Radiofrequency Cingulotomy as a Treatment for Incoercible Pain: Follow-Up for 6 Months.

Incoercible or intractable pain is defined as pain that is refractory to pharmacological treatment to such an extent that opioid and analgesic adverse effects outweigh the therapeutic effects. The anterior cingulate cortex (ACC) is involved in the perception of pain, especially emotional pain, so it is logical that cingulotomy has an effective therapeutic effect. Therefore, we evaluated the effectiveness of cingulotomy for the treatment of incoercible pain. An observational, longitudinal, retrospective, and analytical study was carried out on a series of cases in which bilateral cingulotomy was performed for incoercible pain, and follow-up was performed 6 months after neurosurgery in the outpatient clinic at the Neurotraumatology Clinic. A positive correlation was observed between pain intensity and medication use, indicating that an increase in pain was associated with a greater requirement for analgesics. The result was a significant reduction in pain, as measured by the visual analog scale of pain, and decreased drug use after cingulotomy. We concluded that cingulotomy reduces incoercible pain and the need for medication.

Stereotactic biopsy for intracranial space occupying lesions: Experience in a referral hospital in Mexico.

BACKGROUND: Stereotactic brain biopsy (SBB) is used for establishing the histological diagnosis of intracranial lesions that are not amenable for a direct surgical approach. OBJECTIVE: The objective of the study was to describe our experience having an evaluation of the biopsy sample by a neuropathologist during SBB. MATERIALS AND METHODS: Retrospective analysis of 140 consecutive patients who underwent SBB between 2014 and 2018 in whom trans-operatory analysis of the sample was performed. RESULTS: There were 56% men. The mean age was 45 years. Histological diagnosis was performed in 131 of 140 patients (94% overall diagnostic yield). The presurgical radiological diagnosis was correct in 39%. Neoplastic lesions were reported in 108 cases, and 32 were non-neoplastic. We performed craniotomy and resection after biopsy in 14%. We found complications in 6% of patients. CONCLUSIONS: SBB continues to be a safe, useful, and inexpensive procedure. The diagnostic performance of SBB increases when intraoperative cytological evaluation by a neuropathologist is included in the study.

ANTECEDENTES: la biopsia cerebral por estereotaxia (SBB) se utiliza para establecer el diagnóstico histológico de lesiones intracraneales que no son susceptibles de un abordaje quirúrgico directo. OBJETIVO: describir nuestra experiencia de tener una evaluación de la muestra de biopsia por un neuropatólogo durante el procedimiento. MATERIAL Y MÉTODOS: análisis retrospectivo de 140 pacientes consecutivos sometidos a SBB entre 2014-2018 en los que se realizó análisis transoperatorio de la muestra. RESULTADOS: El 56% fueron hombres. La edad promedio fue de 45 años. El diagnóstico histológico se realizó en 131 de 140 pacientes (rendimiento diagnóstico global del 94%). El diagnóstico radiológico prequirúrgico fue correcto solo en el 39%. Se identificaron lesiones neoplásicas en 108 casos, y en 32 se documentaron lesiones no neoplásicas. En el 14% de los casos se realizó posterior a la biospia craneotomía y resección de la lesión. Encontramos complicaciones en el 6% de los pacientes. CONCLUSIONES: SBB sigue siendo un procedimiento seguro, útil y económico. El rendimiento diagnóstico de SBB aumenta cuando se incluye la evaluación citológica intraoperatoria por un neuropatólogo.

Specific movement and disability improvements in Burke-Fahn-Marsden Dystonia Rating Scale derived from pallidotomy in refractory patients to medical treatment.

BACKGROUND: Dystonia is a movement disorder associated with significant disability and is usually refractory to medical treatment. Pallidotomy may decrease dystonic movements. The aim of this study was to quantify movement and disability improvements through Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). METHODS: We carried out a longitudinal clinical study in patients with refractory primary and secondary dystonia, who underwent radiofrequency (RF) unilateral and bilateral lesions on the postero-ventro-lateral globus pallidus internus (GPi), evaluating the outcomes through BFMDRS and variables as age, time of evolution, etiology, body distribution, planned target coordinates, and lesion size, during a mean follow-up time of 35.67 months. RESULTS: Nine RF pallidotomies were performed on 6 patients, 7 right-sided and 2 left-sided; three patients were treated unilaterally for one occasion, while the others underwent 2 surgeries, including one staged bilateral procedure. Mean BFMDRS scores for movement were 38.5 preoperative and 25.5 postoperative, and for disability were 20.4 preoperative and 17.3 postoperative. We noticed improvement in movement (32.54%, p = 0.001) and disability (17.23%, p = 0.002). There was one right GPi and internal capsule (IC) infarction with contralateral hemiparesis as sequelae. CONCLUSIONS: RF pallidotomy is an effective and accessible procedure to reduce BFMDRS scores in refractory dystonia if patients are correctly selected by severity, evolution, and disability as determining factors.

Long-Term Improvement of Parkinson Disease Motor Symptoms Derived From Lesions of Prelemniscal Fiber Tract Components.

BACKGROUND: Prelemniscal radiations (Raprl) are composed of different fiber tracts, connecting the brain stem and cerebellum with basal ganglia and cerebral cortex. In Parkinson disease (PD), lesions in Raprl induce improvement of tremor, rigidity, and bradykinesia in some patients, while others show improvement of only 1 or 2 symptoms, suggesting different fiber tracts mediate different symptoms. OBJECTIVE: To search for correlations between improvements of specific symptoms with surgical lesions of specific fiber tract components of Raprl in patients with PD. METHODS: A total of 10 patients were treated with unilateral radiofrequency lesions directed to Raprl. The improvement for tremor, rigidity, bradykinesia, posture, and gait was evaluated at 24 to 33 mo after operation through the Unified Parkinson's Disease Rating Scale (UPDRS) score, and the precise location and extension of lesions through structural magnetic resonance imaging and probabilistic tractography at 6 to 8 mo postsurgery. Correlation between percentage of fiber tract involvement and percentage of UPDRS-III score improvement was evaluated through Spearman's correlation coefficient. RESULTS: Group average improvement was 86% for tremor, 62% for rigidity, 56% for bradykinesia, and 45% for gait and posture. Improvement in global UPDRS score correlated with extent of lesions in fibers connecting with contralateral cerebellar cortex and improvement of posture and gait with fibers connecting with contralateral deep cerebellar nuclei. Lesion of fibers connecting the globus pallidum with pedunculopontine nucleus induced improvement of gait and posture over other symptoms. CONCLUSION: Partial lesion of Raprl fibers resulted in symptom improvement at 2-yr follow-up. Lesions of selective fiber components may result in selective improvement of specific symptoms.

Radiofrequency Ablation of Prelemniscal Radiations for the Treatment of Non-Parkinsonian Tremor.

OBJECTIVE: Previous reports proposed prelemniscal radiations (Raprl) as a target to treat motor symptoms of Parkinson's disease, and this was found particularly effective to control rest and postural tremor. However, tremor of other etiologies has been seldom treated with deep brain stimulation or ablation in this target. We present a series of such cases successfully treated by Raprl radiofrequency (RF) lesions. MATERIAL AND METHODS: Six patients with predominant unilateral tremor on the right arm: 4 intention, 1 cerebellar and 1 rubral tremor, incapacitating in spite of at least 2 regimes of medical treatment at maximal tolerated doses, were operated under local anesthesia. RF lesions were performed in Raprl contralateral to most prominent symptoms. Patients had monthly evaluation of tremor severity through the Fahn-Tolosa-Marin Tremor Rating Scale and disability through the Tremor Disability Scale along a 1-year follow-up. RESULTS: In 4/6 patients tremor was stopped by the simple insertion of an RF electrode in Raprl; in the other 2 cases, stimulation through the RF electrode at 100 Hz, with 100 µs and 1.0-1.5 V, stopped the tremor without side effects. Tremor disappeared in all cases immediately after surgery and partially reappeared in 2 cases with an amplitude about 20% of the preoperative condition. RF lesions in postoperative MRI ranked from 1.8 to 2.6 mm in diameter. CONCLUSIONS: RF lesioning in Raprl is a simple, highly effective, inexpensive way to treat tremor of different etiologies.

Astrocytic Tumors in Mexico: An Overview of Characteristics and Prognosis in an Open Reference Center for Low-Income Population.

OBJECTIVE: The authors aimed to analyze the current epidemiology of high- and low-grade gliomas, follow-up strategies, and prognosis in a national reference center of a developing country. MATERIALS AND METHODS: Medical records of patients diagnosed with intracranial gliomas from January 2012 to January 2016 were reviewed. Data were classified by age, symptoms, Karnofsky functional scale (KFS), tumor location, extent of resection (EOR), histopathology, hospital stay, Glasgow outcome scale (GOS), adjuvant treatments, overall survival (OS), and mortality. RESULTS: Astrocytomas accounted for 28.2% of the intracranial tumors and 53.5% were male. Headache was the most common symptom, while sensory disturbance was the least frequent. The right cerebral hemisphere was involved in 56.5% of cases and frontal lobe in 31.3%. Gross total resection (GTR) was achieved in 18.1% cases, 35.3% subtotal resection, and 46.4% biopsy. Regarding the astrocytomas, 43.3% were low grade and 56.4% high grade. Low-grade tumors had the highest frequency in the fourth decade of life, while Grade III and IV in the fifth and seventh decades of life, respectively. In high-grade lesions, there was a slight male predominance (~1.4:1). The initial KFS was regularly 80 for low-grade gliomas and 60 for high-grade. By 1-month postdischarge, the score decreased by 10 points. About half of the patients (47.5%) received adjuvant therapy after surgery. From the Glasgow Outcome Scale (GOS), the majority had a form of disability and 30-month OS was above 88% for Grade I-II and 0% for Grade III and IV. CONCLUSIONS: Astrocytic tumors were the most frequently noted intra-axial tumors. Age, histological grade, and EOR are important prognostic factors. These results are similar to other reports; however, increased variability was noted when treatment-related factors were considered. Additional studies are necessary to identify the factors related to these treatment results. HIGHLIGHTS: There are no data describing the basic epidemiology and prognosis of high-grade and low-grade gliomas in Mexico.Intracranial astrocytomas account for 28.2% tumors in our institution.Age, histological grade, and EOR are important prognostic factors.Poor overall survival was achieved in our target population.

Anatomic characterization of prelemniscal radiations by probabilistic tractography: implications in Parkinson's disease.

To characterize the anatomical connectivity of the prelemniscal radiations (Raprl), a white matter region within the posterior subthalamic area (PSA) that is an effective neurosurgical target for treating motor symptoms of Parkinson's disease (PD). Diffusion-weighted images were acquired from twelve healthy subjects using a 3T scanner. Constrained spherical deconvolution, a method that allows the distinction of crossing fibers within a voxel, was used to compute track-density images with sufficient resolution to accurately delineate distinct PSA regions and probabilistic tractography of Raprl in both hemispheres. Raprl connectivity was reproducible across all subjects and showed fibers traversing through this region towards primary and supplementary motor cortices, the orbitofrontal cortex, ventrolateral thalamus, and the globus pallidus, cerebellum and dorsal brainstem. All brain regions reached by Raprl fibers are part of motor circuits involved in the pathophysiology of PD; while these fiber systems converge at the level of the PSA, they can be spatially segregated. Fibers of distinct and specific motor control networks are identified within Raprl. The description of this anatomical crossroad suggests that, in the future, tractography could allow deep brain stimulation or lesional therapies in white matter targets according to individual patient's symptoms.

Evaluation of bilateral cingulotomy and anterior capsulotomy for the treatment of aggressive behavior.

BACKGROUND: Agressiveness is a psychiatric symptom that may be part of schizophrenia, mental retardation, drug abuse and other conditions. Surgical treatment remains controversial and few therapeutic options are available. We undertook this study to perform a prospective analysis on the efficacy and safety of bilateral cingulotomy and anterior capsulotomy in the treatment of aggressiveness behavior. METHODS: We studied 25 patients with a primary diagnosis of aggressiveness refractory to conventional treatment. Subjects were clinically evaluated with the Mayo-Portland adaptability inventory and the Global Assessment of Functioning score. Lesions were placed stereotactically in both targets and confirmed by postoperative magnetic resonance imaging. Significant changes were evaluated with Wilcoxon test after 3 and 6 months. RESULTS: According to inclusion and exclusion criteria, only 12 patients were finally included and surgical treated. Lesions significantly decreased using the Mayo-Portland adaptability inventory and the Global Assessment of Functioning score (p <0.002) at 3 and 6 months follow-up. Only five patients showed either mild or transitory postsurgical complications. CONCLUSIONS: Combined bilateral anterior capsulotomy and cingulotomy successfully reduced aggressiveness behavior and improved clinical evaluations. These effects were obtained with fewer complications than previously described targets.

Introducción a la neurocirugía psiquiátrica

Resumen: La neurocirugía para tratar los trastornos psiquiátricos tiene sus primeros antecedentes modernos a mediados del siglo XIX con los trabajos de Buckhart, quien resecó parcialmente la corteza frontal de pacientes psiquiátricos. Aunque los resultados fueron alentadores en cuatro de seis casos, la muerte de uno y crisis convulsivas en otros dos frenaron el desarrollo de este procedimiento. En 1936, Egas Moniz y Almeida Lima efectuaron una sección de las fibras frontales en pacientes psiquiátricos con diversos diagnósticos, procedimiento que denominaron lobotomía prefrontal. El éxito de este tratamiento llevó a Moniz a obtener un premio Nobel en 1949. A su vez, esto alentó a Fulton y a Jacobsen a promover este tipo de procedimientos, denominados entonces "psicocirugía", en Estados Unidos. Desafortunadamente, la ausencia de un entendimiento adecuado de la fisiopatología y la sobreindicación de los procedimientos provocó que entre 1935 y 1950 se operaran alrededor de 20,000 pacientes en condiciones cuestionables y con importantes complicaciones. La aparición de los fármacos antipsicóticos y la falta de regulación y entendimiento de la neurocirugía psiquiátrica evitan nuevamente que este tratamiento se realice de manera científica y controlada. Aun así, Spiegel y Wacis iniciaron en 1946 la era de la neurocirugía estereotáctica que reduce el riesgo de complicaciones de la neurocirugía funcional. Cuatro procedimientos fueron aceptados entonces por la OMS para el tratamiento seguro y efectivo de enfermedades psiquiátricas. Estas cirugías incluyen la cingulotomía, la capsulotomía anterior, la tractotomía subcaudada y la leucotomía límbica (combinación de cingulotomía y tractotomía). Por otro lado, los trastornos psiquiátricos que han mostrado mejoría sustancial después de alguno de estos procedimientos neuroquirúrgicos son el trastorno depresivo mayor, el trastorno obsesivo-compulsivo, el trastorno bipolar, algunos trastornos de ansiedad, la adicción a sustancias y los trastornos impulsivos-agresivos. Es importante señalar que los criterios de inclusión a protocolos neuroquirúrgicos asistenciales o de investigación para mejorar los síntomas psiquiátricos han sido bien establecidos, y la selección de pacientes y los grupos neuroquirúrgicos deben ser supervisados por un comité de ética bien acreditado. Actualmente, las indicaciones para proponer como candidato a neurocirugía a un paciente son: Una enfermedad psiquiátrica diagnosticada de acuerdo con los criterios del DSM IV-R; evidencia de refractariedad (mejoría inferior a 50% de los síntomas) con los tratamientos convencionales; ésta debe ser avalada por dos psiquiatras. El padecimiento debe tener una duración de al menos cinco años. Además, un comité ético revisor de los protocolos quirúrgicos y de investigación debe evaluar a cada candidato al procedimiento o protocolo y cerciorarse de que el paciente o las personas responsables de él entiendan los criterios médicos y psiquiátricos para participar en el proceso; el comité supervisa también el proceso de consentimiento. Los procedimientos neuroquirúrgicos sólo podrán ser indicados en pacientes psiquiátricos con capacidad y ellos mismos aprobarán y firmarán un consentimiento informado. Las clínicas de neurocirugía psiquiátrica deberán trabajar estrechamente y contar con los siguientes especialistas: Un equipo de neurocirujanos estereotácticos con experiencia probada en neurocirugía psiquiátrica, neuromodulación, radiocirugía e investigación. Un equipo de psiquiatras con amplia experiencia en condiciones psiquiátricas y de investigación. Preferiblemente, ambos grupos deberán tener experiencia en neurocirugía psiquiátrica o contar con la asesoría de una clínica de neurocirugía psiquiátrica. La neurocirugía psiquiátrica deberá realizarse sólo para restaurar la función normal y aliviar al paciente de su angustia y sufrimiento. Los procedimientos deberán practicarse para mejorar la vida de los pacientes y nunca por motivos políticos, cuestiones legales o propósitos sociales. Finalmente, la neuromodulación ha demostrado ser una técnica útil y segura para el alivio de trastornos psiquiátricos debido a que sus efectos son reversibles y ajustables a cada paciente. Por lo mismo, en la actualidad se ha aplicado con éxito en el tratamiento de la depresión mayor, el trastorno obsesivo compulsivo y la enfermedad de Gilles de la Tourette.

Abstract: Recent background in neurosurgery for psychiatric disorders can be placed in the mid XIXth century. Buckhartd made partial resection of frontal cortex in 6 psychiatric patients, with successful results in 4 of them, but important side effects prevented the development of this scientific approach. In 1936 Egas Moniz and Almeida Lima performed a new neuro-psychiatric technique for treatment of several psychiatric disorders, named prefrontal lobotomy. Results of this treatment won Moniz a Nobel Prize in 1949, and encouraged Freeman and Watts to further develop this kind of surgery in United States of America. Unfortunately, the knowledge about pathophysiology was not sufficient to make a precise indication of surgery in this patients. Between 1935 and 1950, nearly 20,000 surgeries were performed in doubtful conditions, showing important side effects. On the other hand, the emergency of new drugs for the treatment of psychiatric disorders along with the absence of regulation stopped development of "psychosurgery". However, in 1946 Spiegel and Wacis started stereotactic age of neurosurgery, thus reducing risk and complication of this procedures. Nowadays, World Health Organization accepted four neurosurgery procedures for psychiatric disorders: cingulotomy, anterior capsulotomy, subcaudate tractotomy and limbic leucotomy (a combination of cingulotomy and subcaudate tractotomy). Best results for this kind of surgery are shown for affective disorders (major depression disorder, bipolar disorder, anxiety disorders) and obsessive compulsive disorder. Besides, in clinical research protocols the inclusion criteria for neurosurgical procedures in psychiatry have been well defined. Both patients' selection and medical team must be monitored by ethics committee. Currently, the requirements to consider a patient as a candidate for psychiatric neurosurgery are: Clear psychiatric diagnosis in accordance to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM.IV-TR). Evidence of refractivity (improved of symptoms inferior to 50%) to conventional treatments provided by two different psychiatrists. A minimum of 5 years of evolution in symptoms. The ethics committee must monitor surgical and research protocols in a case by case basis. The Committee will made sure that patient and relatives understand medic and psychiatric inclusion criteria. Neurosurgical procedures will only be indicated when the patient is able to understand and accept any details presented to him or her in a formal Consent Form. Neurosurgery psychiatric clinical teams should be integrated by: Stereotactic neurosurgeons whose have experience in psychiatric neurosurgery, neuromodulation, radiosurgery and clinical issues. A psychiatric team with ample experience in psychiatric conditions and research protocols. In case both teams of specialists are not experienced enough in the field of psychiatric neurosurgery, they must look for technical advice from other neurosurgical psychiatric centers. Psychiatric neurosurgery can only be performed to recover healthy conditions and relief suffering. These interventions must always be performed with the sole objective of improving patients quality of life and they must never be used for political, legal or social purposes. Finally, Neuromodulation has shown to be a useful and safe tool in relief of psychiatric disorders. Neuromodulation's effects are reversible and they can adjusted to patient. Nowadays, Neuromodulation is being used in patients with major depression, obsessive compulsive disorder and Tourette's illness.