Gamma knife radiosurgery for recurrent glossopharyngeal neuralgia after microvascular decompression.

BACKGROUND: We report the first application of Gamma Knife radiosurgery (GKR) for recurrent glossopharyngeal neuralgia (GN) after microvascular decompression (MVD). The patient is a 51-year-old male with left-sided GN. He underwent MVD and did well for almost 4 years. Later on, the patient started to experience recurrent intolerable throat pain, frequently 10/10 in intensity. Based on the application of radiosurgery for trigeminal neuralgia, GKR was offered to the patient. METHODS: After careful identification of the nerve with the assistance of a neuroradiologist, we targeted the nerve root complex, which is the cisternal portion of the nerve, using the Coherent Oscillatory State Acquisition for the Manipulation of Image Contrast (COSMIC) pulse sequence with contiguous 1-mm slices obtained by an 1.5 Tesla MRI. The radiosurgery was planned utilizing the Leksell Gamma Plan version 8.1. A single shot with a 4-mm collimator was used to deliver 80 Gy to the 100% isodose line. RESULTS: Four weeks after the treatment, the patient began to notice significant pain relief. At the 12-month follow-up, the patient's pain, which was intolerable prior to radiosurgery, was mild and occasional. CONCLUSION: GKR, which is now widely used for refractory trigeminal neuralgia, can be considered for refractory or recurrent GN. With a multidisciplinary approach and advanced neuroimaging, GKR is feasible for GN after MVD, despite the shortness of the intracranial cisternal nerve portion. Further studies are necessary to establish the role of GKR for refractory GN after MVD; however, given its rarity and the lack of experience with GKR for this condition, retrospective studies with dozens of patients are almost impossible at this time.

Predictors of HVOT performance in Parkinson's disease.

Evidence suggests that the Hooper Visual Organization Test (HVOT) has naming and executive components that vary in size depending on neurological diagnosis. The current study used a sample of individuals with Parkinson's disease (PD) to demonstrate for the first time that an executive measure can be the best predictor of HVOT performance. Forty-eight nondemented and nondepressed individuals with idiopathic PD completed the HVOT and other measures of visuoperception, executive function, and visual confrontation naming. Despite average performance on all neuropsychological measures, an executive measure, time to complete Trail-Making Test Part B minus time to complete Part A, was clearly the best predictor of HVOT performance in a standard regression. The pattern of neurocognitive predictors is unlike that reported in healthy individuals and other patient samples. This finding suggests that the presence of a neuropathological process can alter neurocognitive correlates even when performance is intact, and supports the contention that executive function is paramount in the cognitive profile associated with PD.

Successful frameless radiosurgery for glossopharyngeal neuralgia - Case report.

Idiopathic glossopharyngeal neuralgia (GPN) is a rare disorder of the ninth cranial nerve characterized by severe paroxysmal pain affecting the ear, tongue and throat. Frame-based radiosurgery (SRS) has been shown to be an effective option. We report the first successful pain alleviation by frameless SRS in a GPN patient that failed both medical and surgical interventions.

The option of Linac-based radiosurgery in a Gamma Knife radiosurgery center.

OBJECTIVE: Due to the fundamental differences in treatment delivery, linear-accelerator-based radiosurgery can be complementary to Gamma Knife (GK) for intracranial lesions. We reviewed the effect of adding GK to an existing linear accelerator (Linac)-based radiosurgery practice and analyzed case selections for the two modalities. PATIENTS AND METHODS: UC Davis Medical Center installed a Leksell Gamma Knife Model C in October 2003 to supplement an established Linac-based radiosurgery program. Radiosurgery indications for the 15 months before and after installation were compared. RESULTS: Radiosurgery cases expanded by twofold from 68 patients before GK installation to 139 after, with 106 treated by GK and 33 by Linac. Besides a major increase for trigeminal neuralgia and a general growth for acoustic neuroma, meningioma and brain metastases, case numbers for glioma and arteriovenous malformation (AVM) remained stable. Considering case selections for Linac, glioma decreased from 28 to 18%, while meningioma and metastases increased from 9 to 21% and 38-46%, respectively. The Linac patients receiving fractionated treatment also increased from 37 to 61%. CONCLUSIONS: While the majority of patients were treated with GK, a significant proportion was judged to be suited for Linac treatment. This latter group included particularly patients who benefit from fractionated therapy.

Linear accelerator-based radiosurgery for multiple arteriovenous malformations: case report.

This report presents a rare case of multiple, widely spaced arteriovenous malformations in a single patient treated with linear accelerator-based radiosurgery. The choices associated with the requisite imaging and planning are presented. In light of the anatomic topography, linear accelerator-based radiosurgery was chosen over gamma knife treatment, with CT angiography being used to image all target areas simultaneously.

Frame and frameless linear accelerator-based radiosurgery for idiopathic trigeminal neuralgia.

PURPOSE: We report outcome of linear accelerator (Linac)-based stereotactic radiosurgery (SRS) for trigeminal neuralgia (TGN) utilizing rigid head frame (RF) and facemask (FM) immobilization.Method: From November 2008 to October 2012, 48 patients with idiopathic TGN underwent primary SRS by a dedicated Linac. RF immobilization was utilized for 34 patients, and frameless image-guided radiosurgery (IGRS) with FM immobilization was performed in 14 patients. Treatment outcome was assessed by patient interviews with a 7-item questionnaire. RESULTS: Sub-millimeter targeting accuracy (0.71±0.31 mm) was recorded for frameless IGRS by a novel hidden-target phantom method. With a follow-up of 26 months, significant pain relief was recorded in 43 (89%) patients, including 26 (54%) complete and 17 (35%) partial responses; with a significant reduction of 2.4±1.3 points (p < 0.01) on the 5-point Barrow Neurological Institute pain scale. No significant pain relief difference (p = 0.23) was detected between patients immobilized by RF and FM. Notable pin site problems were reported in 9 (26%) of 34 patients immobilized by RF. CONCLUSION: Frameless IGRS with FM immobilization is more patient friendly and can achieve as excellent treatment outcome as with RF immobilization for idiopathic TGN.

Deep brain stimulation for the treatment of severe, medically refractory obsessive-compulsive disorder.

Deep brain stimulation is a rapidly expanding therapy initially designed for the treatment of movement disorders and pain syndromes. The therapy includes implantation of electrodes in specific targets of the brain, delivering programmable small and safe electric impulses, like a pacemaker, that modulates both local and broad neurologic networks. The effects are thought to primarily involve a focus in the brain, probably inhibitory, which then restores a network of neural circuitry. Psychiatric diseases can be refractory and severe, leading to high medical costs, significant morbidity, and even death. Whereas surgery for psychiatric disease used to include destructive procedures, deep brain stimulation allows safe, reversible, and adjustable treatment that can be tailored for each patient. Deep brain stimulation offers new hope for these unfortunate patients, and the preliminary results are promising.

The clinical significance of neuropsychological changes following bilateral subthalamic nucleus deep brain stimulation for Parkinson's disease.

Despite the clinical importance of the question, a number of methodological issues have limited firm conclusions regarding the cognitive safety of deep brain stimulation (DBS) of the subthalamic nucleus (STN) in Parkinson's disease (PD). Amongst these issues, studies have generally failed to consider the postoperative changes that occur within individual patients. This study utilized reliable change indices (RCIs) derived from a PD sample to determine the frequency of clinically significant postoperative decline on a battery of neuropsychological measures. This approach addresses measurement reliability, potential practice effects, and disease progression. The proportion of patients experiencing clinically significant postoperative decline on measures of list learning and verbal fluency was greater than expected based on disease progression; however, the majority of patients (55%) did not experience a significant decline in performance on any of the cognitive tests administered, and only one experienced decline on more than one test. Therefore, the statistically significant declines on measures of list learning and verbal fluency observed in the sample as a whole were the result of clinically significant declines experienced by a minority of participants.

Cognitive deficits in essential tremor consistent with frontosubcortical dysfunction.

Essential tremor (ET) is increasingly thought to involve a heterogeneous group of patients, with some also exhibiting symptoms of Parkinson's disease (PD), including cognitive deficits. The goal of this study was to utilize a broad battery of neuropsychological measures to compare the cognitive function of 33 ET patients with that of 33 matched PD patients and 21 normal controls. Results indicated that the ET group performed significantly worse than controls across multiple cognitive domains, but performed remarkably similar to PD patients, consistent with frontosubcortical dysfunction.

Temporal evolution of oscillations and synchrony in GPi/muscle pairs in Parkinson's disease.

Both standard spectral analysis and time-dependent phase correlation techniques were applied to 27 pairs of tremor-related single units in the globus pallidus internus (GPi) and EMG of patients with Parkinson's disease (PD) undergoing stereotactic neurosurgery. Over long time-scales (approximately 60 s), GPi tremor-related units were statistically coherent with restricted regions of the peripheral musculature displaying tremor. The distribution of pooled coherence across all pairs supports a classification of GPi cell/EMG oscillatory pairs into coherent or noncoherent. Analysis using approximately 2-s sliding windows shows that oscillatory activity in both GPi tremor units and muscles occurs intermittently over time. For brain/muscle pairs that are coherent, there is partial overlap in the times of oscillatory activity but, in most cases, no significant correlation between the times of oscillatory subepisodes in the two signals. Phase locking between coherent pairs occurs transiently; however, the phase delay is similar for different phase-locking subepisodes. Noncoherent pairs also show episodes of transient phase locking, but they occurred less frequently, and no preferred phase delay was seen across subepisodes. Tremor oscillations in pallidum and EMGs are punctuated by phase slips, which were classified as synchronizing or desynchronizing depending on their effect on phase locking. In coherent pairs, the incidence of synchronizing slips is higher than desynchronizing slips, whereas no significant difference was seen for noncoherent pairs. The results of this quantitative characterization of parkinsonian tremor provide a foundation for hypotheses about the structure and dynamical functioning of basal ganglia motor control networks involved in tremor generation.