Movement disorders following nonfunctional neurosurgery

Severe Cerebral Complications Secondary to Perforation Injury of the Anterior Skull Base During Sinonasal Surgery: An Underappreciated Problem?

OBJECTIVE

Functional endonasal sinus surgery (FESS) is widely practiced and is considered a generally safe procedure. Skull base injuries occur in <1% of procedures and are typically associated with cerebrospinal fluid leaks. Rarely, skull base injuries might result in cerebral lesions. Here we present a series of 4 patients with iatrogenic perforating injuries of the anterior skull base and cerebral lesions after routine FESS.

METHODS

Four patients with iatrogenic perforating cerebral lesions after routine FESS, performed at other institutions, were referred to a tertiary neurosurgery department. Within a 10-year period these procedures were performed in 3 patients as endoscopic FESS and as a microscopic FESS in 1 patient.

RESULTS

There were 3 men and 1 woman. Mean age at the time of surgery was 50 years. In 3 instances (in which an endoscope was used), the ear, nose, and throat physician had noted perforation of the skull base during surgery, but it went unnoticed in 1 patient operated with the microscope. Frontal lobe hematoma occurred in all patients, and in 3 of them cerebral infarction developed secondary to injury of branches of the anterior cerebral artery. Three patients developed acute hydrocephalus. Two had rapid global brain swelling and they succumbed within days. The other 2 patients survived without apparent neurological deficits.

CONCLUSIONS

Cerebral lesions during FESS still occur in contemporary surgery and they are possibly underreported. Even with prompt conservative and surgical measures, these lesions may result in catastrophic outcome. Associated vascular injuries have a worse prognosis. The only risk factor associated with lethal outcome in our series was younger age.

Deep brain stimulation for treatment of hemichorea-hemiballism after craniopharyngioma resection: long-term follow-up

Hemichorea-hemiballism is a rare movement disorder that has various causes. In treatment-resistant cases, both thalamic and pallidal functional procedures have been shown to yield beneficial results. Until now it has not been clarified whether the thalamus or the pallidum would yield a superior outcome. After resection of a craniopharyngioma in this patient at the age of 49 years, hemichorea-hemiballism developed, with a latency of several weeks. Because the patient was greatly impaired by the movement disorder, she underwent implantation of deep brain stimulation (DBS) electrodes in the thalamic ventralis intermedius nucleus and the posteroventral lateral globus pallidus internus. Although both pallidal and thalamic stimulation could suppress the movement disorder, the voltage needed was clearly less with thalamic than with pallidal stimulation. At the last available follow-up 25 months postoperatively, complete subsidence of hemichorea-hemiballism was achieved with long-term thalamic stimulation. Long-term DBS therapy is an efficient treatment modality for refractory hemichorea-hemiballism in the long run (> 2 years). A bifocal (thalamic and pallidal) target paradigm allowed selection of the optimal stimulation site. Thalamic DBS was more favorable with regard to energy consumption.

Hemiballismus

Hemiballism is a relatively rare hyperkinetic movement disorder characterized by involuntary, violent, coarse and wide-amplitude movements involving ipsilateral arm and leg. Although classically related to lesions in the subthalamic nucleus, in clinical-radiological series of hemiballism most patients had lesions outside this nucleus, involving mainly other basal ganglia structures. It has been suggested that abnormal neuronal firing patterns in the internal segment of the globus pallidus may be related to the pathogenesis of hemiballism. Stroke is the most common cause, but in recent years an increasing number of patients with hemiballism associated with nonketotic hyperglycemia or with complications of human immunodeficiency virus (HIV) infection have been reported. Contrarily to what was stated in older literature, hemiballism has, in general, a relatively good prognosis. Depending on the underlying causes, many patients may experience spontaneous improvements or remissions. Treatment should be directed to the cause of hemiballism. Symptomatic treatment includes the use of drugs, particularly blockers of striatal D2 dopamine receptors and tetrabenazine. Surgical treatment, especially pallidotomy, is a therapeutic option for the minority of patients with severe persistent disabling hemiballism.

Movement disorders after intervertebral disc surgery: Coincidence or causal relationship?

It is well known that brain injury or central traumatic lesions may result in the subsequent appearance of movement disorders such as dystonia or tremor. The concept that peripheral lesions to neural structures may be involved in the pathogenesis of movement disorders has been discussed controversely but has gained more widespread acceptance only recently. Here, we report on 6 patients who developed movement disorders after spinal disc surgery. The movement disorders became manifest with a delay of 1 day to 12 months after surgery. Of the six patients, 4 underwent cervical disc surgery, and 2 patients were operated on for lumbar disc herniation; 2 patients presented with paroxysmal kinesigenic segmental dystonia, 1 patient with focal dystonia, 2 with unilateral tremor, and 1 with bilateral tremor. The appearance of the movement disorder was associated with persistent dermatomal or segmental pain. In all patients, the anatomic distribution of the movement disorder was related to the nerve root or spinal segment of the corresponding disc level and the manifestation was in close temporal relation to the surgery. We conclude that spinal disc surgery may be another, thus far neglected, cause for movement disorders. The postoperative pain syndrome in all patients should be considered as an important factor of pathogenesis. Overall, movement disorders associated with disc surgery appear to be rare, yet they may cause significant discomfort to the affected individual.

Absence of movement disorders after surgical resection of glioma invading the right striatum

OBJECT

Despite the high frequency of striatal lesions, the rate of movement disorders reported in the literature is lower than expected (< 10%). To maximize the extent of resection in low-grade gliomas invading the right striatum, the authors performed a striatal resection in a series of 14 patients, observed the lack of movement disorders following these procedures, and discuss herein the mechanisms likely to explain these findings.

METHODS

Fourteen patients harboring a low-grade glioma that was infiltrating the right nondominant striatum, and in whom the results of neurological examination were normal, underwent surgery in which intraoperative electrical mapping was used, allowing the identification of pyramidal pathways. The striatum was resected in all procedures, and corticospinal tracts were systematically detected and preserved. Ten patients presented with a transient postoperative motor deficit, and nine with a loss of interest and affect. These symptoms all resolved within 3 months, except for one case of persistent hemiparesis. No postoperative movement disorder was noted, even transitorily. All resections were categorized as either total or subtotal on control magnetic resonance images.

CONCLUSIONS

These findings show that the nondominant striatum can be removed in cases of glioma invasion without inducing even transitory movement disorders. This phenomenon could be explained by the combined resection of the two classes of striatal neurons, an associated pallidal and thalamocortical resection, or a compensatory recruitment of parallel networks. Thus, these results may allow the surgeon to maximize the extent of removal of low-grade gliomas involving basal ganglia. Striatal resection may induce transient hemiparesis and "athymhormic syndrome," however, necessitating that the patient be clearly informed before surgery.