Long-term efficacy and safety of chronic globus pallidus internus stimulation in different types of primary dystonia.

BACKGROUND: Deep brain stimulation (DBS) of the globus pallidus internus (GPi) offers a very promising therapy for medically intractable dystonia. However, little is known about the long-term benefit and safety of this procedure. We therefore performed a retrospective long-term analysis of 18 patients (age 12-78 years) suffering from primary generalized (9), segmental (6) or focal (3) dystonia (minimum follow-up: 36 months). METHODS: Outcome was assessed using the Burke-Fahn-Marsden (BFM) scores (generalized dystonia) and the Tsui score (focal/segmental dystonia). Follow-up ranged between 37 and 90 months (mean 60 months). RESULTS: Patients with generalized dystonia showed a mean improvement in the BFM movement score of 39.4% (range 0-68.8%), 42.5% (range -16.0 to 81.3%) and 46.8% (range -2.7 to 83.1%) at the 3- and 12-month, and long-term follow-up, respectively. In focal/segmental dystonia, the mean reduction in the Tsui score was 36.8% (range 0-100%), 65.1% (range 16.7-100%) and 59.8% (range 16.7-100%) at the 3- and 12-month, and long-term follow-up, respectively. Local infections were noted in 2 patients and hardware problems (electrode dislocation and breakage of the extension cable) in 1 patient. CONCLUSION: Our data showed Gpi-DBS to offer a very effective and safe therapy for different kinds of primary dystonia, with a significant long-term benefit in the majority of cases.

Chronic electrostimulation of the trigeminal ganglion in trigeminal neuropathy: current state and future prospects.

Over two decades ago, the electrostimulation of the trigeminal ganglion (TGES) was established as a treatment option for patients with trigeminopathic pain due to a (iatrogenic) lesion of the trigeminal nerve, on whom the other therapeutic methods, either neurosurgical or conservative have very limited efficacy and usually are associated with a poor outcome. The technique of TGES which uses the setup also used for the thermocoagulation lesion for trigeminal neuralgia was first published by Steude in 1984 and has not been altered substantially. After a percutaneous puncture with a 16 gage needle of the oval foramen, a monopolar electrode (diameter 0.9mm, custom-made) is placed in the postganglionic trigeminal nerve. After a successful test-stimulation phase, a permanent electrode pulse generator system is implanted. Our experience includes more than 300 patients with a minimum follow-up of one year. Of these patients, 52% showed a good to excellent analgesic effect. The TGES-induced analgesia was persistent in long term-follow-up in all patients. The impact of TGES on cerebral pain modulation was proven by electrophysiology and PET. TGES is an effective, minimally invasive and reversible treatment option in selected patients with trigeminopathic pain; it should, therefore, always be considered as the primary treatment-option. Electrodes with two leads and a diameter not exceeding the 0.9 mm, allowing bipolar stimulation might enhance the neuromodulatory efficacy and options of TGES.

[Seven years of botulinum toxin type A in the treatment of neurogenic detrusor hyperactivity]. / 7 Jahre Botulinum-A-Toxin in der Behandlung der neurogenen Detrusorhyperaktivität.

BACKGROUND: A decompensated storage function with high pressures is the greatest risk factor regarding life expectancy and quality of life in patients with neurogenic detrusor hyperactivity. Previously, this problem could only be managed with administration of anticholinergic medications or--if this approach was either not effective enough or the patients exhibited drug intolerance--by invasive surgical interventions. The use of botulinum toxin type A to treat these patients rapidly proved to be a beneficial alternative to those two therapeutic options ever since its introduction in Germany in 1998 as a minimally invasive procedure and has become established worldwide. MATERIAL AND METHODS: The medical records of first-time users at the clinic were retrospectively analyzed for a 7-year period. The total of 492 injections in 277 patients--of which 365 injections in 216 patients were performed following a standardized protocol--represents the largest number of cases worldwide. The treatment was indicated in patients experiencing insufficient efficacy of anticholinergic agents or drug intolerance who were capable of self-catheterization. RESULTS: The standard injection contained either 300 MU Botox or 750 MU Dysport. Urodynamic parameters before and up to 8 months post-intervention showed significantly lowered detrusor pressure and improved cystometric capacity. This corresponded to the clinical assessment and subjective impression of the patients that detrusor activity had been reduced to a large extent with improved continence. Evacuation was carried out in all cases without any difficulty by aseptic intermittent catheterization. The average duration of the effect was subjectively determined to be 8.7 months. In the vast majority of cases, anticholinergic medications could be discontinued or considerably reduced. Side effects not requiring treatment developed in only four instances. Antibody formation no longer occurred with those products available on the market since 2001. Even after repeated injections (up to ten times) there was no evidence for decreased efficacy. CONCLUSION: Due to its reliable effect and low rate of side effects, botulinum toxin type A quickly became accepted worldwide for the treatment of neurogenic detrusor hyperactivity and has contributed to a substantial enrichment of the more conservative therapy options. Prospective studies focusing especially on injection site and optimizing the duration of efficacy are desirable.

[First experiences in deep brain stimulation for cervical dystonia]. / Tiefe Hirnstimulation bei zervikaler Dystonie. Erste Erfahrungen.

BACKGROUND: Cervical dystonia results in severe disability and cannot be effectively treated with medication. Repeat injections of botulinum toxin into the dystonic neck muscles can relieve the symptoms in most patients. When this treatment fails (mostly due to antibody formation), deep brain stimulation can be considered. PATIENTS AND METHODS: We report our experiences with eight patients who were treated with bilateral deep brain stimulation of the globus pallidus interna for cervical dystonia. The mean observation period was 31 months. RESULTS: Six of eight patients experienced relief from symptoms a few days after the implantation. Improvement of symptoms was a mean of 60% during the 1st year. There were no complications. CONCLUSION: In this and in other studies with small numbers of patients, deep brain stimulation has shown a good effect on cervical dystonia. According to our results, the patients who benefit most are those with no dystonic shoulder involvement and who have a tonic rather than clonic symptomatology. It seems probable that deep brain stimulation will become the therapy of choice for otherwise intractable cervical dystonia.

[The facet syndrome: frequent cause of chronic backaches]. / Häufige Ursache chronischer Rückenbeschwerden: lumbales Facettgelenksyndrom. Mit Kälte gegen den bohrenden Schmerz.

The lumbar facet syndrome (LFS) is a frequent cause of chronic backaches. A reliable diagnosis can be made through repeated facet blockades.The diagnosis is considered confirmed if the pain is significantly reduced over several hours. In addition to oral pain medication and physical measures, alternative minimally invasive therapeutic possibilities include surgical stabilization, as well as facet joint denervation. Both can be performed as thermodenervation or cryotherapy.

[Comparison between TCI-TIVA, manual TIVA and balanced anaesthesia for stereotactic biopsy of the brain]. / Vergleich zwischen TCI-TIVA, manueller TIVA und balanzierter Anästhesie während stereotaktischer Gewebsentnahme in der Neurochirurgie.

PURPOSE: Total intravenous anaesthesia (TIVA) is increasingly used in diagnostic surgery such as stereotactic biopsy of the brain. TIVA could lead to a faster recovery of cerebral function, which may lead to a better behavior and advantages in the postoperative management. The aim of this prospective, single-blind study was to compare the hemodynamics, the postoperative recovery period, the side-effects and the need for additional cardiovascular medication during and after the operation between the three study groups. PATIENTS AND METHODS: After giving informed consent and approval by the ethical committee of our hospital, 51 patients (ASA I and II) undergoing stereotactic biopsy of a brain tumor were randomized to receive either propofol via the TCI-system (group 1: TCI-TIVA), propofol by a manual technique (group 2: MAN-TIVA) or methohexitone-sevoflurane (group 3: BAL-SEVO). Remifentanil was used as the analgetic component in all groups. Systolic and diastolic blood pressure, heart rate und transcutaneous oxygen saturation were noted before and after induction and before and after the end of anaesthesia. The time until return of complete orientation relative to person, location and time were measured. The patients' ranking of their satisfaction with the anaesthesia was questioned 60 min and 24 hours after the end of the procedure (VAS). Undesirable side-effects (i. e. PONV, shivering, pain, dysphoria, tiredness) were noted, whenever they occurred. The number of hemodynamic interventions by the anaesthesiologist was counted, and the total doses of remifentanil and propofol were quoted. Depth of anaesthesia was monitored by using a BIS-system, a range between 40 and 50 was thought to be adequate. Besides this, the total doses of remifentanil, propofol and sevoflurane were ruled out and the costs of the three regimens were ranked. RESULTS: Heart rate dropped markedly in all groups with a maximum in the TIVA-collective. Systolic and diastolic pressure also fell in the groups. In the SEVO-group, the difference was statistically significant only at the end of anaesthesia. After extubation, the three groups reached their hemodynamic starting-point with a slight overshoot in the SEVO-group. The number of required hemodynamic interventions was two (TCI-TIVA) vs. 7 (MAN-TIVA) vs. 8 (BAL-SEVO) in each group, respectively. The difference scarcely failed to get significance. The remifentanil requirements were similar between the collectives, group 1 needed more propofol per time than group 2. The number of side-effects was very little after the different regimens. There were no differences with regard to the other measured parameters between the groups. The use of TCI-TIVA was more expensive than manual TIVA (18,85 euro vs. 12,50 euro). Surprisingly, balanced anaesthesia using Sevoflurane was the most expensive method during the first hour, mainly due to the use of methohexitone as the induction agent (23,90 euro). CONCLUSIONS: Each of the three techniques compared in our study is suitable for anaesthesia in diagnostic neurosurgery. Since fast recovery of vigilance is important to justify the neurological outcome, none of the methods seems to be superior to the others. The hemodynamics were largely stable with a strong trend towards minor necessity for hemodynamic intervention in the TCI-TIVA group. This is also the best method from the subjective point of view of the anaesthesiologist due to the easy handling and the low number of interventions. The use of newer TCI-systems (e. g. fm-controller, Braun, Melsungen) not operating with special application syringes will cheapen TCI-TIVA.

[Therapy and prophylaxis of facial neuralgias and other forms of facial pain syndromes -- revised recommendations of the German Society of Migraine and Headache]. / Therapie und Prophylaxe von Gesichtsneuralgien und anderen Formen der Gesichtsschmerzen -- Uberarbeitete Empfehlungen der Deutschen Migräne- und Kopfschmerzgesellschaft.

Trigeminal neuralgia and postherpetic neuralgia are the most relevant neuralgiform facial pain syndromes. Trigeminal neuralgia is characterized by lancinating intensive pain attacks of very short duration, triggered by external cues,whereas postherpetic neuralgia consists predominantly of long-lasting burning pain. Sodium channel blocking drugs are first choice in treatment of trigeminal neuralgia, operative procedures encompass microvascular decompression,thermocoagulation and percutaneous retrogasserian glycerol rhizotomy. In the acute stage postherpetic neuralgia is treated antivirally and analgesically, in the chronic stage by tricyclic antidepressive substances. Other pain syndromes described encompass the Tolosa-Hunt-syndrome, cervicogenic headache, craniomandibular dysfunction syndrome, atypical facial pain and rarer syndromes. Therapeutic recommendations are based on evidence based medicine criteria (EBM).

Contraversive eye deviation during deep brain stimulation of the globus pallidus internus.

Clinical signs help determine correct electrode positioning during stereotactic implantation for chronic high-frequency pallidal stimulation in Parkinson's diease (PD). The authors describe a patient who had marked, sustained, contraversive eye deviation caused by stimulation during pallidal surgery. The underlying mechanism is probably an excitation of fibers in the internal capsule by volume-conducted current spread. Such conjugate eye deviation is thus not necessarily an indication of incorrect electrode placement.

Surgery of lesions in the motor strip combining a stereotactically-guided mini-craniotomy with electrophysiological mapping of the motor cortex.

The removal of space-occupying lesions in the sensori-motor cortex carries a considerable risk of postoperative palsy. Therefore subcortical lesions located in the sensori-motor strip are often considered to be inoperable. Treatment options are stereotactic biopsy and radiosurgery beside radiological control examinations without surgery or surgery with a higher risk of postoperative deficits. The following article focusses on a combined approach involving a stereotactically guided and electrophysiologically controlled surgery. The instruments used (stereotactical system and electric stimulator) are available in almost every neurosurgical department in the Western and Eastern world and had been the first navigation systems in the human brain.

Intracavitary treatment of intrasellar cystic craniopharyngeomas with 90-Yttrium by trans-sphenoidal approach--a technical note.

Intracavitary irradiation of intrasellar cystic craniopharyngeomas by stereotactic cyst puncture and injection of radioactive solutions is not yet possible. Therefore we designed a new method which allows such intracavitary irradiation. Its principle is a transphenoidal approach with only a small bony opening of the sella floor, followed by cyst puncture, exclusion of cyst leakage by Metrizamid injection under x-ray control, injection of Y-90-colloid solution at a dosage which delivers a radiation of 200 Gy to the cyst wall, and finally tight closure of the puncture site using fibrin glue and gelfoam. This method has been used in three patients with good results (follow-up 12-15 months) and without complications. Even though long-term follow-up is not yet available, our preliminary results suggest that this method will be useful for future patients with intrasellar cystic craniopharyngeomas.

Evaluation of patients with atypical trigeminal neuralgia for permanent electrode implant by test stimulation of the ganglion gasseri.

The treatment of so-called atypical trigeminal neuralgia, characterized by long-lasting burning pain sensations without any pain attacks was for a long time an unsolved problem in contrast to the so-called 'tic douloreux'. Following the experience with our own patients and other groups, destructive procedures in atypical trigeminal neuralgia frequently result in worsening of the clinical conditions. We have therefore transferred the well-established method in the periphery of therapeutic electrostimulation to the trigeminal region. The evaluation of the patients with atypical trigeminal neuralgia is the key for good therapeutic results. Therefore percutaneous test stimulation of the ganglion gasseri has to be performed during a hospital stay. 54% of 149 patients experienced pain relief during test stimulation. Therefore in 81 patients with positive test results, electrodes were implanted together with a neurological pulse generator (Itrel Medtronic).

The stereotactic biopsy diagnosis of focal intracerebral lesions in AIDS patients.

Focal intracerebral lesions were biopsied stereotactically in 23 adult HIV-infected patients, the main indication for which was the failure to respond to anti-toxoplasma treatment. A cerebral disease was the initial or main complaint in 19 of them. In 22 of 25 stereotactic approaches, a clear-cut morphological diagnosis could be established (9 primary brain lymphoma, 7 necrotizing toxoplasma encephalitis, 5 progressive multifocal leukoencephalopathy, 1 HIV encephalitis, 3 unspecific tissue changes). In 7 of 8 deceased patients, autopsy confirmed the bioptical diagnosis. The high diagnostic yield was related to the strategy of the stereotactic method and the sample size (3 to 4 consecutive samples along the stereotactic track including the marginal zones, 1 cm long tissue cylinders). Formalin fixation and paraffin embedding of the samples provide the possibility of serial sections and special stainings (immunohistochemistry, in-situ hybridization) and kill the HIV. Stereotactic brain biopsy is a highly accurate diagnostic tool to ascertain the nature of focal intracerebral lesions in selected AIDS patients.

Multiple contact foramen ovale electrode in the presurgical evaluation of epileptic patients for selective amygdala-hippocampectomy.

For stereo-EEG evaluation of patients suffering from drug resistant mesiobasal temporal lobe epilepsy a method is described to place multi-contact electrodes percutaneously through the foramen ovale near the brain stem and medial surface of the temporal lobe. The experience with 41 cases is reported. In 28 of them a unilateral well localized focus could be identified. All of them were treated by selective amygdala-hippocampectomy according to Wieser and Yasargil. During follow-up for at least one year 22 of patients were seizure-free. An additional 5 had a reduction of seizure frequency. Complications were subarachnoid haemorrhage in one case, transient hypaesthesia in another, and transient herpes simplex of the lips in 7 cases.

Accuracy of stereotactic brain tumor biopsy: comparison of the histologic findings in biopsy cylinders and resected tumor tissue.

Appropriate treatment for intracranial mass lesions depends upon accurate morphological diagnosis. In 47 of 360 patients the findings in stereotactically obtained tissue cylinders were compared with tumor resection (n = 38) or autopsy (n = 9) tissue material to define the accuracy of our stereotactic biopsy method. These biopsies were performed using the LEKSELL CT stereotactic frame and a spiral needle which procured about 10-mm-long tissue cylinders. Usually, three to four successive biopsy specimens were taken along the target trajectory placed through the whole lesion and its margins according to the CT imagings. Final morphological diagnosis was exclusively based on the histological findings of permanent paraffin sections. In 42 cases (89%), the histological results in biopsy and resection/autopsy tissue were identical, including mainly cases of low and high grade gliomas as well as some brain lymphomas, metastases, and cases of inflammatory brain lesions (aspergillosis, toxoplasmosis). In 3 patients with a diagnosis of brain lymphoma and low grade glioma on the basis of the surgical specimens, stereotactic biopsy revealed only unspecific reactive tissue changes. In two cases of the early part of the study, sampling errors occurred. This study provides evidence for the high diagnostic accuracy of the established stereotactic biopsy method which is characterized by representative tissue sampling and histological processing of the specimens.

Epidural spinal electrical stimulation in the treatment of severe arterial occlusive disease.

The effect of epidural spinal cord stimulation (ESES) on peripheral circulation in 10 cases with advanced vascular occlusive disease has been tested, using transcutaneous oxygen measurement (TcpO2), contact thermography and laser-speckle measurements. The values in all cases increased. Improvement was more pronounced during the first 2-3 weeks. Indications and limitations of this treatment modality are discussed.