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Hurwitz TA, Avecillas-Chasin JM, Bogod NM, Honey CR. Ventral targeted anterior capsulotomy for treatment-resistant depression and obsessive-compulsive disorder: A treatment method with cases. J Affect Disord 2024; 350:887-894. [PMID: 38272366 DOI: 10.1016/j.jad.2024.01.176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND Ablative surgery using bilateral anterior capsulotomy (BAC) is an option for treatment resistant depression (TRD) and obsessive-compulsive disorder (TROCD). The location and extent of the lesion within anterior limb of the internal capsule (ALIC) remains uncertain. Accumulating evidence has suggested that the lesion should be located ventrally while limiting the dorsal extent. Our center is now targeting specific fiber tracts within the lower half of the ALIC. METHOD Presurgical diffusion tensor Magnetic Resonance Imaging (MRI) was used to identify individual fibre tracts within the ventral aspect of the ALIC in the last two patients who underwent BAC at our center. One patient had TRD and the other had both TROCD and TRD. Radiofrequency-induced thermal lesions were created in the identified targets with lesion volumes between 20 and 229 mm3 (average 95 mm3). FINDINGS Both patients were responders with neither experiencing significant side effects including compromised executive functions. LIMITATIONS The generalizability of our findings is limited because the outcome is based on two subjects. CONCLUSION This work suggests that BAC can be individually tailored and more limited to the ventral aspect of the ALIC and is effective and safe for TRD and TROCD. Accumulating data also suggests that to be clinically effective the length of the capsulotomy should be about 10mm. BAC's use may increase with the growing utilization and mastery of magnetic resonance guided focused ultrasound.
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Affiliation(s)
- Trevor A Hurwitz
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada.
| | | | - Nicholas M Bogod
- Department of Medicine, Division of Neurology, University of British Columbia, Vancouver, BC, Canada.
| | - Christopher R Honey
- Department of Surgery, University of British Columbia, Vancouver, BC, Canada.
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2
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Hart MG, Polyhronopoulos N, Sandhu MK, Honey CR. Deep Brain Stimulation Improves Symptoms of Spasmodic Dysphonia Through Targeting of Thalamic Sensorimotor Connectivity. Neurosurgery 2024; 94:00006123-990000000-01027. [PMID: 38251897 PMCID: PMC11073779 DOI: 10.1227/neu.0000000000002836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/27/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Spasmodic dysphonia is a dystonia of the vocal chords producing difficulty with speech. Current hypotheses are that this is a condition of dysregulated thalamic sensory motor integration. A recent randomized controlled trial of thalamic deep brain stimulation (DBS) demonstrated its safety and efficacy. Our objective was to determine whether the outcome could be predicted by stimulation of thalamic sensorimotor areas and adjacent white matter connectivity as assessed by diffusion tractography. METHODS A cohort of 6 participants undergoing thalamic DBS for adductor spasmodic dysphonia was studied. Electrodes were localized with the Lead-DBS toolbox. Group-based analyses were performed with atlases, coordinates, and using voxel-based symptom mapping. Diffusion tensor imaging (3 T, 64 directions, 2-mm isotropic) was used to perform individual probabilistic tractography (cerebellothalamic tract and pallidothalamic tract) and segmentation of the thalamus. Monopolar review was performed at 0.5 V and binarised as effective or ineffective. RESULTS Effective contacts stimulated more of thalamic sensorimotor areas than ineffective contacts (P < .05, false discovery rate corrected). This effect was consistent across analytical and statistical techniques. Group-level and tractography analyses did not identify a specific "sweet spot" suggesting the benefit of DBS is derived from modulating individual thalamic sensorimotor areas. Stimulations at 1 year involved predicted thalamic sensorimotor regions with additional cerebellothalamic tract involvement. CONCLUSION Stimulation of thalamic sensorimotor areas was associated with improvement in symptoms of spasmodic dysphonia. These data are consistent with DBS acting on pathophysiologically dysregulated thalamic sensorimotor integration in spasmodic dysphonia.
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Affiliation(s)
- Michael G. Hart
- St George's, University of London & St George's Hospitals NHS Foundation Trust, Institute of Molecular and Clinical Sciences, Neurosciences Research Centre, London, UK
| | - Nancy Polyhronopoulos
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mandeep K. Sandhu
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R. Honey
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
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Harding L, McFarlane J, Honey CR, McDonald PJ, Illes J. Mapping the Landscape of Equitable Access to Advanced Neurotechnologies in Canada. Can J Neurol Sci 2023; 50:s17-s25. [PMID: 37160675 PMCID: PMC10172973 DOI: 10.1017/cjn.2023.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Geographic, social, political, and economic factors shape access to advanced neurotechnologies, yet little previous research has explored the barriers, enablers, and areas of opportunity for equitable and meaningful access for diverse patient communities across Canada. We applied a mixed-mode approach involving semi-structured interviews and rating scale questions to consult with 24 medical experts who are involved in the care of patients who undergo functional neurosurgery targeting the brain. Seven major themes emerged from the qualitative analysis: Health care system, Neurotechnology features, Patient demographics, Target condition features, Ethics, Upstream barriers and enablers, and Areas of opportunity. Descriptive statistics of the Likert-scale responses suggest that interviewees perceive a disparity between the imperative of access to advanced neurotechnologies for people living in rural and remote areas and the likelihood of achieving such access. The results depict a complex picture of access to functional neurosurgery in Canada with pockets of excellence and a motivation to improve the availability of care for vulnerable populations through the expansion of distributed care models, improved health care system efficiencies, increasing funding and support for patient travel, and increasing awareness about and advocacy for advanced neurotechnologies.
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Affiliation(s)
- Louise Harding
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacob McFarlane
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R. Honey
- Faculty of Medicine, Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick J. McDonald
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Medicine, Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Section of Neurosurgery, Departments of Surgery and Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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4
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Alkubaisi A, Dong CCJ, Honey CR. The Location of the Parasympathetic Fibres within the Vagus Nerve Rootlets: A Case Report and a Review of the Literature. Stereotact Funct Neurosurg 2023; 101:68-71. [PMID: 36580909 PMCID: PMC9986834 DOI: 10.1159/000528094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/03/2022] [Indexed: 12/30/2022]
Abstract
The vagus nerve has motor, sensory, and parasympathetic components. Understanding the nerve's internal anatomy, its variations, and relationship to the glossopharyngeal nerve are crucial for neurosurgeons decompressing the lower cranial nerves. We present a case report demonstrating the location of the parasympathetic fibres within the vagus nerve rootlets. A 47-year-old woman presented with a 1-year history of medically refractory left-sided glossopharyngeal neuralgia and a more recent history of left-sided hemi-laryngopharyngeal spasm. magnetic resonance imaging showed her left posterior inferior cerebellar artery distorting the lower cranial nerves on the affected left side. The patient consented to microvascular decompression of the lower cranial nerves with possible sectioning of the glossopharyngeal and upper sensory rootlets of the vagus nerve. During surgery, electrical stimulation of the most caudal rootlet of the vagus nerve triggered profound bradycardia. None of the more rostral rootlets had a similar parasympathetic response. This case is the first demonstration, to our knowledge, of the location of the cardiac parasympathetic fibres within the human vagus nerve rootlets. This new understanding of the vagus nerve rootlets' distribution of pure sensory (most rostral), motor/sensory (more caudal), and parasympathetic (most caudal) fibres may lead to a better understanding and diagnosis of the vagal rhizopathies. Approximately 20% of patients with glossopharyngeal neuralgia also have paroxysmal cough. This could be due to the anatomical juxtaposition of the IXth cranial nerve with the rostral vagal rootlets with pure sensory fibres (which mediate a tickling sensation in the lungs). A subgroup of patients with glossopharyngeal neuralgia have neuralgia-induced syncope. The cause of this rare condition, "vago-glossopharyngeal neuralgia," has been debated since it was first described by Riley in 1942. Our case supports the theory that this neuralgia-induced bradycardia is reflexively mediated through the brainstem with afferent impulses in the IXth and efferent impulses in the Xth cranial nerve. The rarer co-occurrence of glossopharyngeal neuralgia with hemi-laryngopharyngeal spasm (as seen in this case) may be explained by the proximity of the IXth nerve with the more caudal vagus rootlets which have motor (and probably sensory) supply to the throat. Finally, if there is a vagal rhizopathy related to compression of its parasympathetic fibres, one would expect it to be at the most caudal rootlet of the vagus nerve.
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Affiliation(s)
- Aisha Alkubaisi
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada.,Division of Neurosurgery, Hamad General Hospital, Doha, Qatar
| | - Charles C J Dong
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
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Alkubaisi A, Sandhu MK, Polyhronopoulos NE, Honey CR. Deep brain stimulation as a rescue for pediatric dystonic storm. Case reports and literature review. Interdisciplinary Neurosurgery 2022. [DOI: 10.1016/j.inat.2022.101654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
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Hurwitz TA, Honey CR, Sepehry AA. Ablation Surgeries for Treatment-Resistant Depression: A Meta-Analysis and Systematic Review of Reported Case Series. Stereotact Funct Neurosurg 2022; 100:300-313. [PMID: 35973404 DOI: 10.1159/000526000] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 07/04/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Ablative lesion procedures remain as the last option in treatment of refractory depression. Contemporary ablative psychosurgeries involve producing lesions in the anterior limb of the internal capsule (bilateral anterior capsulotomy - BAC), the supragenual anterior cingulate gyrus and cingulum (bilateral anterior cingulotomy - BACING), and subgenual anterior cingulate gyrus and subcortical orbitofrontal white matter (bilateral subcaudate tractotomy - BST). A combination of BACING and BST is known as limbic leukotomy (bilateral limbic leukotomy - BLL). All procedures claim some success, but cohorts are small, depression assessment instruments differ, and inclusion and outcome criteria and follow-up duration vary. In some cohorts, more than one type of surgery was performed in several patients, further confounding interpreting the available data. Current evidence is equivocal on which surgical target works best. Method and Aim: This systematic review and meta-analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) standard on published cohorts was conducted to review and identify which is the best standalone ablative procedure for treatment-resistant depression (TRD) based on response rate (event rate) and adverse-effect profile using the Comprehensive Meta-Analysis software. RESULTS AND CONCLUSION As a standalone neurosurgical procedure, we found that BAC appears to be the most effective and safest of all the ablative targets for TRD. A major limitation of this conclusion is the paucity of published case series where sample sizes are small and all are open label.
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Affiliation(s)
- Trevor A Hurwitz
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amir Ali Sepehry
- Clinical and Counseling Psychology Programs, Adler University, Vancouver, British Columbia, Canada,
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Rebchuk AD, Chang SJ, Griesdale DEG, Honey CR. Non-contrast-enhancing subdural empyema: illustrative case. J Neurosurg Case Lessons 2022; 4:CASE22269. [PMID: 36088564 PMCID: PMC9706330 DOI: 10.3171/case22269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Subdural empyema (SDE) is a life-threatening intracranial infection that, without timely surgical intervention and appropriate antibiotic treatment, is inevitably fatal. SDE is classically recognized on brain imaging as a subdural collection surrounded by a contrast-enhancing ring. OBSERVATIONS The authors describe the case of a 41-year-old male with clinical features consistent with SDE but without any contrast enhancement on multiple computed tomography scans obtained more than 48 hours apart. Given the high clinical suspicion for SDE, a craniotomy was performed that demonstrated frank pus that eventually grew Streptococcus pyogenes. LESSONS This case demonstrates that SDE may present without ring enhancement on contrast-enhanced imaging. In critically ill patients with a high clinical suspicion for SDE despite lack of contrast enhancement, we demonstrate that exploratory burr holes or craniotomy can provide diagnostic confirmation and source control.
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Affiliation(s)
| | | | - Donald E. G. Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, and
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; and
- Center for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
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8
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Honey CR, Kruger MT, Almeida T, Rammage LA, Tamber MS, Morrison MD, Poologaindran A, Hu A. Deep Brain Stimulation for Spasmodic Dysphonia: A Phase I Randomized Controlled Trial. Neuromodulation 2022. [DOI: 10.1016/j.neurom.2022.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Affiliation(s)
- Stephano J Chang
- Division of Neurosurgery, Department of Surgery (S.J.C., A.D.R., C.R.H.), University of British Columbia, Canada
| | - Alexander D Rebchuk
- Division of Neurosurgery, Department of Surgery (S.J.C., A.D.R., C.R.H.), University of British Columbia, Canada
| | - Philip Teal
- Department of Neurology and Stroke Program (P.T., T.S.F.), University of British Columbia, Canada
| | - Christopher R Honey
- Division of Neurosurgery, Department of Surgery (S.J.C., A.D.R., C.R.H.), University of British Columbia, Canada
| | - Thalia S Field
- Department of Neurology and Stroke Program (P.T., T.S.F.), University of British Columbia, Canada
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10
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Avecillas-Chasin JM, Honey CR, Heran MKS, Krüger MT. Sweet spots of standard and directional leads in patients with refractory essential tremor: white matter pathways associated with maximal tremor improvement. J Neurosurg 2022; 137:1811-1820. [PMID: 35535840 DOI: 10.3171/2022.3.jns212374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 03/11/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In patients with essential tremor (ET) treated with standard deep brain stimulation (sDBS) whose ET had progressed and who no longer received optimal benefit from sDBS, directional deep brain stimulation (dDBS) may provide better tremor control. Current steering may provide better coverage of subcortical structures related to tremor control in patients with ET and significant progression without optimal response to sDBS. METHODS This study included 6 patients with ET initially treated with sDBS whose tremor later progressed and who then underwent reimplantation with dDBS to optimize their tremor control. To investigate the differences in the local effects of sDBS and dDBS, the authors generated the volume of tissue activation (VTA) to calculate the sweet spots associated with the best possible tremor control with no side effects. Then, to investigate the anatomical structures associated with maximal tremor control, the white matter pathways of the posterior subthalamic areas (PSAs) were generated and their involvement with the sDBS and dDBS sweet spots was calculated. RESULTS Tremor improvement was significantly better with dDBS (68.4%) than with sDBS (48.7%) (p = 0.017). The sDBS sweet spot was located within the ventral intermediate nucleus, whereas the sweet spot of the dDBS was mainly located within the PSA. The sweet spots of both sDBS and dDBS involved a similar portion of the cerebellothalamic pathway. However, the dDBS had greater involvement of the pallidofugal pathways than the sDBS. CONCLUSIONS In patients with ET treated with sDBS who later had ET progression, dDBS provided better tremor control, which was related to directionality and a more ventral position. The involvement of both the cerebellothalamic and pallidofugal pathways obtained with dDBS is associated with additional improvement over the sDBS.
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Affiliation(s)
- Josue M Avecillas-Chasin
- 1Department of Neurosurgery, University of Nebraska Medical Center, Omaha, Nebraska.,2Department of Neurosurgery, University of California, Los Angeles, California
| | | | - Manraj K S Heran
- 4Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marie T Krüger
- 5Department of Neurosurgery, Cantonal Hospital St. Gallen, Switzerland; and.,6Department of Stereotactic and Functional Neurosurgery, University Medical Center Freiburg, Germany
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Honey CM, Hart MG, Rammage LA, Morrison MD, Hu A, Honey CR. Thalamic Deep Brain Stimulation Ameliorates Mixed and Abductor Spasmodic Dysphonia: Case Reports and Proof of Concept. Neurosurg open 2021. [DOI: 10.1093/neuopn/okab022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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12
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Krüger MT, Avecillas-Chasin JM, Heran MKS, Naseri Y, Sandhu MK, Polyhronopoulos NE, Sarai N, Honey CR. Directional Deep Brain Stimulation Can Target the Thalamic "Sweet Spot" for Improving Neuropathic Dental Pain. Oper Neurosurg (Hagerstown) 2021; 21:81-86. [PMID: 33956987 DOI: 10.1093/ons/opab136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 03/12/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Neuropathic dental pain (NDP) is a chronic pain condition that is notoriously difficult to treat. To date, there are no deep brain stimulation (DBS) studies on this specific pain condition and no optimal target or "sweet spot" has ever been defined. OBJECTIVE To determine the optimal thalamic target for improving this condition by utilizing the steering abilities of a directional DBS electrode (Vercise CartesiaTM Model DB-2202-45, Boston Scientific). METHODS A literature search and review of our database identified 3 potential thalamic targets. A directional lead was implanted in a patient with NDP and its current steering used to test the effects in each nucleus. The patient reported her pain after 2 wk of stimulation in a prospective randomized blinded trial of one. Quality of life measurements were performed before and after 3 mo on their best setting. RESULTS We identified 3 potential nuclei: the centromedian (CM), ventral posterior medial (VPM), and anterior pulvinar. The best results were during VPM stimulation (>90% reduction in pain) and CM stimulation (50% reduction). Following 3 mo of VPM-DBS in combination of lateral CM stimulation, their pain disability index dropped (from 25 to 0) and short form 36 improved (from 67.5 to 90). CONCLUSION VPM stimulation in combination with CM stimulation is a promising target for NDP. DBS electrode directionality can be used to test multiple targets and select a patient specific "sweet spot" for NDP treatment.
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Affiliation(s)
- Marie T Krüger
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Division of Neurosurgery, University of British Columbia, Vancouver, Canada.,Department of Stereotactic and Functional Neurosurgery, Freiburg Medical Center, Freiburg, Germany
| | - Josue M Avecillas-Chasin
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada.,Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA
| | - Manraj K S Heran
- Division of Neuroradiology, University of British Columbia, Vancouver, Canada
| | - Yashar Naseri
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Stereotactic and Functional Neurosurgery, Freiburg Medical Center, Freiburg, Germany
| | - Mini K Sandhu
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | | | - Natasha Sarai
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
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Avecillas-Chasin JM, Hurwitz TA, Bogod NM, Honey CR. Tractography-Guided Anterior Capsulotomy for Major Depression and Obsessive-Compulsive Disorder: Targeting the Emotion Network. Oper Neurosurg (Hagerstown) 2021; 20:406-412. [PMID: 33475697 DOI: 10.1093/ons/opaa420] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 10/07/2020] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Bilateral anterior capsulotomy (BAC) is an effective surgical option for patients with treatment-resistant major depression (TRMD) and treatment-resistant obsessive-compulsive disorder (TROCD). The size of the lesion and its precise dorsal-ventral location within the anterior limb of the internal capsule (ALIC) remain undefined. OBJECTIVE To present a method to identify the trajectories of the associative and limbic white matter pathways within the ALIC for targeting in BAC surgery. METHODS Using high-definition tractography, we prospectively tested the feasibility of this method in 2 patients with TRMD and TROCD to tailor the capsulotomy lesion to their limbic pathway. RESULTS The trajectories of the associative and limbic pathways were identified in the ALIC of both patients and we targeted the limbic pathways by defining the dorsal limit of the lesion in a way to minimize the damage to the associative pathways. The final lesions were smaller than those that have been previously published. This individualized procedure was associated with long-term benefit in both patients. CONCLUSION Tractography-guided capsulotomy is feasible and was associated with long-term benefit in patients with TRMD and TROCD.
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Affiliation(s)
| | - Trevor A Hurwitz
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicholas M Bogod
- Neurosciences Program, Vancouver General Hospital, Division of Neurology, UBC Department of Medicine, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Department of Surgery, Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
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Honey CR, Krüger MT, Almeida T, Rammage LA, Tamber MS, Morrison MD, Poologaindran A, Hu A. Thalamic Deep Brain Stimulation for Spasmodic Dysphonia: A Phase I Prospective Randomized Double-Blind Crossover Trial. Neurosurgery 2021; 89:45-52. [PMID: 33862624 PMCID: PMC8223243 DOI: 10.1093/neuros/nyab095] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/24/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Adductor spasmodic dysphonia (SD) is a dystonia of the vocal folds causing difficulty with speech. The current standard of care is repeated botulinum toxin injections to weaken the adductor muscles. We sought to ameliorate the underlying neurological cause of SD with a novel therapy—deep brain stimulation (DBS). OBJECTIVE To assess the safety of DBS in SD through phase I trial, and to quantify the magnitude of any benefit. METHODS Six patients had left ventral intermediate nucleus (Vim) thalamic DBS and were randomized to 3 mo blinded-DBS “on” or “off” followed by a crossover. Primary outcomes were quality of life and quality of voice during the blinded phase. Patients continued with open-DBS “on.” Secondary outcomes were comparisons of pre- and 1-yr cognitive, mood, and quality of life. This trial was registered with ClinicalTrials.gov (NCT02558634). RESULTS There were no complications. Every patient reported an improvement in quality of life (P = .07) and had an improvement in quality of their voice (P = .06) when their blinded DBS was “on” versus “off.” The trend did not reach statistical significance with the small sample size. Secondary outcomes showed no difference in cognition, an improvement in mood, and quality of life at 1 yr. CONCLUSION This phase I randomized controlled trial confirmed that DBS can be performed safely in patients with SD. Blinded DBS produced a strong trend toward improved quality of life and objective quality of voice despite the small sample size. The cerebellar circuit, not the pallidal circuit, appears to be crucial for motor control of the vocal folds.
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Affiliation(s)
| | - Marie T Krüger
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.,Department of Stereotactic and Functional Neurosurgery, University Medical Clinic Freiburg, Freiburg, Germany
| | - Timóteo Almeida
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Linda A Rammage
- Division of Otolaryngology and School of Audiology and Speech Sciences, University of British Columbia, Vancouver, Canada
| | - Mandeep S Tamber
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Murray D Morrison
- Division of Otolaryngology, University of British Columbia, Vancouver, Canada
| | - Anujan Poologaindran
- Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, UK.,The Alan Turing Institute, British Library, London, UK
| | - Amanda Hu
- Division of Otolaryngology, University of British Columbia, Vancouver, Canada
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15
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Krüger MT, Avecillas-Chasin JM, Tamber MS, Heran MKS, Sandhu MK, Polyhronopoulos NE, Sarai N, Honey CR. Tremor and Quality of Life in Patients With Advanced Essential Tremor Before and After Replacing Their Standard Deep Brain Stimulation With a Directional System. Neuromodulation 2020; 24:353-360. [PMID: 33098185 DOI: 10.1111/ner.13301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 09/07/2020] [Accepted: 10/05/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Patients with essential tremor treated with thalamic deep brain stimulation may experience increased tremor with the progression of their disease. Initially, this can be counteracted with increased stimulation. Eventually, this may cause unwanted side-effects as the circumferential stimulation from a standard ring contact spreads into adjacent regions. Directional leads may offer a solution to this clinical problem. We aimed to compare the ability of a standard and a directional system to reduce tremor without side-effects and to improve the quality of life for patients with advanced essential tremor. MATERIALS AND METHODS Six advanced essential tremor patients with bilateral thalamic deep brain stimulation had their standard system replaced with a directional system. Tremor rating scale scores were prospectively evaluated before and after the replacement surgery. Secondary analyses of quality of life related to tremor, voice, and general health were assessed. RESULTS There was a significantly greater reduction in tremor without side-effects (p = 0.017) when using the directional system. There were improvements in tremor (p = 0.031) and voice (p = 0.037) related quality of life but not in general health for patients using optimized stimulation settings with the directional system compared to the standard system. CONCLUSIONS In this cohort of advanced essential tremor patients who no longer had ideal tremor reduction with a standard system, replacing their deep brain stimulation with a directional system significantly improved their tremor and quality of life. Up-front implantation of directional deep brain stimulation leads may provide better tremor control in those patients who progress at a later time point.
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Affiliation(s)
- Marie T Krüger
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada.,Department of Neurosurgery, Cantonal Hospital St.Gallen, St.Gallen, Switzerland.,Department of Stereotactic and Functional Neurosurgery, University Medical Clinic Freiburg, Freiburg, Germany
| | - Josue M Avecillas-Chasin
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada.,Department of Neurosurgery, Cleveland Clinic, Neurological Institute, Cleveland, OH, USA
| | - Mandeep S Tamber
- Department of Surgery, Division of Pediatric Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| | - Manraj K S Heran
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Mini K Sandhu
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| | | | - Natasha Sarai
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| | - Christopher R Honey
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
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Honey CM, Krüger MT, Rheaume AR, Avecillas-Chasin JM, Morrison MD, Honey CR. Concurrent Glossopharyngeal Neuralgia and Hemi-Laryngopharyngeal Spasm (HeLPS): A Case Report and a Review of the Literature. Neurosurgery 2020; 87:E573-E577. [PMID: 31832655 PMCID: PMC8133322 DOI: 10.1093/neuros/nyz546] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/24/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Hemi-laryngopharyngeal spasm (HeLPS) has been recently described but is not yet widely recognized. Patients describe intermittent coughing and choking and can be cured following microvascular decompression of their Xth cranial nerve. This case report and literature review highlight that HeLPS can co-occur with glossopharyngeal neuralgia (GN) and has been previously described (but not recognized) in the neurosurgical literature. CLINICAL PRESENTATION A patient with GN and additional symptoms compatible with HeLPS is presented. The patient reported left-sided, intermittent, swallow-induced, severe electrical pain radiating from her ear to her throat (GN). She also reported intermittent severe coughing, throat contractions causing a sense of suffocation, and dysphonia (HeLPS). All her symptoms resolved following a left microvascular decompression of a loop of the posterior inferior cerebellar artery that was pulsating against both the IXth and Xth cranial nerves. A review of the senior author's database revealed another patient with this combination of symptoms. An international literature review found 27 patients have been previously described with symptoms of GN and the additional (but not recognized at the time) symptoms of HeLPS. CONCLUSION This review highlights that patients with symptoms compatible with HeLPS have been reported since 1926 in at least 4 languages. This additional evidence supports the growing recognition that HeLPS is another neurovascular compression syndrome. Patients with HeLPS continue to be misdiagnosed as conversion disorder. The increased recognition of this new medical condition will require neurosurgical treatment and should alleviate the suffering of these patients.
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Affiliation(s)
- C Michael Honey
- Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marie T Krüger
- Division of Neurosurgery, University of British Columbia, Vancouver, Canada
| | - Alan R Rheaume
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | | | - Murray D Morrison
- Division of Otolaryngology, University of British Columbia, Vancouver, Canada
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Avecillas-Chasin JM, Honey CR. In Reply: Modulation of Nigrofugal and Pallidofugal Pathways in Deep Brain Stimulation for Parkinson Disease. Neurosurgery 2020; 87:E423-E424. [PMID: 32497216 DOI: 10.1093/neuros/nyaa229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Christopher R Honey
- Department of Surgery Division of Neurosurgery University of British Columbia Vancouver, BC, Canada
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Abstract
OBJECTIVE Hemi-laryngopharyngeal spasm (HeLPS) has recently been described in the neurosurgical literature as a cause of intermittent laryngopharyngeal spasm and cough due to vascular compression of the vagus nerve at the cerebellopontine angle. We present the diagnostic criteria for this syndrome. METHODS A retrospective chart review of six patients with HeLPS and three patients misdiagnosed with this condition are presented. All patients were diagnosed and treated at a tertiary care academic centre from July 2013 to July 2017. RESULTS Patients with HeLPS had five defining characteristics: 1) All patients had symptoms of episodic laryngopharyngeal spasm and coughing. Patients were asymptomatic between episodes and were refractory to speech therapy and reflux management. 2) Laryngoscopy showed hyperactive twitching of the ipsilateral vocal fold in two of the six patients. No other inter-episodic abnormalities were seen. 3) Botulinum toxin A injections into the thyroarytenoid muscle on the affected ipsilateral side reduced laryngopharyngeal spasms. Botulinum toxin injection in the contralateral thyroarytenoid muscle did not improve laryngopharyngeal spasm. 4) Magnetic resonance imaging revealed ipsilateral neurovascular compression of the vagus nerve rootlets by the posterior inferior cerebellar artery. 5) Microvascular decompression (MVD) surgery of the ipsilateral vagus nerve resolved all symptoms (follow-up 2-4 years). CONCLUSION The diagnostic criteria for hemi-laryngopharyngeal spasm (HeLPS) are proposed. Otolaryngology recognition of this new clinical entity may lead to a surgical cure and avoid the unnecessary therapies associated with misdiagnosis. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Amanda Hu
- Department of Surgery, Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Murray Morrison
- Department of Surgery, Division of Otolaryngology - Head & Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Christopher R Honey
- Department of Surgery, Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
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Krüger MT, Hu A, Honey CR. Deep Brain Stimulation for Spasmodic Dysphonia: A Blinded Comparison of Unilateral and Bilateral Stimulation in Two Patients. Stereotact Funct Neurosurg 2020; 98:200-205. [PMID: 32316007 DOI: 10.1159/000507058] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 03/06/2020] [Indexed: 11/19/2022]
Abstract
Deep brain stimulation (DBS) is a promising new therapy for patients with spasmodic dysphonia (SD). The preliminary results from our randomized controlled trial showed good clinical effects with unilateral left thalamic stimulation in 6 right- handed patients. This suggests that the pathological process underpinning SD may have a "hemisphere dominant" pathway. We describe 2 patients with concurrent essential tremor and SD who had previously undergone bilateral thalamic DBS for their limb tremor. Both patients experienced an unanticipated improvement of their SD symptoms. One patient was right-handed, and the other was mixed left-handed. To investigate the amount of SD improvement following DBS therapy in each hemisphere, 4 different settings were tested: both sides on, left side on, right side on, and both sides off. Both patients most improved following bilateral stimulation. There was, however, a powerful unilateral benefit in both patients with only a small additional benefit from bilateral stimulation. The right-handed patient improved most with left-hemisphere stimulation whereas the mixed left-handed patient improved most with right hemisphere stimulation. There was some discrepancy between the two tests applied in the second patient reflecting the known difficulties to evaluate vocal symptom improvement in SD. We discuss the possible correlation of handedness and speech hemisphere dominance as well as the need for more reliable tests to measure SD severity. Ultimately, we recommend a bilateral approach for future studies, using a patient perception test as the primary outcome and functional imaging to further investigate the correlation of handedness and the amount of hemisphere dominance in SD.
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Affiliation(s)
- Marie T Krüger
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada, .,Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland, .,Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany,
| | - Amanda Hu
- Division of Otolaryngology, Head and Neck Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
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20
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Avecillas-Chasin JM, Honey CR. Modulation of Nigrofugal and Pallidofugal Pathways in Deep Brain Stimulation for Parkinson Disease. Neurosurgery 2020; 86:E387-E397. [PMID: 31832650 DOI: 10.1093/neuros/nyz544] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 10/13/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a well-established surgical therapy for patients with Parkinson disease (PD). OBJECTIVE To define the role of adjacent white matter stimulation in the effectiveness of STN-DBS. METHODS We retrospectively evaluated 43 patients with PD who received bilateral STN-DBS. The volumes of activated tissue were analyzed to obtain significant stimulation clusters predictive of 4 clinical outcomes: improvements in bradykinesia, rigidity, tremor, and reduction of dopaminergic medication. Tractography of the nigrofugal and pallidofugal pathways was performed. The significant clusters were used to calculate the involvement of the nigrofugal and pallidofugal pathways and the STN. RESULTS The clusters predictive of rigidity and tremor improvement were dorsal to the STN with most of the clusters outside of the STN. These clusters preferentially involved the pallidofugal pathways. The cluster predictive of bradykinesia improvement was located in the central part of the STN with an extension outside of the STN. The cluster predictive of dopaminergic medication reduction was located ventrolateral and caudal to the STN. These clusters preferentially involved the nigrofugal pathways. CONCLUSION Improvements in rigidity and tremor mainly involved the pallidofugal pathways dorsal to the STN. Improvement in bradykinesia mainly involved the central part of the STN and the nigrofugal pathways ventrolateral to the STN. Maximal reduction in dopaminergic medication following STN-DBS was associated with an exclusive involvement of the nigrofugal pathways.
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Affiliation(s)
| | - Christopher R Honey
- Department of Surgery, Division of Neurosurgery, University of British Columbia, Vancouver, Canada
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Hurwitz TA, Honey CR, McLeod KR, Poologaindran A, Kuan AJ. Hypoactivity in the Paraterminal Gyrus Following Bilateral Anterior Capsulotomy. Can J Psychiatry 2020; 65:46-55. [PMID: 31518505 PMCID: PMC6966241 DOI: 10.1177/0706743719874181] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Bilateral anterior capsulotomy (BAC) is one of the ablative neurosurgical procedures used to treat major depressive disorder or obsessive-compulsive disorder when all other therapies fail. Tristolysis, a reduction in sadness, is the most striking clinical effect of BAC and is seen in the first 1 to 2 weeks after surgery. This retrospective study measured regional cerebral blood flow (rCBF) following surgery to identify which cortical regions were impacted and could account for this clinical effect. METHODS All patients had their capsulotomies done in Vancouver by the same team. Pre- and postoperative single-photon emission computed tomography perfusion scans were analyzed for 10 patients with major depressive disorder and 3 with obsessive-compulsive disorder. rCBF was measured semiquantitatively by calculating the ratio between an identified region of interest and a whole brain reference area. RESULTS Decreased rCBF was found in the paraterminal gyri. Increased rCBF was found in the dorsolateral prefrontal cortices and in the left lateral temporal lobe. CONCLUSIONS BAC causes hypoactivity in the paraterminal gyri and is the most likely explanation for its tristolytic effect, suggesting that the paraterminal gyrus is the limbic cortical locus for the emotion of sadness. Increased activity in the dorsolateral prefrontal cortices may be occurring via connectional diaschisis, and suppression by overactive paraterminal gyri during depression may account for some of the neurocognitive deficits observed during depressive episodes.
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Affiliation(s)
- Trevor A Hurwitz
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kevin R McLeod
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anujan Poologaindran
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada.,Brain Mapping Unit, Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom.,The Alan Turing Institute, British Library, London, United Kingdom
| | - Annie J Kuan
- Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada
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Honey CR, Krüger MT, Morrison MD, Dhaliwal BS, Hu A. Vagus Associated Neurogenic Cough Occurring Due to Unilateral Vascular Encroachment of Its Root: A Case Report and Proof of Concept of VANCOUVER Syndrome. Ann Otol Rhinol Laryngol 2019; 129:523-527. [PMID: 31786948 DOI: 10.1177/0003489419892287] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES A patient is presented with neurogenic cough due to a unilateral vascular compression of a vagus nerve rootlet at the brainstem with complete resolution of cough following microvascular decompression of that nerve. This etiology of a neurogenic cough has not been previously reported to our knowledge. The proportion of patients with neurogenic cough refractory to all current therapies and suffering with this treatable condition remains to be defined. We introduce the concept of Vagus Associated Neurogenic Cough Occurring due to Unilateral Vascular Encroachment of its Root (VANCOUVER syndrome) and present the salient features of this condition. METHODS A case review is presented with details of the patient's history, examination, imaging, laryngoscopy, intraoperative findings, and long-term clinical outcome. RESULTS A 60-year-old man presented with a 15-year history of non-productive cough refractory to antibiotics, and anti-reflux medications. Investigations by an allergist, a cardiologist, a gastroenterologist, two pulmonologists, and an otolaryngologist were negative. MRI demonstrated a vascular compression of his left vagus nerve and microvascular decompression of that nerve resolved his symptoms. There were no surgical complications and the patient remains asymptomatic at 1 year. CONCLUSIONS Neurogenic cough has been likened to a vagus nerve neuropathy in a similar way that trigeminal neuralgia is a trigeminal nerve neuropathy. Both cause intermittent sensory phenomena in their distribution and can be ameliorated with neuropathic medications. We demonstrate that neurogenic cough, like trigeminal neuralgia, may be caused by a vascular compression of its nerve root. A proposed mechanism of this type of neurogenic cough is presented along with a potential diagnostic paradigm for these patients.
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Affiliation(s)
- Christopher R Honey
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Marie T Krüger
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Murray D Morrison
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Baljinder S Dhaliwal
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Amanda Hu
- Division of Otolaryngology, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
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23
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Krüger MT, Hirmer TJ, Honey CR. Coughing as a Side Effect of Deep Brain Stimulation due to Peripheral Stimulation of the Vagus Nerve: Case Report. Stereotact Funct Neurosurg 2019; 97:207-211. [PMID: 31600763 DOI: 10.1159/000503364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 09/13/2019] [Indexed: 11/19/2022]
Abstract
The authors describe how severe coughing and breathing issues were caused by a deep brain stimulation (DBS) system due to current induction in the adjacent vagus nerve. A 57-year-old man with Parkinson's disease (PD) who received bilateral subthalamic nucleus DBS presented with coughing and breathing difficulty when his DBS system was activated. The intensity of coughing was directly related to the amount of stimulation. When the DBS system was turned off, his cough resolved immediately. A system check revealed no radiographic abnormalities and all electrode impedances were within the normal range. We hypothesize that the coughing was caused by an induced electromagnetic stimulation of the vagus nerve from the extensions, which were running in close proximity to the nerve in the neck. Since the patient could not tolerate the coughing at stimulation settings required to ameliorate his PD symptoms, we ultimately exchanged the extensions and moved them further away from the vagus nerve. This resulted in immediate, complete, and continuous relief of the patient's symptoms.
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Affiliation(s)
- Marie T Krüger
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada,
| | - Thomas J Hirmer
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
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Honey CM, Ivanishvili Z, Honey CR, Heran MKS. Somatotopic organization of the human spinothalamic tract: in vivo computed tomography-guided mapping in awake patients undergoing cordotomy. J Neurosurg Spine 2019; 30:722-728. [PMID: 30771779 DOI: 10.3171/2018.11.spine18172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 11/02/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The location of the human spinothalamic tract (STT) in the anterolateral spinal cord has been known for more than a century. The exact nature of the neuronal fiber lamination within the STT, however, remains controversial. After correlating in vivo macrostimulation-induced pain/temperature sensation during percutaneous cervical cordotomy with simultaneous CT imaging of the electrode tip location, the authors present a modern description of the somatotopy of the human cervical STT. METHODS Twenty patients underwent CT-guided percutaneous cervical cordotomy to alleviate contralateral medication-refractory cancer pain. Patient responses to electrical stimulation (0.01-0.1 V, 50 Hz, 1 msec) were recorded and the electrode location for each response was documented with a contemporaneous CT scan. In a post hoc analysis of the data, the location for each patient's response(s) was measured and drawn on a diagram of their cord. Positive responses were represented only when the lowest possible voltage (≤ 0.02 V) elicited a response. Negative responses were recorded if there was no clinical response at 0.1 V. RESULTS Clinically, patients did well with an average reduction in opiates of 75% at 1 week, and 67% were able to leave the palliative care unit. The size of the cervical cord varied between patients, with an average lateral extent (width) of 11 mm and a height of 9 mm. Responses from the lower limb were represented superficially (lateral) and posteriorly within the anterolateral cord. The area with responses from the upper limb was larger and surrounded those with responses from the lower limb primarily anteriorly and medially, but also posteriorly. CONCLUSIONS In this study, the somatotopic organization of the human STT was elucidated for the first time using in vivo macrostimulation and contemporaneous CT imaging during cordotomy. In this cohort of patients, the STT from the lower-limb region was located superficially and posteriorly in the anterolateral quadrant of the cervical cord, with the STT from the upper-limb region surrounding it primarily anteriorly and medially (deep) but also posteriorly. The authors discuss how the previous methods of cordotomy may have biased the earlier versions of STT lamination. They suggest that an ideal spinal cord entry site for cordotomy of either the upper- or lower-limb pain fibers is halfway between the equator and anterior pole of the cord.
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Affiliation(s)
- C Michael Honey
- 1Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba
| | - Zurab Ivanishvili
- 2Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia; and
| | - Christopher R Honey
- 2Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia; and
| | - Manraj K S Heran
- 3Department of Radiology, University of British Columbia, Vancouver, British Columbia, Canada
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Avecillas-Chasin JM, Poologaindran A, Morrison MD, Rammage LA, Honey CR. Unilateral Thalamic Deep Brain Stimulation for Voice Tremor. Stereotact Funct Neurosurg 2019; 96:392-399. [PMID: 30625492 DOI: 10.1159/000495413] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 11/13/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Voice tremor (VT) is the involuntary and rhythmical phonatory instability of the voice. Recent findings suggest that unilateral deep brain stimulation of the ventral intermediate nucleus (Vim-DBS) can sometimes be effective for VT. In this exploratory analysis, we investigated the effect of Vim-DBS on VT and tested the hypothesis that unilateral thalamic stimulation is effective for patients with VT. METHODS Seven patients with VT and previously implanted bilateral Vim-DBS were enrolled in the study. Each patient was randomized and recorded performing sustained phonation during the following conditions: left thalamic stimulation, right thalamic stimulation, bilateral thalamic stimulation (Bil-ON), and no stimulation (Bil-OFF). Perceptual VT ratings and an acoustic analysis to find the rate of variation of the fundamental frequency measured by the standard deviation of the pitch (f0SD) were performed in a blinded manner. For the purposes of this study, a "dominant" side was defined as one with more than twice as much reduction in VT following Vim-DBS compared to the contralateral side. The Wilcoxon signed-rank test was performed to compare the effect of the dominant side stimulation in the reduction of VT scores and f0SD. The volume of activated tissue (VAT) of the dominant stimulation side was modelled against the degree of improvement in VT to correlate the significant stimulation cluster with thalamic anatomy. Finally, tractography analysis was performed to analyze the connectivity of the significant stimulation cluster. RESULTS Unilateral stimulation was beneficial in all 7 patients. Five patients clearly had a "dominant" side with either benefit only seen following stimulation of one side or more than twice as much benefit from one side compared to the other. Two patients had similar benefit with unilateral stimulation from either side. The Wilcoxon paired test showed significant differences between unilateral dominant and unilateral nondominant stimulation for VT scores (p = 0.04), between unilateral dominant and Bil-OFF (p = 0.04), and between Bil-ON and unilateral nondominant stimulation (p = 0.04). No significant differences were found between Bil-ON and unilateral dominant condition (p = 0.27), or between Bil-OFF and unilateral nondominant (p = 0.23). The dominant VAT showed that the significant voxels associated with the best VT control were located in the most ventral and medial part of the Vim nucleus and the ventralis caudalis anterior internus nucleus. The connectivity analysis showed significant connectivity with the cortical areas of the speech circuit. CONCLUSIONS Unilateral dominant-side thalamic stimulation and bilateral thalamic stimulation were equally effective in reducing VT. Nondominant unilateral stimulation alone did not significantly improve VT.
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Affiliation(s)
- Josue M Avecillas-Chasin
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Anujan Poologaindran
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Murray D Morrison
- Department of Surgery, Division of Otolaryngology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Linda A Rammage
- Department of Surgery, Division of Otolaryngology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R Honey
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada,
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Avecillas-Chasin J, Kozoriz MG, Shewchuk JR, Heran MKS, Honey CR. Imaging and Surgical Findings in Patients with Hemi-Laryngopharyngeal Spasm and the Potential Role of MRI in the Diagnostic Work-Up. AJNR Am J Neuroradiol 2018; 39:2366-2370. [PMID: 30361431 DOI: 10.3174/ajnr.a5851] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 09/04/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Hemi-laryngopharyngeal spasm is a recently discovered condition characterized by episodic coughing and unilateral throat contractions that may lead to severe stridor. These symptoms are caused by a vascular compression of the ipsilateral vagus nerve, typically the PICA. Microvascular decompression of the vagus nerve has been demonstrated to be a potential cure for this neurovascular compression syndrome. The main aim of this study was to clarify the role of MR imaging in the diagnostic work-up of this rare condition. MATERIALS AND METHODS We describe the imaging and surgical findings of 3 patients from our prospective case series of patients with hemi-laryngopharyngeal spasm from 2015 to 2017. Second, the imaging data of 100 patients (control cohort) with symptoms unrelated to hemi-laryngopharyngeal spasm were reviewed to investigate the rate and degree of neurovascular conflict of the vagus nerve. RESULTS All patients with hemi-laryngopharyngeal spasm reported to date have had vascular compression of the vagus nerve due to the PICA. In the control cohort, there was a good interrater agreement in scoring the "contact" and "compression" of the vagus nerve (κ = 0.73. P = < .001). The frequency of contact or compression of the vagus nerve was approximately 50%. The PICA was the most frequent vessel involved in 74%. CONCLUSIONS The presence of unilateral neurovascular contact or compression of the vagus nerve does not confirm the diagnosis of hemi-laryngopharyngeal spasm. The MR imaging finding of ipsilateral vascular compression of the vagus nerve is a necessary but not sufficient finding for the diagnosis of hemi-laryngopharyngeal spasm.
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Affiliation(s)
- J Avecillas-Chasin
- From the Department of Surgery (J.A.-C., C.R.H.), Division of Neurosurgery
| | - M G Kozoriz
- Department of Radiology (M.G.K., J.R.S., M.K.S.H.), University of British Columbia, Vancouver, British Columbia, Canada
| | - J R Shewchuk
- Department of Radiology (M.G.K., J.R.S., M.K.S.H.), University of British Columbia, Vancouver, British Columbia, Canada
| | - M K S Heran
- Department of Radiology (M.G.K., J.R.S., M.K.S.H.), University of British Columbia, Vancouver, British Columbia, Canada
| | - C R Honey
- From the Department of Surgery (J.A.-C., C.R.H.), Division of Neurosurgery .,Vancouver General Hospital (C.R.H.), Vancouver, British Columbia, Canada
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Honey CR, Morrison MD, Heran MKS, Dhaliwal BS. Hemi-laryngopharyngeal spasm as a novel cause of inducible laryngeal obstruction with a surgical cure: report of 3 cases. J Neurosurg 2018; 130:1865-1869. [PMID: 30028264 DOI: 10.3171/2018.2.jns172952] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/08/2018] [Indexed: 11/06/2022]
Abstract
Inducible laryngeal obstruction has been described under at least 40 different monikers, including vocal cord dysfunction, paroxysmal vocal fold motion, and irritable larynx. The etiology of this condition is believed to be laryngeal hyperactivity in response to psychological issues or acid reflux. Most patients are treated with some combination of proton pump inhibitors, speech therapy, and psychotherapy. However, a small cohort of patients remains refractory to all medical interventions. The authors describe a novel condition, hemi-laryngopharyngeal spasm (HELPS), which can cause severe episodic stridor leading to unconsciousness in association with cough. The first recognized and surgically cured patient with HELPS was reported in an earlier issue of this journal. Three additional patients have been followed up for at least a year postoperatively, and their cases are reported here.Each patient presented with a similar pattern of episodic coughing and choking that increased in frequency, severity, and duration over years. The episodes eventually occurred while sleeping and could cause severe stridor with loss of consciousness. All three patients were initially misdiagnosed with a psychiatric illness and subjected to multiple intubations and one tracheostomy. Unilateral botulinum toxin injections in the vocal fold eased the severity of the throat contractions but not the cough. Magnetic resonance imaging showed a looping posterior inferior cerebellar artery juxtaposed to a vagus nerve in each case. Microvascular decompression (MVD) of that vessel relieved all symptoms.The introduction of this new medical condition may help a small cohort of patients with inducible laryngeal obstructions that have not responded to the current standard treatments. Patients are asymptomatic between episodes of progressively severe coughing and choking with stridor that may lead to intubation. Severe anxiety about the unpredictable symptoms is expected and may contribute to a psychiatric misdiagnosis. Microvascular decompression for HELPS is more difficult than that for trigeminal neuralgia because the involved nerve is more susceptible to manipulation. Ultimately, the final proof that HELPS is a real and distinct syndrome will require its recognition and successful treatment by colleagues around the world.
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Affiliation(s)
| | | | | | - Baljinder S Dhaliwal
- 4Anesthesiology, Pharmacology and Therapeutics at the University of British Columbia, Vancouver, British Columbia, Canada
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Holtzheimer PE, Husain MM, Lisanby SH, Taylor SF, Whitworth LA, McClintock S, Slavin KV, Berman J, McKhann GM, Patil PG, Rittberg BR, Abosch A, Pandurangi AK, Holloway KL, Lam RW, Honey CR, Neimat JS, Henderson JM, DeBattista C, Rothschild AJ, Pilitsis JG, Espinoza RT, Petrides G, Mogilner AY, Matthews K, Peichel D, Gross RE, Hamani C, Lozano AM, Mayberg HS. Subcallosal cingulate deep brain stimulation for treatment-resistant depression: a multisite, randomised, sham-controlled trial. Lancet Psychiatry 2017; 4:839-849. [PMID: 28988904 DOI: 10.1016/s2215-0366(17)30371-1] [Citation(s) in RCA: 290] [Impact Index Per Article: 41.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/05/2017] [Accepted: 08/21/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subcallosal cingulate white matter has shown promise as an intervention for patients with chronic, unremitting depression. To test the safety and efficacy of DBS for treatment-resistant depression, a prospective, randomised, sham-controlled trial was conducted. METHODS Participants with treatment-resistant depression were implanted with a DBS system targeting bilateral subcallosal cingulate white matter and randomised to 6 months of active or sham DBS, followed by 6 months of open-label subcallosal cingulate DBS. Randomisation was computer generated with a block size of three at each site before the site started the study. The primary outcome was frequency of response (defined as a 40% or greater reduction in depression severity from baseline) averaged over months 4-6 of the double-blind phase. A futility analysis was performed when approximately half of the proposed sample received DBS implantation and completed the double-blind phase. At the conclusion of the 12-month study, a subset of patients were followed up for up to 24 months. The study is registered at ClinicalTrials.gov, number NCT00617162. FINDINGS Before the futility analysis, 90 participants were randomly assigned to active (n=60) or sham (n=30) stimulation between April 10, 2008, and Nov 21, 2012. Both groups showed improvement, but there was no statistically significant difference in response during the double-blind, sham-controlled phase (12 [20%] patients in the stimulation group vs five [17%] patients in the control group). 28 patients experienced 40 serious adverse events; eight of these (in seven patients) were deemed to be related to the study device or surgery. INTERPRETATION This study confirmed the safety and feasibility of subcallosal cingulate DBS as a treatment for treatment-resistant depression but did not show statistically significant antidepressant efficacy in a 6-month double-blind, sham-controlled trial. Future studies are needed to investigate factors such as clinical features or electrode placement that might improve efficacy. FUNDING Abbott (previously St Jude Medical).
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Affiliation(s)
- Paul E Holtzheimer
- Department of Psychiatry and Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| | - Mustafa M Husain
- Department of Psychiatry, Neurology and Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA; Department of Psychiatry and Behavioral Science, Duke University School of Medicine, Durham, NC, USA
| | | | - Stephan F Taylor
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Louis A Whitworth
- Neurological Surgery, Radiation Oncology, Department of Neurological Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Shawn McClintock
- Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA; Department of Psychiatry and Behavioral Science, Duke University School of Medicine, Durham, NC, USA
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Joshua Berman
- Department of Psychiatry, Division of Experimental Therapeutics, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Guy M McKhann
- Department of Neurosurgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - Parag G Patil
- Department of Neurosurgery, Neurology, Anesthesiology and Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Barry R Rittberg
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA
| | - Aviva Abosch
- Department of Neurosurgery and Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Ananda K Pandurangi
- Department of Psychiatry, Virginia Commonwealth University, Richmond, VA, USA
| | - Kathryn L Holloway
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Raymond W Lam
- Department of Psychiatry, University of British Columbia, Vancouver, BC, Canada
| | - Christopher R Honey
- Department of Surgery (Neurosurgery), University of British Columbia, Vancouver, BC, Canada
| | - Joseph S Neimat
- Department of Neurological Surgery, University of Louisville, Louisville, KY, USA
| | - Jaimie M Henderson
- Stanford Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Charles DeBattista
- Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, USA
| | - Anthony J Rothschild
- Department of Psychiatry, University of Massachusetts Medical School and UMass Memorial HealthCare, Worcester, MA, USA
| | - Julie G Pilitsis
- Department of Neuroscience and Experimental Therapeutics and the Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Randall T Espinoza
- Department of Psychiatry and Biobehavioral Sciences, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Georgios Petrides
- The Zucker Hillside Hospital, Northwell Health System, Glen Oaks, NY, USA; Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | - Alon Y Mogilner
- Department of Neurosurgery, Center for Neuromodulation, NYU Langone Medical Center, New York, NY, USA
| | - Keith Matthews
- Division of Neuroscience, School of Medicine, University of Dundee, Dundee, UK; Advanced Interventions Service, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - DeLea Peichel
- Clinical Studies Department, Abbott (previously St Jude Medical), Plano, TX, USA
| | - Robert E Gross
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Clement Hamani
- Behavioural Neurobiology Laboratory, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health and Division of Neurosurgery, Toronto Western Hospital, Toronto, ON, Canada
| | - Andres M Lozano
- Department of Neurosurgery and Neuroscience, Toronto Western Hospital, Toronto, ON, Canada
| | - Helen S Mayberg
- Department of Psychiatry and Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Ivanishvili Z, Poologaindran A, Honey CR. Cyclization of Motor Cortex Stimulation for Neuropathic Pain: A Prospective, Randomized, Blinded Trial. Neuromodulation 2017; 20:497-503. [PMID: 28524457 DOI: 10.1111/ner.12610] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 03/10/2017] [Accepted: 04/05/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Programming guidelines for motor cortex stimulation (MCS) in neuropathic pain requires further investigation. After optimizing voltage as a percentage of motor threshold, we evaluated the effect of cyclizing time of stimulation on pain relief for chronic neuropathic pain. METHODS Six patients were enrolled into this trial. In a prospective, randomized, double-blinded manner, patients were programmed to receive stimulation 100, 83.3, 66.7, or 50% of the time in 30-min intervals. Outcomes were assessed after 14 days on each setting with a visual analogue scale (VAS) for pain and the SF36 quality of life questionnaire. RESULTS There was no significant difference (p > 0.05) between the different cyclized settings as measured by the VAS, MGPQ, or SF36 in our cohort. There were two distinct subgroups: responders (n = 4) and nonresponders (n = 2) to cyclization. Responders continued to have pain relief when stimulation was reduced to only 50% of the time (15 min ON/15 min off). Interestingly, this group subjectively preferred the 50% stimulation timing compared to 100%. Nonresponders could not tolerate cyclizing because of increased pain. CONCLUSIONS In this small cohort, cyclization of MCS settings revealed two distinct subgroups: responders and nonresponders. Responders tolerated stimulation in all settings and 50% stimulation (15 min ON/15 min off) was their subjectively preferred setting. Cyclization in responders will prolong battery life and delay the need for INS replacement and may offer improved pain relief. Building from our previous work, we recommend clinicians consider following the Vancouver MCS programming algorithm presented in this manuscript.
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Affiliation(s)
- Zurab Ivanishvili
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, Canada
| | - Anujan Poologaindran
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, Canada
| | - Christopher R Honey
- Department of Surgery, Division of Neurosurgery, The University of British Columbia, Vancouver, Canada
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Honey CR, Gooderham P, Morrison M, Ivanishvili Z. Episodic hemilaryngopharyngeal spasm (HELPS) syndrome: case report of a surgically treatable novel neuropathy. J Neurosurg 2017; 126:1653-1656. [DOI: 10.3171/2016.5.jns16308] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe a novel cranial neuropathy manifesting with life-threatening episodic hemilaryngopharyngeal spasm (HELPS). A 50-year-old woman presented with a 4-year history of intermittent throat contractions, escalating to life-threatening respiratory distress. Botulinum toxin injections into her right vocal cord reduced the severity of her spasms, but the episodes continued to occur. MRI demonstrated a possible neurovascular conflict involving the cranial nerve IX–X complex and the posterior inferior cerebellar artery. Microvascular decompression of the upper rootlets of the vagal nerve eliminated her HELPS without complication. The authors propose a mechanism of HELPS implicating isolated involvement of the upper motor rootlets of the vagus nerve.
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Affiliation(s)
| | | | - Murray Morrison
- 2Otolaryngology, University of British Columbia, Vancouver, British Columbia, Canada
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Poologaindran A, Ivanishvili Z, Morrison MD, Rammage LA, Sandhu MK, Polyhronopoulos NE, Honey CR. The effect of unilateral thalamic deep brain stimulation on the vocal dysfunction in a patient with spasmodic dysphonia: interrogating cerebellar and pallidal neural circuits. J Neurosurg 2017; 128:575-582. [PMID: 28304188 DOI: 10.3171/2016.10.jns161025] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Spasmodic dysphonia (SD) is a neurological disorder of the voice where a patient's ability to speak is compromised due to involuntary contractions of the intrinsic laryngeal muscles. Since the 1980s, SD has been treated with botulinum toxin A (BTX) injections into the throat. This therapy is limited by the delayed-onset of benefits, wearing-off effects, and repeated injections required every 3 months. In a patient with essential tremor (ET) and coincident SD, the authors set out to quantify the effects of thalamic deep brain stimulation (DBS) on vocal function while investigating the underlying motor thalamic circuitry. A 79-year-old right-handed woman with ET and coincident adductor SD was referred to our neurosurgical team. While primarily treating her limb tremor, the authors studied the effects of unilateral, thalamic DBS on vocal function using the Unified Spasmodic Dysphonia Rating Scale (USDRS) and voice-related quality of life (VRQOL). Since dystonia is increasingly being considered a multinodal network disorder, an anterior trajectory into the left thalamus was deliberately chosen such that the proximal contacts of the electrode were in the ventral oralis anterior (Voa) nucleus (pallidal outflow) and the distal contacts were in the ventral intermediate (Vim) nucleus (cerebellar outflow). In addition to assessing on/off unilateral thalamic Vim stimulation on voice, the authors experimentally assessed low-voltage unilateral Vim, Voa, or multitarget stimulation in a prospective, randomized, doubled-blinded manner. The evaluators were experienced at rating SD and were familiar with the vocal tremor of ET. A Wilcoxon signed-rank test was used to study the pre- and posttreatment effect of DBS on voice. Unilateral left thalamic Vim stimulation (DBS on) significantly improved SD vocal dysfunction compared with no stimulation (DBS off), as measured by the USDRS (p < 0.01) and VRQOL (p < 0.01). In the experimental interrogation, both low-voltage Vim (p < 0.01) and multitarget Vim + Voa (p < 0.01) stimulation were significantly superior to low-voltage Voa stimulation. For the first time, the effects of high-frequency stimulation of different neural circuits in SD have been quantified. Unexpectedly, focused Voa (pallidal outflow) stimulation was inferior to Vim (cerebellar outflow) stimulation despite the classification of SD as a dystonia. While only a single case, scattered reports exist on the positive effects of thalamic DBS on dysphonia. A Phase 1 pilot trial (DEBUSSY; clinical trial no. NCT02558634, clinicaltrials.gov) is underway at the authors' center to evaluate the safety and preliminary efficacy of DBS in SD. The authors hope that this current report stimulates neurosurgeons to investigate this new indication for DBS.
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Affiliation(s)
| | | | - Murray D Morrison
- 2Otolaryngology, The University of British Columbia, Vancouver, British Columbia,Canada
| | - Linda A Rammage
- 2Otolaryngology, The University of British Columbia, Vancouver, British Columbia,Canada
| | - Mini K Sandhu
- Department of Surgery, Divisions of1Neurosurgery and
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Coenen VA, Jenkner C, Honey CR, Mädler B. Electrophysiologic Validation of Diffusion Tensor Imaging Tractography during Deep Brain Stimulation Surgery. AJNR Am J Neuroradiol 2016; 37:1470-8. [PMID: 27032969 DOI: 10.3174/ajnr.a4753] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 01/22/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND PURPOSE Diffusion tensor imaging fiber tractography-assisted planning of deep brain stimulation is an emerging technology. We investigated its accuracy by using electrophysiology under clinical conditions. We hypothesized that a level of concordance between electrophysiology and DTI fiber tractography can be reached, comparable with published modeling approaches for deep brain stimulation surgery. MATERIALS AND METHODS Eleven patients underwent subthalamic nucleus deep brain stimulation. DTI scans and high-resolution T1- and T2-weighted MR imaging was performed at 3T. Corticospinal tracts were traced. We studied electrode positions and current amplitudes that elicited corticospinal tract effects during the operation to determine relative corticospinal tract distance. Postoperatively, 3D deep brain stimulation electrode contact locations and stimulation patterns were applied for the same corticospinal tract distance estimation. RESULTS Intraoperative electrophysiologic (n = 40) clinical effects in 11 patients were detected. The mean intraoperative electrophysiologic corticospinal tract distance was 3.0 ± 0.6 mm; the mean image-derived corticospinal tract distance (DTI fiber tractography) was 3.0 ± 1.3 mm. The 95% limits of agreement were ±2.4 mm. Postoperative electrophysiology (n = 44) corticospinal tract activation effects were encountered in 9 patients; 39 were further evaluated. Mean electrophysiologic corticospinal tract distance was 3.7 ± 0.7 mm; for DTI fiber tractography, it was 3.2 ± 1.9 mm. The 95% limits of agreement were ±2.5 mm. CONCLUSIONS DTI fiber tractography depicted the medial corticospinal tract border with proved concordance. Although the overall range of measurements was relatively small and variance was high, we believe that further use of DTI fiber tractography to assist deep brain stimulation procedures is advisable if inherent limitations are respected. These results confirm our previously published electric field simulation studies.
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Affiliation(s)
- V A Coenen
- From the Department of Stereotactic and Functional Neurosurgery (V.A.C., B.M.)
| | - C Jenkner
- the Clinical Trial Unit (C.J.), Freiburg University Medical Center, Freiburg, Germany
| | - C R Honey
- Surgical Center for Movement Disorders/Division of Neurosurgery (C.R.H.)
| | - B Mädler
- From the Department of Stereotactic and Functional Neurosurgery (V.A.C., B.M.) Department of Physics and Astronomy (B.M.), University of British Columbia, Vancouver, British Columbia, Canada Philips Healthcare (B.M.), Hamburg, Germany
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Honey CM, Tronnier VM, Honey CR. Deep brain stimulation versus motor cortex stimulation for neuropathic pain: A minireview of the literature and proposal for future research. Comput Struct Biotechnol J 2016; 14:234-7. [PMID: 27413477 PMCID: PMC4925438 DOI: 10.1016/j.csbj.2016.06.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/10/2016] [Accepted: 06/13/2016] [Indexed: 11/24/2022] Open
Abstract
The treatment of neuropathic pain remains a public health concern. A growing cohort of patients is plagued by medically refractory, unrelenting severe neuropathic pain that ruins their quality of life and productivity. For this group, neurosurgery can offer two different kinds of neuromodulation that may help: deep brain simulation (DBS) and motor cortex stimulation (MCS). Unfortunately, there is no consensus on how to perform these procedures, which stimulation parameters to select, how to measure success, and which patients may benefit. This brief review highlights the literature supporting each technique and attempts to provide some comparisons and contrasts between DBS and MCS for the treatment of neuropathic pain. Finally, we highlight the current unanswered questions in the field and suggest future research strategies that may advance the care of our patients with neuropathic pain.
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Affiliation(s)
- C. Michael Honey
- Section of Neurosurgery, University of Manitoba, Winnipeg, Canada
| | - Volker M. Tronnier
- Department of Neurosurgery, Medical Faculty Lübeck, University Hospital of Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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Ivanishvili Z, Pujara S, Honey CM, Chang S, Honey CR. Stereotactic mesencephalotomy for palliative care pain control: A case report, literature review and plea to rediscover this operation. Br J Neurosurg 2016; 30:444-7. [PMID: 26760110 DOI: 10.3109/02688697.2015.1133805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Introduction Stereotactic mesencephalotomy is an ablative procedure which lesions the pain pathways (spinothalamic and trigeminothalamic tracts) at the midbrain level to treat medically refractory, nociceptive, contralateral pain. Sparsely reported in contemporary English language literature, this operation is at risk of being lost from the modern-day neurosurgical practice. Methods We present a case report and brief review of the literature on stereotactic mesencephalotomy. A 17-year-old girl with cervical cord glioblastoma and medically refractory unilateral head and neck pain was treated with contralateral stereotactic mesencephalotomy. The lesion was placed at the level of the inferior colliculus, half way between the lateral edge of the aqueduct and lateral border of the midbrain. Results The patient had no head and neck pain immediately after the procedure and remained pain-free for the remainder of her life (five months). She was weaned off her pre-operative narcotics and was able to leave hospital, meeting her palliative care goals. Conclusions Cancer-related unilateral head and neck nociceptive pain in the palliative care setting can be successfully treated with stereotactic mesencephalotomy. We believe that stereotactic mesencephalotomy is the treatment of choice for a small number of patients typified by our case. The authors make a plea to the palliative care and neurosurgical communities to rediscover this operation.
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Affiliation(s)
- Zurab Ivanishvili
- a Department of Surgery, Division of Neurosurgery , University of British Columbia , Vancouver , BC , Canada
| | - Shyam Pujara
- b Department of Neurosurgery, University of Leicester , Leicester , UK
| | - C Michael Honey
- a Department of Surgery, Division of Neurosurgery , University of British Columbia , Vancouver , BC , Canada
| | - Stephano Chang
- a Department of Surgery, Division of Neurosurgery , University of British Columbia , Vancouver , BC , Canada
| | - Christopher R Honey
- a Department of Surgery, Division of Neurosurgery , University of British Columbia , Vancouver , BC , Canada
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Moro E, Schüpbach M, Wächter T, Allert N, Eleopra R, Honey CR, Rueda M, Schiess MC, Shimo Y, Valkovic P, Whone A, Stoevelaar H. Referring Parkinson's disease patients for deep brain stimulation: a RAND/UCLA appropriateness study. J Neurol 2015; 263:112-9. [PMID: 26530503 PMCID: PMC4723622 DOI: 10.1007/s00415-015-7942-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/04/2015] [Accepted: 10/13/2015] [Indexed: 02/03/2023]
Abstract
In 2005, a European expert panel developed and validated an electronic tool to support the appropriate referral of patients with Parkinson’s disease (PD) for the consideration of deep brain stimulation (DBS). Since new evidence has become available over the last decade an update of the tool is necessary. A world-wide expert panel (71 neurologists and 11 neurosurgeons) used the RAND/UCLA Appropriateness Method to assess the appropriateness of referral for 1296 scenarios (9-point scale). Scenarios were permutations of 8 clinical variables relevant to the decision of referral. Appropriateness of referral was calculated on the basis of the median score and the extent of agreement. Compared to 2005, the impact of clinical variables on the appropriateness of referral was similar for severity of on–off fluctuations, dyskinesias and refractory tremor (positive association, p < 0.001), and cognitive impairment (negative association, p < 0.001). A relatively stronger negative impact was seen for levodopa-unresponsive gait and balance disturbances as well as older age, the latter most likely due to a higher cut-off value (75 versus 70 years in the previous study). The impact of PD duration on the appropriateness of referral was less pronounced than in 2005. The contribution of the newly included variable ‘non-motor side effects of anti-PD medication’ was very modest. Based on these results the panel produced new recommendations on the appropriateness of referral for the evaluation of DBS in PD patients. Differences from the previous study reflect the new clinical evidence, particularly related to the use of DBS in an earlier stage of PD. The validation of the updated recommendations is in progress.
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Affiliation(s)
- Elena Moro
- Division of Neurology, CHU of Grenoble, Joseph Fourier University, INSERM U836, Grenoble, France
| | - Michael Schüpbach
- Department of Neurology, Movement Disorders Center, Bern University Hospital and University of Bern, Bern, Switzerland
- Assistance-Publique Hôpitaux de Paris; Centre d'Investigation Clinique 9503, Institut du Cerveau et de la Moelle épinière; Département de Neurologie, Université Pierre et Marie Curie, Paris 6 et INSERM, CHU Pitié-Salpêtrière, Paris, France
| | - Tobias Wächter
- Department of Neurology and Hertie Institute for Clinical Brain Research, University of Tübingen, Tübingen, Germany
- Center of Rehabilitation, Bad Gögging, Germany
| | - Niels Allert
- Neurological Rehabilitation Center Godeshoehe, Bonn, Germany
| | - Roberto Eleopra
- Department of Neurology, Santa Maria della Misericordia University Hospital, Udine, Italy
| | | | - Mauricio Rueda
- Departamento de Neurociencias, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Mya C Schiess
- Department of Neurology, University of Texas Medical School at Houston, Texas, USA
| | - Yasushi Shimo
- Department of Neurology, Juntendo University School of Medicine, Tokyo, Japan
| | - Peter Valkovic
- 2nd Department of Neurology, Comenius University Faculty of Medicine and University Hospital Bratislava, Bratislava, Slovakia
| | - Alan Whone
- Department of Neurology, Frenchay Hospital, Bristol, UK
| | - Herman Stoevelaar
- Centre for Decision Analysis and Support, Ismar Healthcare, Lier, Belgium.
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Slotty PJ, Poologaindran A, Honey CR. A prospective, randomized, blinded assessment of multitarget thalamic and pallidal deep brain stimulation in a case of hemidystonia. Clin Neurol Neurosurg 2015; 138:16-9. [DOI: 10.1016/j.clineuro.2015.07.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Revised: 07/13/2015] [Accepted: 07/14/2015] [Indexed: 10/23/2022]
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Slotty PJ, Chang S, Honey CR. Motor Threshold: A Possible Guide to Optimizing Stimulation Parameters for Motor Cortex Stimulation. Neuromodulation 2015; 18:566-71; discussion 571-3. [DOI: 10.1111/ner.12336] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/04/2015] [Accepted: 06/25/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Philipp J. Slotty
- Division of Neurosurgery; University of British Columbia; Vancouver BC Canada
- Department of Stereotactic and Functional Neurosurgery; Heinrich-Heine University; Düsseldorf Germany
| | - Stephano Chang
- Division of Neurosurgery; University of British Columbia; Vancouver BC Canada
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Schutz PW, Honey CR, Yip S. 35-Year-Old Man with Lytic Skull Lesion. Langerhans Cell Histiocytosis (LCH). Brain Pathol 2015; 25:367-8. [PMID: 26086055 DOI: 10.1111/bpa.12258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Slotty PJ, Eisner W, Honey CR, Wille C, Vesper J. Long-term follow-up of motor cortex stimulation for neuropathic pain in 23 patients. Stereotact Funct Neurosurg 2015; 93:199-205. [PMID: 25895546 DOI: 10.1159/000375177] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 01/13/2015] [Indexed: 11/19/2022]
Abstract
BACKGROUND Motor cortex stimulation (MCS) is being offered to patients suffering from neuropathic pain. Outcome prediction, programming and especially sustaining a long-term treatment effect represent major challenges. We report a retrospective long-term analysis of our patients treated with MCS over a median follow-up of 39.1 months. OBJECTIVES To investigate the time course of the treatment effect in MCS for neuropathic pain. METHODS Twenty-three closely followed patients treated with MCS were retrospectively analyzed. Reduction in pain measured on a visual analogue scale (VAS) was defined as the primary outcome parameter. VAS pain level and adverse events were documented at the 1-, 3-, 6-, 12-, 18- and 24-month follow-ups. RESULTS The mean VAS under best medical treatment was 7.8 (SD 1.2, range 5-9) with escalation to 9.3 (SD 0.9, range 6-10) when the patients' medications were missed or delayed. About half of the patients (47.8%) experienced a satisfactory (>50%) reduction in pain during the first month of treatment. The best treatment results were seen at the 3-month follow-up (mean VAS 4.8, SD 1.9, -37.2% compared to baseline). A decline in the treatment effect was generally observed at the subsequent follow-up assessments. Six patients had their devices explanted during the follow-up period due to loss of treatment effect. CONCLUSIONS In this study, MCS failed to provide long-term pain control for neuropathic pain. Many aspects of MCS still remain unclear, especially the neural circuits involved and their response to long-term stimulation. Means must be developed to overcome the problems in this promising technique.
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Affiliation(s)
- Philipp J Slotty
- Department of Stereotactic and Functional Neurosurgery, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
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Chang S, Ranjan M, Slotty PJ, Honey CR. The Influence of Positioning and Muscle Activity on Motor Threshold during Motor Cortex Stimulation Programming. Stereotact Funct Neurosurg 2015; 93:122-126. [DOI: 10.1159/000369355] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 10/26/2014] [Indexed: 11/19/2022]
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Fasano A, Aquino CC, Krauss JK, Honey CR, Bloem BR. Axial disability and deep brain stimulation in patients with Parkinson disease. Nat Rev Neurol 2015. [PMID: 25582445 DOI: 10.1038/nrneurol.2014.252.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Axial motor signs-including gait impairment, postural instability and postural abnormalities-are common and debilitating symptoms in patients with advanced Parkinson disease. Dopamine replacement therapy and physiotherapy provide, at best, partial relief from axial motor symptoms. In carefully selected candidates, deep brain stimulation (DBS) of the subthalamic nucleus or globus pallidus internus is an established treatment for 'appendicular' motor signs (limb tremor, bradykinesia and rigidity). However, the effects of DBS on axial signs are much less clear, presumably because motor control of axial and appendicular functions is mediated by different anatomical-functional pathways. Here, we discuss the successes and failures of DBS in managing axial motor signs. We systematically address a series of common clinical questions associated with the preoperative phase, during which patients presenting with prominent axial signs are considered for DBS implantation surgery, and the postoperative phase, in particular, the management of axial motor signs that newly develop as postoperative complications, either acutely or with a delay. We also address the possible merits of new targets-including the pedunculopontine nucleus area, zona incerta and substantia nigra pars reticulata-to specifically alleviate axial symptoms. Supported by a rapidly growing body of evidence, this practically oriented Review aims to support decision-making in the management of axial symptoms.
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Affiliation(s)
- Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Toronto Western Hospital, UHN, University of Toronto, 399 Bathurst Street, 7 Mc412, Toronto, ON M5T 2S8, Canada
| | - Camila C Aquino
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Toronto Western Hospital, UHN, University of Toronto, 399 Bathurst Street, 7 Mc412, Toronto, ON M5T 2S8, Canada
| | - Joachim K Krauss
- Department of Neurosurgery, Medical School Hannover, Carl-Neuberg Straße 1, 30625 Hannover, Germany
| | - Christopher R Honey
- Division of Neurosurgery at the University of British Columbia, 8105-2775 Laurel Street, Vancouver General Hospital, Vancouver, BC V5Z 1M9, Canada
| | - Bastiaan R Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, PO Box 9101, 6500 HB Nijmegen, Netherlands
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Abstract
Background:Deep brain stimulation (DBS) is increasingly used to treat a variety of neurological conditions (e.g. movement disorders and chronic pain). This prospective study was designed to detect electrocardiogram (ECG) artifacts induced by deep brain stimulation and to investigate which factors (patient disease, electrode position within the brain or type of stimulation) produced these artifacts.Methods:Twelve patients (four women, eight men) with deep brain stimulators were enrolled in the study. Patients were selected to represent the common indications for DBS (Parkinson's disease, tremor, dystonia), the common electrode locations (pallidum, thalamus, subthalamic nucleus) and the two types of stimulation (monopolar, bipolar). Patients had one ECG with the DBS turned 'on'and another with the DBS turned 'off'. The ECGs were then randomized and read by a cardiologist blinded to the status of the patient and DBS and artifacts were noted to be either present or absent.Results:The six patients using monopolar stimulation all had artifacts on their electrocardiograms. These artifacts were severe enough to interfere with ECG interpretation. There were no artifacts detected in the six patients using bipolar stimulation. Electrode location and patient disease appeared to have no effect on ECG artifact.Conclusion:Deep brain stimulation can cause ECG artifacts when monopolar settings are used. These artifacts are not present with bipolar settings or when the DBS is turned 'off'. Knowledge of these potential ECG artifacts and how to avoid them is essential to facilitate accurate ECG interpretation.
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Abstract
ABSTRACT:Background:Deep brain stimulation (DBS) is used increasingly worldwide for the treatment of Parkinson's disease, dystonia, tremor and pain. As with any implanted system, however, DBS introduces a new series of problems related to its hardware. Infection, malfunction and lead migration or fracture may increase patient morbidity and should be considered when evaluating the risk/benefit ratio of this therapy. This work highlights several factors felt to increase DBS hardware complications.Methods:The authors undertook a prospective analysis of their patients receiving this therapy in two Canadian centres, over a four-year period.Results:One hundred and forty-four patients received 204 permanent electrode implants. The average follow-up duration was 24 months. Complications related to the DBS hardware were seen in 11 patients (7.6%). There were two lead fractures (1.4%) and nine infections (6.2%) including two erosions (1.4%). There was a significantly greater risk of infection in patients who underwent staged procedures with externalization. In patients with straight scalp incisions, the rate of infection was higher than that seen with curved incisions.Conclusion:Hardware complications were not common. A period of externalization of the electrodes for a stimulation trial was associated with an increased infection rate. It is also possible that a straight scalp incision instead of curvilinear incision may lead to an increase in the rate of infection. With a clear understanding of the accepted DBS device indications and their potential complications, patients may make a truly informed decision about DBS technology.
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Bogod NM, Sinden M, Woo C, Defreitas VG, Torres IJ, Howard AK, Ilcewicz-Klimek MI, Honey CR, Yatham LN, Lam RW. Long-term neuropsychological safety of subgenual cingulate gyrus deep brain stimulation for treatment-resistant depression. J Neuropsychiatry Clin Neurosci 2014; 26:126-33. [PMID: 24763760 DOI: 10.1176/appi.neuropsych.12110287] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Deep brain stimulation (DBS) of the subgenual cingulate gyrus (SCG) is a promising investigational intervention for treatment-resistant depression (TRD), but long-term outcome data are limited. Serial neuropsychological evaluations, using a comprehensive battery, were conducted on four subjects with TRD prior to surgery, and up to 42 months post-operatively. Reliable change methodology suggested general stability and/or select statistically reliable improvement in cognitive abilities over time. This is the first known set of multi-year neuropsychological follow-up data for SCG DBS for TRD. Observed improvements are likely attributable to reduced depressive symptomatology, recovery of functional capacities, and/or specific practice effects of repeated assessment.
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Lehman AM, Dong CC, Harries AM, Patel A, Honey CR, Patel MS. Evidence of ancillary trigeminal innervation of levator palpebrae in the general population. J Clin Neurosci 2013; 21:301-4. [PMID: 24120706 DOI: 10.1016/j.jocn.2013.03.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 02/26/2013] [Accepted: 03/10/2013] [Indexed: 10/26/2022]
Abstract
The cranial synkineses are a group of disorders encompassing a variety of involuntary co-contractions of the facial, masticatory, or extraocular muscles that occur during a particular volitional movement. The neuroanatomical pathways for synkineses largely remain undefined. Our studies explored a normal synkinesis long observed in the general population - that of jaw opening during efforts to open the eyelids widely. To document this phenomenon, we observed 186 consecutive participants inserting or removing contact lenses to identify jaw opening. Seeking electrophysiological evidence, in a second study we enrolled individuals undergoing vascular decompression for trigeminal neuralgia or hemifacial spasm, without a history of jaw-winking, ptosis, or strabismus, to record any motor responses in levator palpebrae superioris (LPS) upon stimulation of the trigeminal motor root. Stimulus was applied to the trigeminal motor root while an electrode in levator recorded the response. We found that 37 participants (20%) opened their mouth partially or fully during contact lens manipulation. In the second study, contraction of LPS with trigeminal motor stimulation was documented in two of six patients, both undergoing surgery for trigeminal neuralgia. We speculate these results might provide evidence of an endogenous synkinesis, indicating that trigeminal-derived innervation of levator could exist in a significant minority of the general population. Our observations demonstrate plasticity in the human cranial nerve innervation pattern and may have implications for treating Marcus Gunn jaw-winking.
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Affiliation(s)
- A M Lehman
- Department of Medical Genetics and Child and Family Research Institute, University of British Columbia, C234 4500 Oak Street, Vancouver, BC, Canada V6H 3N1
| | - C C Dong
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - A M Harries
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - A Patel
- Alberta Eye Health Clinic, Edmonton, AB, Canada
| | - C R Honey
- Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - M S Patel
- Department of Medical Genetics and Child and Family Research Institute, University of British Columbia, C234 4500 Oak Street, Vancouver, BC, Canada V6H 3N1.
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Ranjan M, Dupre S, Honey CR. Trigeminal neuralgia secondary to giant Virchow-Robin spaces: a case report with neuroimaging. Pain 2013; 154:617-619. [PMID: 23452387 DOI: 10.1016/j.pain.2013.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 12/20/2012] [Accepted: 01/07/2013] [Indexed: 11/28/2022]
Abstract
Virchow-Robin spaces are pial-lined, interstitial, fluid-filled structures that accompany penetrating arteries and arterioles as they enter the cerebral substance. Occasionally they may enlarge and become giant Virchow-Robin spaces (GVRS) and produce mass effect. Various neurological symptoms have been described in association with GVRS, however, trigeminal neuralgia has not yet been reported in this context. We present a case of trigeminal neuralgia secondary to dorsal pontine giant Virchow-Robin spaces (GVRS) and highlight the diagnostic radiologic features. Routine 1.5 T MRI sequences were sufficient to diagnose the GVRS and a diffusion tensor imaging (DTI) study revealed distortion of the intrinsic trigeminal pathway. This study highlights the utility of routine MRI to study the intrinsic anatomy of the trigeminal pathway in pathological conditions.
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Affiliation(s)
- Manish Ranjan
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada Division of Neuroradiology, University of British Columbia, Vancouver, British Columbia, Canada
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Harries AM, Sandhu M, Spacey SD, Aly MM, Honey CR. Unilateral Pallidal Deep Brain Stimulation in a Patient with Dystonia Secondary to Episodic Ataxia Type 2. Stereotact Funct Neurosurg 2013; 91:233-5. [DOI: 10.1159/000345265] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Accepted: 10/15/2012] [Indexed: 11/19/2022]
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Abstract
A group of eight patients with severe depression lasting 6 years or longer were treated with anterior capsulotomy and followed prospectively. Stereotactic surgery was used to produce radiofrequency lesions in the anterior limbs of both internal capsules. For all patients, there are follow-up data for at least 24 months. At 24-to-36 months postoperatively, four patients were either not-depressed or mildly depressed; one was mildly-to-moderately depressed; one was moderately-to-severely depressed; and only one remained severely depressed. One patient developed a progressive vascular dementia with parkinsonism caused by autopsy-proven arteriolosclerosis.
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Affiliation(s)
- Trevor A Hurwitz
- Department of Surgery, University of British Columbia, and Department of Psychiatry, UBC Hospital, Vancouver, BC, Canada.
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Lozano AM, Giacobbe P, Hamani C, Rizvi SJ, Kennedy SH, Kolivakis TT, Debonnel G, Sadikot AF, Lam RW, Howard AK, Ilcewicz-Klimek M, Honey CR, Mayberg HS. A multicenter pilot study of subcallosal cingulate area deep brain stimulation for treatment-resistant depression. J Neurosurg 2012; 116:315-22. [PMID: 22098195 DOI: 10.3171/2011.10.jns102122] [Citation(s) in RCA: 232] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Deep brain stimulation (DBS) has been recently investigated as a treatment for major depression. One of the proposed targets for this application is the subcallosal cingulate gyrus (SCG). To date, promising results after SCG DBS have been reported by a single center. In the present study the authors investigated whether these findings may be replicated at different institutions. They conducted a 3-center prospective open-label trial of SCG DBS for 12 months in patients with treatment-resistant depression.
Methods
Twenty-one patients underwent implantation of bilateral SCG electrodes. The authors examined the reduction in Hamilton Rating Scale for Depression (HRSD-17) score from baseline (RESP50).
Results
Patients treated with SCG DBS had an RESP50 of 57% at 1 month, 48% at 6 months, and 29% at 12 months. The response rate after 12 months of DBS, however, increased to 62% when defined as a reduction in the baseline HRSD-17 of 40% or more. Reductions in depressive symptomatology were associated with amelioration in disease severity in patients who responded to surgery.
Conclusions
Overall, findings from this study corroborate the results of previous reports showing that outcome of SCG DBS may be replicated across centers.
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Affiliation(s)
| | - Peter Giacobbe
- 2Department of Psychiatry, University of Toronto
- 8Department of Psychiatry, University Health Network, University of Toronto, Canada
| | | | - Sakina J. Rizvi
- 8Department of Psychiatry, University Health Network, University of Toronto, Canada
| | - Sidney H. Kennedy
- 2Department of Psychiatry, University of Toronto
- 8Department of Psychiatry, University Health Network, University of Toronto, Canada
| | | | | | - Abbas F. Sadikot
- 6Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | | | - Andrew K. Howard
- 6Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | | | | | - Helen S. Mayberg
- 7Department of Psychiatry, Emory University, Atlanta, Georgia; and
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