers before removing the stereotactic frame.

Semidirect targeting-based stereotactic mesencephalotomy for the treatment of refractory pain: a case series.

OBJECTIVE: One of the few resources for treating medically intractable pain is ablative surgery, but its indications have fallen dramatically over the last decades. One such procedure is mesencephalotomy. This study aims to determine current risks and benefits of MR-guided semidirect targeting-based stereotactic mesencephalotomy. METHODS: This was a retrospective study based on a review of the medical records of 22 patients with nociceptive (n = 5), neuropathic (n = 10), or mixed (n = 7) refractory pain treated with unilateral mesencephalotomy alone (17 patients) or associated with bilateral anterior cingulotomy (5 patients) between 2014 and 2021 in the authors' institutions. The confidence interval adopted in this study was 95%. RESULTS: The sample included 12 women and 10 men with ages ranging from 23 to 80 years (mean 55.1 ± 17.1 years). Using MR-guided semidirect targeting, the following structures were targeted: spinoreticulothalamic (neuropathic/mixed pain, n = 17), trigeminothalamic (nociceptive/mixed pain in the face, n = 5), and neospinothalamic (nociceptive/mixed pain in the body, n = 7) pathways. The most common response to macrostimulation was central heat/moderate discomfort. Radiofrequency thermocoagulation was made with 70°C-75°C/60 sec. A total of 86.3% (3 months) and 76.9% (12 months) of the patients achieved excellent or good results (improvement of pain > 50%), presenting with a significant mean pain relief of 80.1% at 3 months and 71.4% at 12 months postoperatively. The addition of bilateral anterior cingulotomy did not improve the results. Patients with upper limb, cervicobrachial, and face pain did significantly better than those with trunk pain. The worst results were seen in patients with neuropathic and/or trunk pain. The surgical failure (pain relief ≤ 25%) and recurrence rates were 9.1% each, apparently related to the use of lower lesioning parameters (70°C/60 sec) and to the presence of neuropathic and/or trunk pain. The morbidity rate was 8%, with both complications (vertical diplopia and confusion/agitation) happening in patients lesioned with 75°C/60 sec. There were no deaths in this series. CONCLUSIONS: These results show that contemporary stereotactic mesencephalotomy is an effective, relatively low-risk, and probably underused procedure for treating medically intractable pain. Careful semidirect determination of the target coordinates associated with close attention to electrical macrostimulation responses certainly plays an important role in avoiding complications in most of the procedures. A higher lesioning temperature (75°C) apparently prevents recurrence, but at the cost of an increased risk of complications.

The impact of subcaudate tractotomy on delusions and hallucinations in psychotic patients.

BACKGROUND: Delusions and hallucinations, hallmarks of the psychotic disorders, usually do not respond to surgical intervention. For many years, the surgical technique of choice for the treatment of refractory aggressiveness in psychotic patients in our Service was amygdalotomy in isolation or associated with anterior cingulotomy. No improvement of hallucinations and delusions was noticed in any of these patients. To improve the control of aggression, subcaudate tractotomy was added to the previous surgical protocol. The main goal of the present study was to investigate the impact of this modified surgical approach on delusions and hallucinations. METHODS: Retrospective analysis of the medical records of psychotic patients presenting with treatment-resistant aggressiveness, delusions, and hallucinations submitted to bilateral subcaudate tractotomy + bilateral anterior cingulotomy + bilateral amygdalotomy in our institution. RESULTS: Five patients, all males, with ages ranging from 25 to 65 years, followed up by a mean of 45.6 months (17-72 months), fulfilled the inclusion criteria. Delusions and hallucinations were abolished in four of them. CONCLUSION: These results suggest that the key element for relieving these symptoms was the subcaudate tractotomy and that the orbitofrontal and ventromedial prefrontal cortices play an important role in the genesis of hallucinatory and delusional symptoms of schizophrenia and other psychoses.

Induction of Ticlike Involuntary Movements in Rats by Striatotomy and Subsequent Neurochemical Sensitization.

OBJECTIVE: It has been proposed that Tourette syndrome is associated with dysfunction in widespread cortical areas and globus pallidus externus hyperactivity secondary to dopaminergic hyperactivity and serotonergic/dynorphinergic hypoactivity. The main objective of this study was to test this hypothesis by developing an animal model of Tourette syndrome via striatotomy, followed by administration of drugs that mimic the neurotransmitter environment, so as to induce globus pallidus externus hyperactivity. METHODS: Rats were assigned to 3 groups: stereotactic striatotomy (STT) and striatal sham -lesion (SHAM) groups, treated with anterior and posterior striatum procedures in both hemispheres, and a group of nonoperated animals (NAIVE). Postoperatively, all rodents were blindly administered 3 drug protocols: levodopa/benserazide; levodopa/benserazide/ergotamine/naloxone (MIX); and saline. The animals were filmed at the peak action of these drugs. The videos were evaluated by a single blinded researcher. RESULTS: Six types of involuntary movements (IMs) were observed: cephalic, trunk jerks, oromandibular, forepaw jerks, dystonic, and locomotive. The number of animals with IM and the mean number of IM after both levodopa/benserazide and MIX was significantly higher in the STT compared with the SHAM and NAIVE groups. In the SHAM and NAIVE, MIX was superior to levodopa/benserazide in the induction of IM. In the STT, MIX was superior to levodopa/benserazide in the induction of trunk jerks. Appendicular IM were more common after posterior than after anterior striatotomy. CONCLUSIONS: These results show that striatotomy, followed by administration of levodopa/benserazide alone or associated with ergotamine and naloxone, is efficacious in inducing IM, supporting the hypothesis that led to this study.

Gamma probe-assisted brain tumor microsurgical resection: a new technique.

OBJECTIVES: The pioneering performance of gamma probe-assisted surgery (GPAS) for brain tumors, aiming not only an improvement of tumor detection, but mainly assurance of its complete removal and the study of the usual distribution of the 99mTc-MIBI in the brain SPECT of normal individuals. METHOD: Patient's informed consent and demonstration of the tumor by the preoperative MIBI SPECT were the inclusion criteria adopted for GPAS, which was performed in one patient with a right parietal lobe metastatic tumor. The radiotracer (99mTc-MIBI) was injected in a peripheral vein 5 hours before the operation. A tumor to-normal tissue count ratio equal to or greater than 2/1 was considered indicative of tumor. MIBI SPECT was performed in five normal individuals in a pilot study. RESULTS: The gamma probe greatly facilitated intraoperative tumor detection (tumor to-normal brain count ratio was 5/1) and indicated a small piece of residual tumor after what was thought to be a complete tumor removal, allowing its resection, which, otherwise, would have been left behind. Postoperative CT confirmed complete tumor resection. The MIBI SPECT in normal individuals showed an increased uptake by the hypophisis, choroid plexus, skull, scalp and salivary glands and absence of uptake by the normal brain tissue. There were no complications. CONCLUSION: GPAS proved to be, in this single case, a safe and reliable technique to improve brain tumor detection and to confirm the presence or absence of residual tumor.

Unilateral subthalamic nucleus lesioning: a safe and effective treatment for Parkinson's disease.

The present study, the largest in the literature, was performed to assess the effectiveness and safety of unilateral subthalamic nucleus (STN) lesioning for Parkinson's disease (PD). From August 1999 to September 2000, 21 consecutive patients evaluated pre- and postoperatively by a single examiner were operated. Levodopa intake and dyskinesia, Hoehn & Yahr, Schwab & England and UPDRS motor scores were recorded. Stereotactic CT and MRI and the effects of macrostimulation were used to determine STN coordinates. A single radiofrequency lesion was made (60-75 degrees C/60"). Concomitant ipsilateral Vim/VOp lesions were made in 8 patients. Using a new technique, we were able to determine the territory of STN involved by the surgical lesion. The Wilcoxon and Mann-Whitney statistical tests were applied to evaluate the surgical results. All recorded parameters showed stable improvement after a mean follow up of 13.5 months. Recurrence occurred in two patients. Contralateral tremor arrest and decrease of rigidity and bradykinesia should be regarded as STN hallmarks to stimulation. Hyperintense lesions in the early-phase MRI seem to be a poor prognostic factor. Lateral territory lesioning correlates with better results. There was no significant difference between the cohorts with and without a Vim/VOp lesion. Dyskinesias happened in two patients (promptly abolished by a Vim/VOp lesion). Other complications were transient and/or rare. In conclusion, STN lesioning is a safe and very effective procedure to treat PD and probably an underutilized operation for those who can not afford the costs of DBS.