Effective long-term subthalamic stimulation in PARK8 positive Parkinson's disease

Whether patients with genetically defined Parkinson's disease (PD) may be particularly eligible to benefit from deep brain stimulation of the nucleus subthalamicus (STN-DBS) is currently the subject of debate. We report on a patient with advanced PD due to R793M missense mutation in the LRRK2 gene successfully treated by STN-DBS. Disease onset was at age 42 with bradykinesia, rigidity and rest tremor. During the course of the disease he developed severe motor fluctuations, dyskinesias, postural instability with falls, but preserved levodopa responsiveness. At age 60 the patient was treated by bilateral DBS of the STN. At one year after surgery a 66% improvement of the UPDRS motor score in the off-medication state was determined. During the long-term follow-up there was sustained benefit with 56% improvement of motor score after 8 years. Our report adds evidence that patients with LRRK2 monogenetic Parkinsonism are well suited candidates for DBS treatment and may indicate a potential genetic predictor for positive long-term effect of STN-DBS treatment.

Effective thalamic deep brain stimulation for neuropathic tremor in a patient with severe demyelinating neuropathy

Postural and action tremor in peripheral neuropathy is characteristic of Roussy-Levy syndrome. A patient with a severe demyelinating neuropathy and disabling neuropathic tremor successfully treated by deep brain stimulation (DBS) is reported. Disease onset was at age 63 years with sensory symptoms and slight action tremor. Within the following 9 years a severe, drug resistant, postural and action tremor developed rendering the patient unable to feed himself. At age 72 years the patient was treated by bilateral DBS of the ventral intermediate thalamic nucleus, with a useful 30% reduction in tremor. The clinical benefit of the stimulation remained stable over a 1 year postoperative observation period.

Meningeal dissemination in primary CNS lymphoma: prospective evaluation of 282 patients

BACKGROUND

The impact of meningeal dissemination in primary CNS lymphoma (PCNSL) is debated, and the reported frequency varies. We prospectively evaluated the diagnostic value of PCR in comparison with CSF cytomorphology and MRI for diagnosing meningeal dissemination in PCNSL.

METHODS

We evaluated 282 patients from a multicenter therapy study for PCNSL for the presence of meningeal dissemination: 205 with CSF cytomorphology, 171 with PCR of the rearranged immunoglobulin heavy-chain genes in CSF, and 217 with cranial MRI.

RESULTS

Meningeal dissemination was found in 33 of 205 patients (16%) by cytomorphology, in 19 of 171 (11%) patients evaluated by PCR, and in 8 of 217 patients (4%) by MRI. Considering either of these methods, the relative frequency of meningeal dissemination was 17.4% (49 of 282 patients). PCR was monoclonal in 6 of 19 (32%) samples with positive cytomorphology, 1 of 13 samples (8%) with suspicious cytology, and in 10 of 105 (10%) cytologically negative samples. In 11 samples with positive and 12 with suspicious cytology, PCR showed only a polyclonal pattern. The probability of meningeal dissemination detection was higher in cases with CSF pleocytosis (>5/microL) with an OR of 2.48 (95% CI 1.15-5.34, p = 0.018). CSF protein had no predictive value for meningeal dissemination detection.

CONCLUSIONS

We found a low rate of meningeal dissemination in primary CNS lymphoma in this large prospective study. The rate of discordant PCR and cytomorphologic results was high. Thus, the methods should be regarded as complementary. CSF pleocytosis had predictive value for meningeal dissemination detection.

Surgical planning for retrosigmoid craniotomies improved by 3D computed tomography venography

OBJECTIVE

It is impossible to precisely anticipate the crooked course of the transverse and sigmoid sinuses and their individual relationship to superficial landmarks such as the asterion during retrosigmoid approaches. This study was designed to evaluate this anatomical relationship with the help of a surgical planning system and to analyze the impact of these in vivo findings on trepanation placement in retrosigmoid craniotomies.

METHODS

In a consecutive series of 123 patients with pathologies located in the cerebellopontine angle, 72 patients underwent surgical planning for retrosigmoid craniotomies based on 3D volumetric renderings of computed tomography venography. By opacity modulation of surfaces in 3D images the position of the asterion was assessed in relationship to the transverse-sigmoid sinus transition (TST) and compared to its intraoperative localization. We evaluated the impact of this additional information on trepanation placement.

RESULTS

The spatial relationship of the asterion and the underlying TST complex could be identified and recorded in 66 out of 72 cases. In the remaining 6 cases the sutures were ossified and not visible in the 3D CT reconstructions. The asterion was located on top of the TST in 51 cases, above the TST in 4 cases, and below the TST in 11 cases. The location of the trepanation was modified in 27 cases due to the preoperative imaging findings with major and minor modifications in 10 and 17 cases, respectively.

CONCLUSION

Volume-rendered images provide reliable 3D visualization of complex and hidden anatomical structures in the posterior fossa and thereby increase the precision in retrosigmoid approaches.

Effects of age and symptom status on silent ischemic lesions after carotid stenting with and without the use of distal filter devices

BACKGROUND AND PURPOSE

The routine use of distal filter devices during carotid angioplasty and stent placement (CAS) is controversial. The aim of this study was to analyze their effects on the incidence of new diffusion-weighted imaging (DWI) lesions as surrogate markers for stroke in important subgroups.

MATERIALS AND METHODS

DWI was performed immediately before and after CAS in 68 patients with and 175 without protection, and patients were further subdivided according to their age or symptom status.

RESULTS

The proportion of patients with new ipsilateral DWI lesion(s) was significantly lower after protected versus unprotected CAS (52% versus 68%), as well as in symptomatic patients (56% versus 74%) or those at or younger than 75 years of age (46% versus 67%; all P < .05). Similarly, the total number of lesions was significantly lower after protected versus unprotected CAS (median, 1; interquartile range [IQR], 0-2; versus median, 1; IQR 0-4.75) and in symptomatic patients (median, 1; IQR, 0-3; versus median, 2; IQR, 0-6) or those at or younger than 75 years of age (median, 0; IQR, 0-2; versus median, 1; IQR, 0-4; all P < .05). In contrast, for asymptomatic patients (48% versus 52%; P = .8; median, 0; IQR, 0-2; versus median, 1; IQR, 0-2.5; P = .6) or those older than 75 years of age (73% versus 69%; P = .7; median, 1; IQR, 0-4; versus median, 1.5; IQR, 0-5.75; P = .6), the proportion of patients with new lesion(s) and the total number of these lesions were not significantly different between protected and unprotected CAS.

CONCLUSIONS

The use of distal filter devices generally reduces the incidence of new DWI lesions; however, this beneficial effect might not necessarily pertain to older and asymptomatic patients.