RESUMO
Twenty cases of facial neuralgia associated with tumors of the contralateral posterior fossa were collected from the world literature. Only four of these conform to the description of typical trigeminal neuralgia. We report on a fifth such case with a critical review of the literature. Subtotal excision of the tumor improves the pain and may convert a carbamazepine-resistant neuralgia into a responsive one. Total excision is often followed by a cure. Faced with such a case, the tumor should always be excised first, as this usually cures the neuralgia. Surgical treatment of the neuralgia in the presence of the tumor may be followed by disastrous results. An alternative hypothesis to the pathogenesis of the contralateral neuralgia is presented.
Assuntos
Neoplasias Encefálicas/complicações , Ângulo Cerebelopontino , Meningioma/complicações , Neuralgia do Trigêmeo/etiologia , Idoso , Neoplasias Encefálicas/diagnóstico por imagem , Ângulo Cerebelopontino/diagnóstico por imagem , Fossa Craniana Posterior , Feminino , Humanos , Meningioma/diagnóstico por imagem , Tomografia Computadorizada por Raios X , Neuralgia do Trigêmeo/diagnóstico por imagemRESUMO
Physicians disagree about the best surgical treatment for patients with idiopathic neuralgias of the glossopharyngeal and vagal nerves after medical treatment has failed. Some favor percutaneous thermal rhizotomy, and other prefer extracranial section of the glossopharyngeal or branches of the vagal nerve, intracranial section of the glossopharyngeal and upper vagal rootlets, or microvascular decompression. However, the results of these procedures are limited to series with follow-up periods of less than 5 years or to series with longer follow-ups that were performed before the microneurosurgical era. We reviewed the long-term results of 14 patients with vagoglossopharyngeal neuralgia treated surgically at our center between 1976 and 1987 to determine the best treatment. Sixteen procedures were performed: 2 percutaneous thermal rhizotomies; 2 extracranial sections of the superior laryngeal nerve; and 12 intracranial glossopharyngeal and upper vagal rhizotomies, 4 with and 8 without microvascular decompression. The follow-ups ranged from 4 to 17 years (mean, 10 yr). All 14 patients who underwent percutaneous or intracranial rhizotomies were pain free. Two patients who underwent percutaneous rhizotomies developed persistent dysphagia and hoarseness. Both patients who underwent extracranial nerve section experienced pain recurrence 2 and 4 years later. Of 12 patients who underwent intracranial section of the glossopharyngeal and upper vagal rootlets, 2 developed dysphagia, which resolved completely in 1 patient and persisted mildly in the other; 1 had transient hoarseness; and 2 developed frequent coughing episodes, which persisted in 1 patient and resolved completely in the other. Side effects due to motor vagal deficits may be eliminated by intraoperative monitoring.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Nervo Glossofaríngeo/cirurgia , Neuralgia/cirurgia , Nervo Vago/cirurgia , Adulto , Idoso , Feminino , Humanos , Nervos Laríngeos/cirurgia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias , Resultado do TratamentoRESUMO
In this study, we reevaluate the results of radiofrequency rhizotomy and review the effectiveness of other surgical procedures for the treatment of trigeminal neuralgia. Five hundred patients with trigeminal neuralgia underwent radiofrequency rhizotomy at the University of Cincinnati Medical Center, Cincinnati, OH, between 1981 and 1986. Their results are compared with those of patients reported in the literature who underwent radiofrequency rhizotomy (6205 patients), glycerol rhizotomy (1217 patients), balloon compression (759 patients), microvascular decompression (MVD) (1417 patients), and partial trigeminal rhizotomy (250 patients). Comparisons were based on the following outcome parameters: technical success, pain relief and recurrence, facial numbness, dysesthesia, corneal anesthesia, keratitis, trigeminal motor dysfunction, permanent cranial nerve deficit, intracranial hemorrhage or infarction, perioperative morbidity, and perioperative mortality. We found that MVD had the lowest rate of technical success. Radiofrequency rhizotomy and MVD had the highest rates of initial pain relief and the lowest rates of pain recurrence. Glycerol rhizotomy had the highest rate of pain recurrence. Balloon compression had the highest rate of trigeminal motor dysfunction. Balloon compression and MVD had the lowest rates of corneal anesthesia or keratitis. MVD had the lowest rates of facial numbness and dysesthesia. All percutaneous procedures had similar rates of dysesthesia. Posterior fossa exploration had the highest rates of permanent cranial nerve deficit, intracranial hemorrhage or infarction, and perioperative morbidity and mortality. On the basis of our experience and a review of the literature, we conclude the following: 1) percutaneous techniques and posterior fossa exploration offer advantages and disadvantages, 2) radiofrequency rhizotomy is the procedure of choice for most patients undergoing first surgical treatments, and 3) MVD is recommended for healthy patients who have isolated pain in the first ophthalmic trigeminal division or in all three trigeminal divisions and patients who desire no sensory deficit.
Assuntos
Eletrocoagulação/métodos , Complicações Pós-Operatórias/etiologia , Rizotomia/métodos , Neuralgia do Trigêmeo/cirurgia , Adulto , Feminino , Seguimentos , Humanos , Masculino , Exame Neurológico , Complicações Pós-Operatórias/mortalidade , Recidiva , Estudos Retrospectivos , Análise de Sobrevida , Resultado do Tratamento , Neuralgia do Trigêmeo/diagnósticoRESUMO
This study reviews the features of 30 intracranial infections complicating 600 penetrating head injuries from missiles in patients treated at the American University of Beirut Medical Center between 1981 and 1988. The follow-up period ranged from 1 month to 7 years (mean, 2.5 years). Sixteen patients had a brain abscess, 9 had cerebritis, 2 had an infected intracerebral hematoma, and 5 had meningitis. Infection developed 4 days to 7 years after the initial debridement. The infecting organisms were Gram positive in 11 patients (36%), Gram negative in 12 (40%), and a combination of Gram positive and Gram negative in 2 (7%). Twenty-four patients (80%) had wound dehiscence or cerebrospinal fluid leakage at the time the infection appeared. There was a 76% correlation between the organisms cultured from the dehiscent scalp wound and the brain. Twenty-three patients had intracranial retention of bone. Infection developed in 16 of the 30 patients (70%) around bone fragments, in 4 around a metallic fragment, in 2 around absorbable gelatin sponge, and in 3 along the missile tract; 2 had an infected intracerebral hematoma, and 3 had meningitis. At least one of the following risk factors was present in each patient: extensive brain injury, coma, trajectory through an air sinus, cerebrospinal fluid fistula, inadequate initial debridement, or incomplete dural closure. The incidence of intracranial infection in patients with postoperative retention of bone was 4% in the absence of scalp wound dehiscence, compared with 84.6% when wound dehiscence was present. Ten patients (43%) still retained a bone fragment measuring less than 1 cm after excision of a brain abscess or treatment of cerebritis or meningitis.(ABSTRACT TRUNCATED AT 250 WORDS)
Assuntos
Encefalopatias/etiologia , Lesões Encefálicas/complicações , Traumatismos Craniocerebrais/complicações , Infecções por Bactérias Gram-Negativas/etiologia , Infecções por Bactérias Gram-Positivas/etiologia , Ferimentos Penetrantes/complicações , Osso e Ossos/lesões , Líquido Cefalorraquidiano , Fístula/etiologia , Humanos , Líbano , GuerraRESUMO
This is a prospective study of the treatment of penetrating missile injuries to the brain without intracranial surgery carried out at the American University of Beirut Medical Center between 1981 and 1988. Of 600 patients treated for missile injuries to the head, 32 satisfied the study criteria. There were 27 shrapnel and 5 bullet injuries. The mean patient age was 23 years (range, 3-51 years). Twenty patients had intracranial indriven bone fragments. Six patients had exposed brain tissue. The mean follow-up was 3.5 years (range, 1-7.5 years). The superficial entry wound was debrided and closed without drainage in the Emergency Room within a mean of 3 hours (range, 0.5-6 hours), and the patient received methicillin for 14 days. All patients survived and had no or improved neurological deficits. No leakage of the cerebrospinal fluid, infection, or seizures occurred in 31 patients. One patient with indriven bone fragments had leakage of the cerebrospinal fluid and developed seizures and a brain abscess 20 days after the injury. The management of penetrating missile injuries to the brain without intracranial surgery in a select patient population is a reasonable option. This treatment becomes important for a surgeon facing large numbers of casualties, or when operative personnel or resources are limited or unavailable.
Assuntos
Lesões Encefálicas/cirurgia , Ferimentos Penetrantes/cirurgia , Adolescente , Adulto , Lesões Encefálicas/complicações , Criança , Pré-Escolar , Protocolos Clínicos , Estudos de Coortes , Terapia Combinada , Desbridamento , Feminino , Humanos , Líbano , Masculino , Meticilina/uso terapêutico , Pessoa de Meia-Idade , Estudos Prospectivos , Guerra , Ferimentos Penetrantes/complicaçõesRESUMO
OBJECTIVE: Pallidotomy has recently regained acceptance as a safe and effective treatment for Parkinson's disease symptoms. The goal of this study was to obtain the patients' perspective on their results after undergoing this procedure. Special attention was focused on the potential complications and the respective advantages and risks of unilateral versus bilateral pallidotomy. METHODS: Fifty-six patients were studied during a 2-year period; 44 completed the evaluation, with a median follow-up of 7 months. Of these patients, 22 underwent unilateral pallidotomy, and 17 had bilateral simultaneous pallidotomy. Five patients who underwent staged bilateral pallidotomy were excluded from the statistical analysis, because the number of patients was considered too small for analysis. The procedures were performed with magnetic resonance imaging determination of the target, combined with physiological confirmation, including microelectrode recording. RESULTS: According to Visual Analog Scale scores, unilateral pallidotomy significantly improved dyskinesias (P < 0.05) but no other symptoms. Simultaneous bilateral pallidotomy improved slowness, rigidity, tremor, and dyskinesias (P < 0.05) but worsened speech function (P < 0.05). According to the patients' most frequently chosen answers to multiple-choice questions, unilateral pallidotomy improved night sleep, muscle pain, freezing, overall "on," overall "off," and the duration of "off periods," but it worsened the volume of the voice and articulation, increased drooling, and reduced concentration. Bilateral pallidotomy improved night sleep, muscle pain, freezing, overall "on," overall "off," duration of "off periods," and the amount of medication taken, but it increased drooling and worsened the volume of the voice, articulation, and writing. Subjective visual disturbance was noted in 36 and 41% of patients who underwent unilateral and simultaneous bilateral pallidotomy, respectively. Globally, the result of the procedure was rated "good" or "excellent" by 64% of the patients who underwent unilateral pallidotomy and by 76% of the patients who underwent bilateral pallidotomy. An age less than 70 years was a positive prognostic factor for the global outcome (P < 0.05), as were severe preoperative dyskinesias (P < 0.05). CONCLUSION: This study confirms that, from a patient standpoint, unilateral and simultaneous bilateral pallidotomy can reduce all the key symptoms of Parkinson's disease (i.e., akinesia, tremor, and rigidity) and the side effects of L-dopa treatment (i.e., dyskinesias). Preoperative severe dyskinesias and younger age are positive prognostic factors for a successful outcome. Simultaneous bilateral pallidotomy was more effective than unilateral pallidotomy regarding tremor, rigidity, and dyskinesias, but it conferred a higher risk of postoperative speech deterioration.
Assuntos
Dominância Cerebral/fisiologia , Globo Pálido/cirurgia , Doença de Parkinson/cirurgia , Atividades Cotidianas/classificação , Adulto , Idoso , Idoso de 80 Anos ou mais , Avaliação da Deficiência , Feminino , Globo Pálido/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Destreza Motora/fisiologia , Doença de Parkinson/fisiopatologia , Complicações Pós-Operatórias/etiologia , Prognóstico , Resultado do TratamentoRESUMO
OBJECTIVE: The purpose of this study is to define the morphology of the boundary between the globus pallidus and the ansa lenticularis (i.e., pallidal base) in humans. This information is important for surgeons who perform pallidotomy. METHODS: Thirty-eight patients with Parkinson's disease underwent pallidotomy using microrecording techniques. The pallidal base was identified by the loss of neuronal single unit activity and by the change in background noise, as analyzed on the audio monitor and by fast Fourier transformation. RESULTS: Three quarters of the patients had an abrupt transition of the background noise from neuronal to axonal activity. One quarter of the patients had multiple successive transitions of the background activity, over a distance of 0.4 to 2 mm (median, 1 mm). CONCLUSION: We conclude that the pallidal base is not a smooth, sharp boundary between the globus pallidus and the ansa lenticularis. We propose two models that define the morphology of the pallidal base. One model depicts the pallidal base as a multifolded boundary that distinctly separates pallidal neurons from ansa lenticularis axons. Another model depicts the pallidal base as an indistinct transitional boundary between the globus pallidus and the ansa lenticularis, which contains axonal fibers intermixed with small clusters of pallidal neurons. We discuss the clinical relevance of these findings.
Assuntos
Globo Pálido/patologia , Globo Pálido/fisiopatologia , Doença de Parkinson/patologia , Doença de Parkinson/fisiopatologia , Adulto , Idoso , Eletrofisiologia , Feminino , Análise de Fourier , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Neurológicos , Monitorização Intraoperatória/métodos , Neurônios/fisiologiaRESUMO
In the literature, clinical descriptions of sigmoid sinus thrombosis occurring after closed head injury in children are rare. One to 5 days after trauma to the back of the head, five children (aged 1 to 7 yr) presented with gait ataxia, vomiting, and headache. Trauma was mild in four children. Computed tomography of all the children, performed within 5 days after the injury, showed focal hyperdensity in the region of the left sigmoid sinus. Four children had extra-axial hyperdense collections along the left transverse sinus, and three had skull fractures adjacent to the left sigmoid sinus. Magnetic resonance imaging (MRI) of all the children, performed 2 to 6 days after injury, showed left sigmoid-sinus thrombosis and decreased flow or thrombosis within the lateral third of the left transverse sinus. All the children had MRI scans 4 to 6 weeks after their diagnosis and were followed up for 1 to 12 months. In four children whose symptoms subsided completely within 2 to 10 weeks, MRI showed recanalization of the sigmoid sinus within 4 to 6 weeks after injury. In one child whose symptoms resolved after 6 months, sigmoid-sinus thrombosis persisted with the formation of collateral flow. We conclude that traumatic sigmoid-sinus thrombosis should be suspected when a child has persistent or delayed gait ataxia and vomiting after injury to the back of the head. Computed tomography characteristically demonstrated focal hyperdensity within the sigmoid sinus that we term the dense sigmoid-sinus sign. Because the sinus recanalized and the symptoms subsided in most children within 6 weeks, we conclude that prophylactic medical or surgical intervention is not indicated.
Assuntos
Traumatismos Craniocerebrais/complicações , Trombose dos Seios Intracranianos/etiologia , Ferimentos não Penetrantes/complicações , Criança , Pré-Escolar , Traumatismos Craniocerebrais/diagnóstico , Feminino , Humanos , Lactente , Imageamento por Ressonância Magnética , Masculino , Doenças do Sistema Nervoso/etiologia , Trombose dos Seios Intracranianos/diagnóstico , Tomografia Computadorizada por Raios X , Ferimentos não Penetrantes/diagnósticoRESUMO
Intracranial section of the glossopharyngeal and upper vagal rootlets for the treatment of vagoglossopharyngeal neuralgia may cause dysphagia or vocal cord paralysis from injury to the motor vagal rootlets in 10% to 20% of cases. To minimize this complication, we recently applied a technique of intraoperative monitoring of the vagus nerve (previously described by Lipton and McCaffery to monitor the recurrent laryngeal nerve during thyroid surgery) in a patient undergoing intracranial rhizotomy for vagoglossopharyngeal neuralgia. By inserting an electrode in the ipsilateral false vocal cord and stimulating the rostral vagal rootlets intraoperatively under general anesthesia, we could differentiate the rostral vagal motor rootlets from the sensory rootlets. In this patient, the technique allowed us to preserve a rostral vagal rootlet, which if sectioned, could have caused dysphagia or vocal cord paralysis. We conclude that intraoperative monitoring of the rostral vagal rootlets is an important technique to minimize complications of upper vagal rhizotomy.
Assuntos
Nervo Glossofaríngeo/cirurgia , Monitorização Intraoperatória , Neuralgia/cirurgia , Faringe/inervação , Raízes Nervosas Espinhais/cirurgia , Nervo Vago/cirurgia , Adulto , Nervo Glossofaríngeo/fisiopatologia , Humanos , Masculino , Neurônios Motores/fisiologia , Neuralgia/fisiopatologia , Nociceptores/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Complicações Pós-Operatórias/prevenção & controle , Raízes Nervosas Espinhais/fisiopatologia , Nervo Vago/fisiopatologia , Prega Vocal/inervaçãoRESUMO
Twenty-eight centers completed a survey about their current practice of pallidotomy. This sample represents a non-exhaustive survey of the current practice of pallidotomy in North America and is not a study of outcomes. 1015 patients underwent 1219 pallidotomies: 811 (80%) unilateral, 72 (7%) staged bilateral, and 132 (13%) simultaneous bilateral. Pallidotomy has long been an accepted procedure and the indications for this surgery, in the opinion of the responding centers, were rated on a scale of 1 (poor) to 4 (excellent) and demonstrated dyskinesia as the best indication (median = 4); on-off fluctuations, dystonia, rigidity, and bradykinesia as good indications (median = 3); and freezing, tremor and gait disturbance as fair indications (median = 2). Most centers used MRI alone (50%) or in combination with CT scan (n = 6) or ventriculopathy (n = 5) to localize the target. The median values of pallidal coordinates were: 2 mm anterior to the midcommissural point 21 mm lateral to the midsagittal plane and 5 mm below the intercommissural line. Microrecording was performed by half of the centers (n = 14) and half of the remaining centers were considering starting it (n = 7). Main criteria used to define the target included the firing pattern of spontaneous neuronal discharges (n = 13) and the response to joint movement (n = 10). Most centers performed motor (n = 26) and visual (n = 23) macrostimulation. Twenty four centers performed test lesions using median values of 55 degrees C temperatures for 30 s. Final lesions consisted of 3 permanent lesions placed 2 mm apart, each lesion created with median values of 75 degrees C temperatures for 1 minute. Median hospital stay was 2 days.
Assuntos
Globo Pálido/cirurgia , Doença de Parkinson/cirurgia , Mapeamento Encefálico , Dominância Cerebral/fisiologia , Seguimentos , Globo Pálido/fisiopatologia , Humanos , Destreza Motora/fisiologia , Exame Neurológico , Doença de Parkinson/fisiopatologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/fisiopatologia , Resultado do Tratamento , Estados UnidosRESUMO
OBJECT: In published series of patients who undergo deep brain stimulation (DBS) of the thalamus the effects of unilateral stimulation on contralateral limb tremor have been reported. The authors detail their experience with bilateral thalamic DBS in the treatment of head, voice, and bilateral limb tremor and compare it with earlier studies of unilateral stimulation. METHODS: Twenty-three patients (six with Parkinson's disease, 15 with essential tremor, and two with multiple sclerosis) underwent 19 bilateral DBS procedures (nine staged, 10 simultaneous) and four procedures contralateral to thalamotomy to control tremor of the head in 10, voice in seven, and limbs in 20 patients. Limb tremor improvement was graded as follows: 4, no tremor; 3, stress-induced tremor; 2, functional improvement; 1, no functional improvement; and 0, persistent tremor. Improvement of head or voice tremor was graded as follows: 4, greater than 75%; 3, between 50% and 75%; 2, between 25% and 50%; 1, less than 25%; and 0, no improvement. The mean follow-up period was 10 months. Twenty-two patients (96%) demonstrated improved tremor at the last follow-up review. Of 20 patients with bilateral limb tremor, 17 (85%) improved to Grades 3 and 4, two patients (10%) with multiple sclerosis improved to Grade 2, and one (5%) exhibited tremor recurrence 8 months later. Nine (90%) of 10 patients with severe head tremor improved to Grades 4 or 3. Six (86%) of seven patients with voice tremor improved to Grade 3. Seven patients (30%) developed dysarthria, and seven (30%) developed disequilibrium; symptoms reversed in the majority of patients after the stimulation parameters were changed. One patient (4%) developed mild memory decline. There were no deaths. CONCLUSIONS: The following findings are reported: 1) bilateral thalamic DBS and stimulation contralateral to thalamotomy are safe; 2) staging the procedure does not reduce the risk of dysarthria or gait disequilibrium; and 3) head and voice tremor are primary indications for bilateral DBS.
Assuntos
Terapia por Estimulação Elétrica , Tálamo/cirurgia , Tremor/terapia , Distúrbios da Voz/terapia , Terapia por Estimulação Elétrica/instrumentação , Terapia por Estimulação Elétrica/métodos , Eletrodos Implantados , Extremidades/fisiopatologia , Cabeça/fisiopatologia , Humanos , Esclerose Múltipla/complicações , Doença de Parkinson Secundária/complicações , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do Tratamento , Tremor/etiologia , Distúrbios da Voz/etiologiaRESUMO
The role of hemispherectomy in treating holohemispheric hemimegaloencephaly, a unilateral brain malformation, is still not well defined. The authors describe the cases of five infants presenting with intractable seizures, progressive neurological deficits, and severe developmental delay. Electroencephalography (EEG) showed generalized polyspikes from the megaloencephalic hemisphere and progressive slowing on the opposite side in all children; contralateral seizure spikes occurred in three children. Three of the five children underwent hemispherectomy for intractable seizures before 2 years of age, after which the seizures subsided completely in two children and improved remarkably in the third. Preoperative Wada testing proved useful in evaluating pharmacologically the effect of hemispherectomy on contralateral polyspikes. Postoperative EEG revealed the absence of polyspikes in the operated hemisphere and decreased slowing on the contralateral side. Psychomotor development in the surgically treated infants exceeded that of the children not undergoing hemispherectomy. Of the two children treated medically, one died at 4 years of age in status epilepticus and the other (now 5 years old) has frequent seizures and severe developmental delay. Based on these results, hemispherectomy appears to be a useful procedure for controlling seizures and improving psychomotor development in children with hemimegaloencephaly involving the entire hemisphere. Surgery in infancy can prevent or minimize seizure foci and encephalopathic changes that may develop in the contralateral hemisphere. Staging the procedure and exercising meticulous hemostasis make surgery relatively safe in infants who otherwise may have significant blood loss associated with increased blood flow to the megaloencephalic hemisphere.
Assuntos
Encéfalo/anormalidades , Encéfalo/cirurgia , Anticonvulsivantes/uso terapêutico , Encéfalo/patologia , Derivações do Líquido Cefalorraquidiano , Criança , Transtornos do Comportamento Infantil/etiologia , Transtornos do Comportamento Infantil/cirurgia , Desenvolvimento Infantil , Pré-Escolar , Deficiências do Desenvolvimento/etiologia , Deficiências do Desenvolvimento/cirurgia , Eletroencefalografia , Epilepsia Tônico-Clônica/tratamento farmacológico , Epilepsia Tônico-Clônica/etiologia , Epilepsia Tônico-Clônica/cirurgia , Feminino , Seguimentos , Humanos , Lactente , Recém-Nascido , Masculino , Destreza Motora , Exame Neurológico , Desempenho Psicomotor , Convulsões/tratamento farmacológico , Convulsões/etiologia , Convulsões/cirurgia , Resultado do TratamentoRESUMO
The Pelorus stereotactic system guided by magnetic resonance imaging was used to implant intracerebral depth electrodes for monitoring seizure activity. This stereotactic system is frameless and does not require the use of a computer. It is based on the concept of a ball-and-socket type stereotactic arc director and uses the center-of-arc principle to establish a trajectory for electrode placement. The system not only allows the use of the orthogonal approach, but also provides ample working space and flexibility to choose different entry points and trajectory angles.
Assuntos
Encéfalo/cirurgia , Eletrodos Implantados , Convulsões/fisiopatologia , Técnicas Estereotáxicas/instrumentação , Adolescente , Adulto , Desenho de Equipamento , Humanos , Imageamento por Ressonância Magnética , Pessoa de Meia-Idade , Modelos Estruturais , Monitorização Fisiológica/instrumentaçãoRESUMO
There is a lack of prospective studies for the long-term results of percutaneous stereotactic radiofrequency rhizotomy (PSR) in the treatment of patients with trigeminal neuralgia. The authors present results in 154 consecutive patients with trigeminal neuralgia treated by PSR and prospectively followed for 15 years. Ninety-nine percent of the patients obtained initial pain relief after one PSR. Dysesthesia occurred in 31 patients (23%): in 7% with mild initial hypalgesia; in 15% with dense hypalgesia; and in 36% with analgesia. Dysesthesia was mild and did not require treatment in most patients. The corneal reflex was absent or depressed in 29 patients, and keratitis developed in three patients. In 19 of 22 patients with trigeminal motor weakness, the paresis resolved within 1 year. Of 33 patients who had pain recurrence, 10 patients had pain that was mild or controlled with medications, and 23 patients required additional surgical treatment. The authors estimated using Kaplan-Meier analysis that the 14-year recurrence rate was 25% in the total group: 60% in patients with mild hypalgesia, 25% in those with dense hypalgesia, and 20% in those with analgesia. Timing of pain recurrence varied according to the degree of sensory loss. All pain recurrences in patients with mild hypalgesia occurred within 4 years after surgery; 10% more of the patients with dense hypalgesia had pain recurrences within the first 10 years compared with patients with analgesia. The median pain-free survival rate was 32 months for patients with mild hypalgesia and more than 15 years for patients with either analgesia or dense hypalgesia. Of the 100 patients followed for 15 years after one or two PSR procedures, 95 patients (95%) rated the procedure excellent (77 patients) or good (18 patients). The authors conclude that PSR is an effective, safe treatment for trigeminal neuralgia. Dense hypalgesia in the painful trigger zone, rather than analgesia, should be the target lesion.
Assuntos
Eletrocoagulação , Manejo da Dor , Rizotomia , Neuralgia do Trigêmeo/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Recidiva , Estatística como Assunto , Resultado do TratamentoRESUMO
Electrophysiological studies (for example, electroneuronography, nerve action potentials, absolute amplitudes of the muscle compound action potentials, and stimulation thresholds) do not accurately predict facial nerve function after the excision of acoustic neuromas. To eliminate individual nerve variability, the authors measured the ratio of the amplitudes of muscle compound action potentials produced by stimulating the facial nerve at the brainstem proximally and at the internal auditory meatus near the transverse crest distally after total tumor excision in 20 patients. The mean tumor size was 36 mm. The facial nerves were anatomically intact in all patients after tumor excision. The follow-up period ranged from 14 to 28 months. Facial nerve outcome was determined by a modified House-Brackmann grading scale. Initial facial nerve function was measured at Days 4 to 7 postoperatively, and final function was the grade at last follow up. The following results were obtained: all patients with proximal-to-distal amplitude ratios greater than 2:3 had Grade III or better initial function and Grade I final facial nerve function; 90% of patients with amplitude ratios between 1:3 and 2:3 had Grade III or worse initial facial nerve function, and 100% of these patients had Grade III or better final facial nerve function; all patients with amplitude ratios less than 1:3 had Grade IV or worse initial and final facial nerve function. The authors conclude that the proximal-to-distal amplitude ratios after acoustic neuroma excision can accurately predict postoperative facial nerve function.
Assuntos
Potenciais de Ação , Nervo Facial/fisiologia , Neuroma Acústico/cirurgia , Adulto , Idoso , Estimulação Elétrica , Eletrofisiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do TratamentoRESUMO
The goals of this study were to analyze the effect of pallidotomy on parkinsonian tremor and to ascertain whether an association exists between microrecording findings and tremor outcome. Forty-four patients with Parkinson's disease who had drug-induced dyskinesia, bradykinesia, rigidity, and tremor underwent posteroventral pallidotomy. Using a 1-mu-tip tungsten electrode, microrecordings were obtained through one to three tracts, starting 10 mm above the pallidal base. Tremor severity was measured on a patient-rated, 100-mm Visual Analog Scale (VAS), both preoperatively and 3 to 9 months (mean 6 months) postoperatively. Preoperatively, tremor was rated as 50 mm or greater in 24 patients (55%) and as less than 25 mm in 13 patients (30%). Postoperatively, tremor was rated as 50 mm or greater in five patients (11%) and less than 25 mm in 29 patients (66%). The difference was significant (p = 0.0001). Four patients (9%) had no postoperative tremor. Tremor improved by at least 50% in eight (80%) of 10 patients in whom tremor-synchronous cells were recorded (Group A) and in 12 (35%) of 34 patients in whom tremor-synchronous cells were not recorded (Group B). This difference was significant (p = 0.03). Tremor improved by at least 50 mm in all (100%) of the seven Group A patients with severe (> or = 50 mm) preoperative tremor and in nine (53%) of 17 Group B patients with severe preoperative tremor. This difference was also significant (p = 0.05). The authors prefer two conclusions: 1) after pallidotomy, tremor improves by at least 50% in two-thirds of patients with Parkinson's disease who have severe (> or = 50 mm on the VAS) preoperative tremor; and 2) better tremor control is obtained when tremor-synchronous cells are included in the lesion.
Assuntos
Globo Pálido/cirurgia , Doença de Parkinson/fisiopatologia , Doença de Parkinson/cirurgia , Tremor/fisiopatologia , Tremor/cirurgia , Adulto , Idoso , Eletrofisiologia , Feminino , Globo Pálido/patologia , Globo Pálido/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Intraoperatória , Neurônios/fisiologia , Resultado do TratamentoRESUMO
Information is limited on the characteristics and topographic localization of pallidal kinesthetic cells in patients with Parkinson's disease. The authors analyzed the data from 298 neurons recorded in 38 patients with Parkinson's disease who underwent pallidotomy via microrecording techniques. Sixty-five neurons (22%) responded to passive movement of contralateral limbs. Of 17 kinesthetic cells that were tested in six patients, seven (41%) responded to ipsilateral limb movement as well. Nineteen cells (6%) fired synchronously with tremor. More kinesthetic cells were activated (63%) than inhibited (28%) by movement of single (68%) rather than multiple (32%) joints, and proximal (75%) rather than distal (25%) joints. The lateral globus pallidus externus (GPe) and medial globus pallidus internus (GPi) pallidal segments contained similar proportions of kinesthetic cells, activated or inhibited cells, arm- or leg-activated cells, and cells responding to single or multiple joints. Significantly more kinesthetic cells that responded to distal joints were recorded in GPi compared to GPe segments (p = 0.01). Arm and leg cells had similar characteristics pertaining to activation versus inhibition and responses to single, multiple, proximal, or distal joint movements. Arm and leg cells were somatotopically organized in GPi. Arm cells were clustered at the rostral and caudal segments of GPi and leg cells were clustered centrally. In GPe, leg cells were clustered at the caudal border. No somatotopic organization was identified for activated or inhibited cells; cells that responded to single, multiple, proximal, or distal joints; tremor-synchronous cells; or cells responding to specific joints within somatotopic arm or leg cells. It is concluded that kinesthetic cells provide a roadmap that localizes limb cells during pallidotomy. More studies are needed to identify the clinical significance of the different characteristics of kinesthetic cells.
Assuntos
Globo Pálido/fisiopatologia , Cinestesia , Doença de Parkinson/fisiopatologia , Adulto , Idoso , Braço/fisiopatologia , Eletrofisiologia , Feminino , Globo Pálido/patologia , Humanos , Articulações/fisiopatologia , Perna (Membro)/fisiopatologia , Masculino , Pessoa de Meia-Idade , Movimento , Doença de Parkinson/patologia , Tremor/patologia , Tremor/fisiopatologiaRESUMO
The authors report a new technique to anchor deep brain stimulation electrodes using a titanium microplate. This technique has been safely used to secure 20 quadripolar deep brain stimulation electrodes implanted for movement disorders (18 electrodes) and pain (two electrodes). Twelve electrodes were implanted in the thalamus, four in the subthalamic nucleus, and four in the pallidum. No electrode migration or rupture occurred, and all electrodes have been shown to work properly after internalization of the system.
Assuntos
Encéfalo , Estimulação Elétrica/instrumentação , Eletrodos , Humanos , Transtornos dos Movimentos/terapia , Manejo da DorRESUMO
Trigeminal neurinomas have traditionally been excised through conventional approaches. Because symptomatic tumor recurrence exceeds 50% after conventional procedures, the authors evaluated the use of skull base approaches to achieve complete resection and a lower rate of symptomatic recurrence. Comparisons of skull base with conventional approaches to trigeminal neurinomas have been limited to small series with short-term follow-up periods. The authors reviewed their experiences with conventional (frontotemporal transsylvian, subtemporal-intradural, subtemporal-transtentorial, and suboccipital) and skull base (frontotemporal extradural-intradural, frontoorbitozygomatic, subtemporal anterior petrosal, and presigmoid posterior petrosal) surgical approaches for the excision of trigeminal neurinomas. In this paper they report the results of 15 patients with trigeminal neurinoma who underwent 27 surgical procedures between 1980 and 1990. Seventeen of the procedures used conventional and 10 used skull base approaches. All patients had tumors arising from Meckel's cave and the porus trigeminus either initially or on recurrence. Tumors located in the cavernous sinus recurred most frequently (83%); other tumors that recurred frequently were those located in Meckel's cave and the porus trigeminus (67%), and the posterior fossa (17%). The tumor extended into the anterolateral wall of the cavernous sinus in 38% of patients with cavernous sinus involvement. Tumor exposure and ease of dissection were superior with skull base approaches. Residual or recurrent tumors were found in 65% of patients following conventional approaches compared with 10% of patients following skull base approaches. Using skull base approaches, the surgeon was more accurate (90%) in estimating tumor excision than when using conventional approaches (43%). Perioperative complications were similar with both. The authors discuss the indications, advantages, and limitations of each approach. Based on anatomical considerations, they propose a strategy to best resect these tumors.
Assuntos
Neoplasias dos Nervos Cranianos/cirurgia , Neurilemoma/cirurgia , Crânio/cirurgia , Nervo Trigêmeo/cirurgia , Adolescente , Adulto , Criança , Neoplasias dos Nervos Cranianos/complicações , Neoplasias dos Nervos Cranianos/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/cirurgia , Neurilemoma/complicações , Neurilemoma/diagnóstico , Complicações Pós-Operatórias , Estudos Retrospectivos , Resultado do TratamentoRESUMO
Percutaneous radiofrequency rhizotomy (PSR) is recognized as a simple, effective, and safe surgical treatment for trigeminal neuralgia. Rates of pain recurrence after PSR are the lowest versus those of other percutaneous procedures, and similar to those of microvascular decompression.