RESUMEN
BACKGROUND: The head of the caudate nucleus and adjacent mediobasal frontal lobe are deeply localized and have complex anatomical and topographic relationships with surrounding functionally significant cerebral structures. These aspects determine difficult surgical treatment of pathology in this zone. OBJECTIVE: To propose a new anterior transperiinsular approach for optimizing surgical access to the head of the caudate nucleus and mediobasal frontal lobe. MATERIAL AND METHODS: Two patients with cavernoma of the head of the caudate nucleus and oligodendroglioma of the head of the caudate nucleus and mediobasal frontal lobe underwent resection via transsylvian anterior transperiinsular approach in 2018. In both cases, tumors were localized in dominant hemisphere. Standard MRI was performed before and after surgery. Luria's neurological and neuropsychological examination was carried out before surgery, in 7 days after surgery and then every 3 months. RESULTS: Surgical access was performed via stage-by-stage proximal dissection of Sylvian fissure with visualization of anterior and superior periinsular grooves. After that, periinsular groove was dissected at the base of anterior short gyrus. Then, we moved apart white matter using microinstruments and approached the area of interest. In case of this trajectory, surgical approach was performed at the level of the upper parts of inferior frontooccipital fascicle under the arcuate fascicle. Both patients underwent total resection of tumors that was confirmed by MRI. No pre- and postoperative neurological or neuropsychological abnormalities were observed. CONCLUSION: Anterior transperiinsular approach provides minimally invasive access to the head of the caudate nucleus and mediobasal frontal lobe. It can be used on dominant hemisphere without significant risk of speech or other cognitive impairments. The advantages of this approach are minimal damage to associative pathways and small distance between periinsular groove and zone of interest. Dissection of commissural fibers of the corpus callosum is not required compared to conventional transcallosal approach.
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Núcleo Caudado , Sustancia Blanca , Núcleo Caudado/diagnóstico por imagen , Núcleo Caudado/cirugía , Corteza Cerebral , Lóbulo Frontal/diagnóstico por imagen , Lóbulo Frontal/cirugía , Humanos , Imagen por Resonancia MagnéticaRESUMEN
OBJECTIVE: We analyzed cortical landmarks, trajectory of approach, and various fiber tracts in the vicinity of our earlier described approach through the orbital/basal surface of the frontal lobe to access tumors located in the region of the caudate nucleus. We also present a new lateral orbital trajectory to approach these tumors. METHODS: The orbital surfaces of 3 formalin fixed and frozen cadaveric brain specimens were dissected to decipher the white fibers in the region of the caudate nucleus. Safe trajectories to lesions of the head of the caudate nucleus were identified, and the anatomic landmarks of the approach were evaluated. Three patients with caudate head tumors were operated using this approach. RESULTS: The caudate head lies at an average distance of 34 mm from the tip of the frontal pole, 24 mm from the basal medial orbital surface of the frontal lobe, 35 mm from the basal lateral orbital surface, and 37 mm from the superior surface of the frontal lobe. Two avenues were identified to approach the caudate head: one by making a cortical incision in the lateral orbital gyrus (lateral orbital approach), and the second by making a corticectomy in the medial orbital gyrus (medial orbital approach) in line with the temporal pole. All 3 patients were operated successfully using this approach. CONCLUSIONS: Surgical approach to the caudate head through the orbital surface of the frontal lobe as described by us provides the shortest trajectory and safe surgical route to access tumors of the caudate nucleus.
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Neoplasias Encefálicas/cirugía , Núcleo Caudado/anatomía & histología , Núcleo Caudado/cirugía , Procedimientos Neuroquirúrgicos/métodos , Corteza Prefrontal/anatomía & histología , Corteza Prefrontal/cirugía , Adulto , Puntos Anatómicos de Referencia , Cadáver , Femenino , Lóbulo Frontal/anatomía & histología , Humanos , Imagen por Resonancia Magnética , Persona de Mediana Edad , Fibras Nerviosas , Red Nerviosa/anatomía & histología , Red Nerviosa/cirugía , Adulto JovenRESUMEN
BACKGROUND: The caudate nucleus is a C-shaped structure that is located in the center of the brain and is divided into 3 parts: the head, body, and tail. METHODS: We detail the anatomic connections, relationships with other basal ganglia structures, and clinical implications of injury to the caudate nucleus. RESULTS: Anatomically, the most inferior transcapsular gray matter is the lentiform peduncle, which is the connection between the lentiform nucleus and caudate nucleus as well as the amygdala. The border between the tail and body of the caudate nucleus is the posterior insular point. The tail of the caudate nucleus is extraependymal in some parts and intraependymal in some parts of the roof of the temporal horn of the lateral ventricle. The tail of the caudate nucleus crosses the inferior limiting sulcus (temporal stem), and section of the tail during approaches to lesions involving the temporal stem may cause motor apraxia. The mean distance from the temporal limen point, which is the junction of the limen insula and inferior limiting sulcus, to the tail of the caudate nucleus in the temporal stem is 15.87 ± 3.10 mm. CONCLUSIONS: Understanding of the functional anatomy and connections of the distinct parts of the caudate nucleus is essential for deciding the extent of resection of lesions involving the caudate nucleus and the types of deficits that may be found postoperatively.
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Núcleo Caudado/anatomía & histología , Núcleo Caudado/cirugía , Amígdala del Cerebelo/anatomía & histología , Ganglios Basales/anatomía & histología , Lesiones Encefálicas/patología , Cadáver , Núcleo Caudado/irrigación sanguínea , Corteza Cerebral/anatomía & histología , Ventrículos Cerebrales/anatomía & histología , Circulación Cerebrovascular , Sustancia Gris/anatomía & histología , Humanos , Vías Nerviosas , Procedimientos Neuroquirúrgicos , Lóbulo Temporal/anatomía & histologíaRESUMEN
Methylphenidate (MPD) is a widely prescribed psychostimulant for the treatment of attention deficit hyperactivity disorder, and is growing in use as a recreational drug and academic enhancer. MPD acts on the reward/motive and motor circuits of the CNS to produce its effects on behavior. The caudate nucleus (CN) is known to be a part of these circuits, so a lesion study was designed to elucidate the role of the CN in response to acute and chronic MPD exposure. Five groups of nâ¯=â¯8 rats were used: control, sham CN lesions, non-specific electrolytic CN lesions, dopaminergic-specific (6-OHDA toxin) CN lesion, and glutaminergic-specific (ibotenic acid toxin) CN lesions. On experimental day (ED) 1, all groups received saline injections. On ED 2, surgeries took place, followed by a 5-day recovery period (ED 3-7). Groups then received six daily MPD 2.5â¯mg/kg injections (ED 9-14), then three days of washout with no injection (ED 15-17), followed by a re-challenge with the previous 2.5â¯mg/kg MPD dose (ED 18). Locomotive activity was recorded for 60â¯min after each injection by a computerized animal activity monitor. The electrolytic CN lesion group responded to the MPD acute and chronic exposures similarly to the control and sham groups, showing an increase in locomotive activity, i.e. sensitization. The dopaminergic-specific CN lesion group failed to respond to MPD exposure both acute and chronically. The glutaminergic-specific CN lesion group responded to MPD exposure acutely but failed to manifest chronic effects. This confirms the CN's dopaminergic system is necessary for MPD to manifest its acute and chronic effects on behavior, and demonstrates that the CN's glutaminergic system is necessary for the chronic effects of MPD such as sensitization. Thus, the dopaminergic and glutaminergic components of the CN play a significant role in differentially modulating the acute and chronic effects of MPD respectively.
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Conducta Animal/efectos de los fármacos , Núcleo Caudado/metabolismo , Estimulantes del Sistema Nervioso Central/farmacología , Agonistas de Dopamina/farmacología , Ácido Glutámico/metabolismo , Metilfenidato/farmacología , Animales , Trastorno por Déficit de Atención con Hiperactividad/tratamiento farmacológico , Núcleo Caudado/anatomía & histología , Núcleo Caudado/cirugía , Estimulantes del Sistema Nervioso Central/administración & dosificación , Dopamina/metabolismo , Agonistas de Dopamina/administración & dosificación , Agonistas de Dopamina/uso terapéutico , Relación Dosis-Respuesta a Droga , Locomoción/efectos de los fármacos , Masculino , Metilfenidato/administración & dosificación , Metilfenidato/uso terapéutico , Motivación/efectos de los fármacos , Ratas , Ratas Sprague-Dawley , RecompensaRESUMEN
The thalamus located in the deep site of cerebrum with the risk of internal capsule injury during operation. The purpose of this study was to compare the anatomy for exposure and injury using simulative surgical corridor of 3-dimensional model. The 3-dimensional anatomy model of thalamus in cerebrum was created based on magnetic resonance imaging performed for 15 patients with trigeminal neuralgia. The midpoint of line between anterior edge and top of thalamus was the target exposed. Axis connecting the target with the anterior edge and top of caudate head was used to outline the cylinder, respectively, simulating surgical corridors 1 and 2 of transfrontal approach. Cerebral tissues involved in the corridors were observed, measured, and compared. Incision of cortex was made on the anterior portion of inferior frontal gyrus through corridor 1 and middle frontal gyrus through corridor 2. Both of the 2 corridors passed the caudate nucleus, the anterior limb and genu of internal capsule, ultimately reached the upper anterior portion of thalamus. The volumes of white matter, caudate head, and thalamus in the corridor 1 were more than those in corridor 2. Conversely, the volumes of cortex, internal capsule in corridor 2 were more than those in corridor 1. In conclusion, surgical anatomy-specific volume is helpful to postulate the intraoperative injury of transfrontal approach exposing anterior portion of the thalamus. The detailed information in the quantification of microsurgical anatomy will be used to develop minimally invasive operation.
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Núcleo Caudado/anatomía & histología , Cápsula Interna/anatomía & histología , Microcirugia , Corteza Prefrontal/anatomía & histología , Tálamo/anatomía & histología , Tálamo/cirugía , Núcleo Caudado/diagnóstico por imagen , Núcleo Caudado/cirugía , Simulación por Computador , Humanos , Cápsula Interna/diagnóstico por imagen , Cápsula Interna/cirugía , Imagen por Resonancia Magnética , Modelos Anatómicos , Corteza Prefrontal/diagnóstico por imagen , Corteza Prefrontal/cirugía , Tálamo/diagnóstico por imagenRESUMEN
OBJECTIVE: To evaluate the possible influence of electrode trajectories penetrating the caudate nucleus (CN) on cognitive outcomes in deep brain stimulation (DBS) surgery for Parkinson's disease (PD). BACKGROUND: It is currently unclear how mandatory CN avoidance during trajectory planning is. DESIGN/METHODS: Electrode trajectories were determined to be inside, outside, or in border region of the CN. Pre- and postoperative neuropsychological tests of each trajectory group were compared in order to evaluate possible differences in cognitive outcomes 12 months after bilateral STN DBS. RESULTS: One hundred six electrode tracks in 53 patients were evaluated. Bilateral penetration of the CN occurred in 15 (28%) patients, while unilateral penetration occurred in 28 (53%). In 19 (36%) patients tracks were located in the border region of the CN. There was no electrode penetration of the CN in 10 (19%) patients. No difference in cognitive outcomes was found between the different groups. CONCLUSION: Cognitive outcome was not influenced by DBS electrode tracks penetrating the CN. It is both feasible and sensible to avoid electrode tracks through the CN when possible, considering its function and anatomical position. However, penetration of the CN can be considered without major concerns regarding cognitive decline when this facilitates optimal trajectory planning due to specific individual anatomical variations.
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Núcleo Caudado/cirugía , Cognición/fisiología , Estimulación Encefálica Profunda/métodos , Enfermedad de Parkinson/terapia , Núcleo Subtalámico/cirugía , Anciano , Núcleo Caudado/fisiopatología , Electrodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Enfermedad de Parkinson/fisiopatología , Estudios Retrospectivos , Núcleo Subtalámico/fisiopatología , Resultado del TratamientoRESUMEN
OBJECTIVE The purpose of this study was to describe in detail the cortical and subcortical anatomy of the central core of the brain, defining its limits, with particular attention to the topography and relationships of the thalamus, basal ganglia, and related white matter pathways and vessels. METHODS The authors studied 19 cerebral hemispheres. The vascular systems of all of the specimens were injected with colored silicone, and the specimens were then frozen for at least 1 month to facilitate identification of individual fiber tracts. The dissections were performed in a stepwise manner, locating each gray matter nucleus and white matter pathway at different depths inside the central core. The course of fiber pathways was also noted in relation to the insular limiting sulci. RESULTS The insular surface is the most superficial aspect of the central core and is divided by a central sulcus into an anterior portion, usually containing 3 short gyri, and a posterior portion, with 2 long gyri. It is bounded by the anterior limiting sulcus, the superior limiting sulcus, and the inferior limiting sulcus. The extreme capsule is directly underneath the insular surface and is composed of short association fibers that extend toward all the opercula. The claustrum lies deep to the extreme capsule, and the external capsule is found medial to it. Three fiber pathways contribute to form both the extreme and external capsules, and they lie in a sequential anteroposterior disposition: the uncinate fascicle, the inferior fronto-occipital fascicle, and claustrocortical fibers. The putamen and the globus pallidus are between the external capsule, laterally, and the internal capsule, medially. The internal capsule is present medial to almost all insular limiting sulci and most of the insular surface, but not to their most anteroinferior portions. This anteroinferior portion of the central core has a more complex anatomy and is distinguished in this paper as the "anterior perforated substance region." The caudate nucleus and thalamus lie medial to the internal capsule, as the most medial structures of the central core. While the anterior half of the central core is related to the head of the caudate nucleus, the posterior half is related to the thalamus, and hence to each associated portion of the internal capsule between these structures and the insular surface. The central core stands on top of the brainstem. The brainstem and central core are connected by several white matter pathways and are not separated from each other by any natural division. The authors propose a subdivision of the central core into quadrants and describe each in detail. The functional importance of each structure is highlighted, and surgical approaches are suggested for each quadrant of the central core. CONCLUSIONS As a general rule, the internal capsule and its vascularization should be seen as a parasagittal barrier with great functional importance. This is of particular importance in choosing surgical approaches within this region.
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Corteza Cerebral/anatomía & histología , Corteza Cerebral/cirugía , Cerebro/anatomía & histología , Cerebro/cirugía , Microcirugia/métodos , Ganglios Basales/anatomía & histología , Ganglios Basales/cirugía , Mapeo Encefálico , Tronco Encefálico/anatomía & histología , Tronco Encefálico/cirugía , Núcleo Caudado/anatomía & histología , Núcleo Caudado/cirugía , Arterias Cerebrales/anatomía & histología , Arterias Cerebrales/cirugía , Venas Cerebrales/anatomía & histología , Venas Cerebrales/cirugía , Dominancia Cerebral/fisiología , Sustancia Gris/anatomía & histología , Sustancia Gris/cirugía , Humanos , Vías Nerviosas/anatomía & histología , Vías Nerviosas/cirugía , Tubérculo Olfatorio/anatomía & histología , Tubérculo Olfatorio/cirugía , Tálamo/cirugía , Sustancia Blanca/anatomía & histología , Sustancia Blanca/cirugíaRESUMEN
PURPOSE: To summarize the clinical and radiologic features of pediatric basal ganglia region tumors (PBGRT) in correlation with their histopathologic findings to reduce inappropriate surgery and identify tumors that can benefit from maximal safe resection. METHODS: The records of 35 children with PBGRT treated in our hospital from December 2011 to December 2015 were analyzed retrospectively. The clinical and radiologic features of these tumors were summarized and correlated with their histopathologic diagnosis. RESULTS: Our series included 15 astrocytomas and 11 germ cell tumors (GCTs). Basal ganglia astrocytomas were characterized by various clinical presentations and an ill-circumscribed mass with the involvement of surrounding structures on neuroimaging and mostly occurred in the first decade of life (n = 10; 66.7%). Basal ganglia GCT mostly occurred in the second decade of life (n = 8; 72.7%) with hemiparesis as the most common symptom (n = 9; 81.8%). The tumors were located predominantly in the caput of caudate nucleus (n = 8; 72.7%) with hemiatrophy as the typical sign (n = 8; 72.7%). Occasionally, other tumors also could occur in this region, including primitive neuroectodermal tumor (n = 1), atypical teratoid/rhabdoid tumor (n = 1), anaplastic ependymoma (n = 1), lymphoma (n = 1), extraventricular neurocytoma (n = 1), gangliogliomas (n = 2), oligodendroglioma (n = 1), and dysembryoplastic neuroepithelial tumor (n = 1). CONCLUSIONS: Astrocytoma and GCT are the most common PBGRTs. Low-grade astrocytomas could benefit from maximal surgical resection, whereas GCTs merit neoadjuvant chemoradiation therapy followed by second-look surgery. We advocate routine testing of tumor markers and analysis of their clinical and radiologic features to optimize the therapeutic strategy.
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Astrocitoma/terapia , Enfermedades de los Ganglios Basales/terapia , Biomarcadores de Tumor/metabolismo , Neoplasias Encefálicas/terapia , Quimioradioterapia , Terapia Neoadyuvante , Neoplasias de Células Germinales y Embrionarias/terapia , Procedimientos Neuroquirúrgicos , Adolescente , Astrocitoma/complicaciones , Astrocitoma/diagnóstico por imagen , Astrocitoma/metabolismo , Enfermedades de los Ganglios Basales/complicaciones , Enfermedades de los Ganglios Basales/diagnóstico por imagen , Enfermedades de los Ganglios Basales/metabolismo , Neoplasias Encefálicas/complicaciones , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/metabolismo , Núcleo Caudado/diagnóstico por imagen , Núcleo Caudado/cirugía , Niño , Preescolar , Mareo/etiología , Ependimoma/complicaciones , Ependimoma/diagnóstico por imagen , Ependimoma/metabolismo , Ependimoma/terapia , Femenino , Ganglioglioma/complicaciones , Ganglioglioma/diagnóstico por imagen , Ganglioglioma/metabolismo , Ganglioglioma/terapia , Cefalea/etiología , Humanos , Lactante , Linfoma/complicaciones , Linfoma/diagnóstico por imagen , Linfoma/metabolismo , Linfoma/terapia , Masculino , Técnicas de Diagnóstico Molecular , Neoplasias de Células Germinales y Embrionarias/complicaciones , Neoplasias de Células Germinales y Embrionarias/diagnóstico por imagen , Neoplasias de Células Germinales y Embrionarias/metabolismo , Neoplasias Neuroepiteliales/complicaciones , Neoplasias Neuroepiteliales/diagnóstico por imagen , Neoplasias Neuroepiteliales/terapia , Neurocitoma/complicaciones , Neurocitoma/diagnóstico por imagen , Neurocitoma/metabolismo , Neurocitoma/terapia , Tumores Neuroectodérmicos Primitivos/complicaciones , Tumores Neuroectodérmicos Primitivos/diagnóstico por imagen , Tumores Neuroectodérmicos Primitivos/metabolismo , Tumores Neuroectodérmicos Primitivos/terapia , Oligodendroglioma/complicaciones , Oligodendroglioma/diagnóstico por imagen , Oligodendroglioma/metabolismoRESUMEN
BACKGROUND: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) in Parkinson disease (PD) is associated with postoperative cognitive decline. One of the proposed underlying mechanisms is the surgical procedure with the lead trajectory penetrating the caudate nucleus. OBJECTIVE: To study whether penetration of the caudate nucleus affects neuropsychological outcome. METHODS: Neuropsychological and imaging data of 30 PD patients who underwent bilateral STN DBS were analysed. Lead trajectories were evaluated leading to a group with (n = 10) and a group without penetration of the caudate nucleus (n = 20). The neuropsychological performance of each group was compared to baseline, both at 3 and 12 months postoperatively. RESULTS: Only the Trail-Making Test part B (TMT-B) showed an interaction effect within the groups over time at 3 months postoperatively. At 12 months postoperatively, there was only a main effect of time with a decrease in performance in TMT-B for both groups. Also verbal fluency showed a significant decrease over time for both groups at 3 and 12 months postoperatively. CONCLUSION: Caudate nucleus penetration affects cognitive flexibility only in the short term after surgery.
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Núcleo Caudado/cirugía , Estimulación Encefálica Profunda/tendencias , Electrodos Implantados , Pruebas Neuropsicológicas , Núcleo Subtalámico/cirugía , Anciano , Núcleo Caudado/diagnóstico por imagen , Estimulación Encefálica Profunda/instrumentación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Desempeño Psicomotor/fisiología , Estudios Retrospectivos , Núcleo Subtalámico/diagnóstico por imagen , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVE: Pediatric basal ganglia germ cell tumors (GCTs) represent a rare subset of tumors about which little is known. We aimed to summarize the clinical features and radiological findings of this special subgroup of GCTs. METHODS: From January 2010 to January 2015, 12 pediatric patients with basal ganglia GCTs were treated in our hospital. The clinical features, radiologic findings, diagnosis, treatment, and outcome of these patients were analyzed retrospectively. Our institutional diagnostic principle and treatment strategy of this disease were discussed. RESULTS: GCTs accounted for 25.5% of all the pediatric basal ganglia tumors treated in our hospital. There were 9 male and 3 female patients with a mean age of 11.5 ± 2.1 years. The most common symptom was progressive hemiparesis (n = 9, 75%). The radiologic findings showed that the lesions predominately located in caput of caudate nucleus (n = 9, 75.0%), followed by lenticular nucleus (n = 3, 25.0%). Hemiatrophy was commonly observed (n = 8, 66.7%). Eight patients were diagnosed as having germinomas, and 4 patients as having nongerminomatous germ cell tumors. During the follow-up period, preoperative neurologic dysfunctions improved in 7 patients and remained stable in 3. Two patients developed new onset of neurologic dysfunction after the treatment. Two patients suffered from tumor recurrence. CONCLUSIONS: GCTs are not as rare as considered in pediatric basal ganglia tumors. They bear some distinctive clinical and radiologic features, which can help with the accurate diagnosis and successful management of such tumors.
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Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Enfermedades de los Ganglios Basales/terapia , Neoplasias Encefálicas/terapia , Neoplasias de Células Germinales y Embrionarias/terapia , Adolescente , Cuidados Posteriores , Enfermedades de los Ganglios Basales/complicaciones , Enfermedades de los Ganglios Basales/diagnóstico por imagen , Enfermedades de los Ganglios Basales/metabolismo , Neoplasias Encefálicas/complicaciones , Neoplasias Encefálicas/diagnóstico por imagen , Neoplasias Encefálicas/metabolismo , Carboplatino/administración & dosificación , Carcinoma Embrionario/complicaciones , Carcinoma Embrionario/diagnóstico por imagen , Carcinoma Embrionario/metabolismo , Carcinoma Embrionario/terapia , Núcleo Caudado/diagnóstico por imagen , Núcleo Caudado/cirugía , Niño , Coriocarcinoma no Gestacional/complicaciones , Coriocarcinoma no Gestacional/diagnóstico por imagen , Coriocarcinoma no Gestacional/metabolismo , Coriocarcinoma no Gestacional/terapia , Gonadotropina Coriónica Humana de Subunidad beta/metabolismo , Cisplatino/administración & dosificación , Disfunción Cognitiva/etiología , Cuerpo Estriado/diagnóstico por imagen , Cuerpo Estriado/cirugía , Irradiación Craneana , Imagen de Difusión Tensora , Tumor del Seno Endodérmico/complicaciones , Tumor del Seno Endodérmico/diagnóstico por imagen , Tumor del Seno Endodérmico/metabolismo , Tumor del Seno Endodérmico/terapia , Etopósido/administración & dosificación , Femenino , Germinoma/complicaciones , Germinoma/diagnóstico por imagen , Germinoma/metabolismo , Germinoma/terapia , Humanos , Imagen por Resonancia Magnética , Masculino , Terapia Neoadyuvante , Neoplasias de Células Germinales y Embrionarias/complicaciones , Neoplasias de Células Germinales y Embrionarias/diagnóstico por imagen , Neoplasias de Células Germinales y Embrionarias/metabolismo , Procedimientos Neuroquirúrgicos , Paresia/etiología , Estudios Retrospectivos , Segunda Cirugía , Convulsiones/etiología , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: To evaluate the microsurgical anatomy of the fiber tract connections of the supplementary motor area (SMA) and pre-SMA, and examine its potential functional role with reference to clinical trials in the literature. METHODS: Ten postmortem formalin-fixed human brains (20 sides) and 1 cadaveric head were prepared following Klingler's method. The fiber dissection was performed in a stepwise fashion, from lateral to medial and also from medial to lateral, under an operating microscope, with 3D images captured at each stage. Our findings were supported by in vivo magnetic resonance imaging tractography in 2 healthy subjects. RESULTS: The connections of the SMA complex, composed of the pre-SMA and the SMA proper, are composed of short "U" association fibers and the superior longitudinal fasciculus I, cingulum, claustrocortical fibers, callosal fibers, corticospinal tract, frontal aslant tract, and frontostriatal tract. The claustrocortical fibers may play an important role in the integration of motor, language, and limbic functions of the SMA complex. The frontostriatal tract connects the pre-SMA to the putamen and caudate nucleus, and also forms parts of both the internal capsule and the dorsal external capsule. CONCLUSIONS: The SMA complex has numerous connections throughout the cerebrum. An understanding of these connections is important for presurgical planning for lesions in the frontal lobe and helps explain symptoms related to SMA injury.
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Núcleo Caudado/anatomía & histología , Lóbulo Frontal/anatomía & histología , Corteza Motora/anatomía & histología , Putamen/anatomía & histología , Tractos Piramidales/anatomía & histología , Cadáver , Núcleo Caudado/diagnóstico por imagen , Núcleo Caudado/cirugía , Cuerpo Calloso/anatomía & histología , Cuerpo Calloso/diagnóstico por imagen , Cuerpo Calloso/cirugía , Imagen de Difusión por Resonancia Magnética , Imagen de Difusión Tensora , Lóbulo Frontal/diagnóstico por imagen , Lóbulo Frontal/cirugía , Voluntarios Sanos , Humanos , Imagenología Tridimensional , Microscopía , Microcirugia , Corteza Motora/diagnóstico por imagen , Corteza Motora/cirugía , Vías Nerviosas/anatomía & histología , Vías Nerviosas/diagnóstico por imagen , Vías Nerviosas/cirugía , Putamen/diagnóstico por imagen , Putamen/cirugía , Tractos Piramidales/diagnóstico por imagen , Tractos Piramidales/cirugíaRESUMEN
Functional neurological disorders (FND) have been a challenge to treat both for neurologists and neurosurgeons. Various ablative as well as non-ablative techniques have been used to treat these disorders. Gamma knife radiosurgery (GKRS) is also being practised to treat refractory obsessive- compulsive disorder (OCD). The subsequent complications of GKRS reported have been variable, with headache being the most common. We discuss here a rare complication of 'late onset radiation necrosis in bilateral caudate nuclei' in a patient after receiving GKRS three years back. This case highlights the need to be more cautious before administering ablative procedures in patients suffering with functional disorders.
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Procedimientos Neuroquirúrgicos/métodos , Trastorno Obsesivo Compulsivo/cirugía , Complicaciones Posoperatorias/cirugía , Psicocirugía/métodos , Radiocirugia/efectos adversos , Radiocirugia/métodos , Núcleo Caudado/patología , Núcleo Caudado/cirugía , Quistes/patología , Quistes/cirugía , Resistencia a Medicamentos , Femenino , Humanos , Necrosis/etiología , Pruebas Neuropsicológicas , Procedimientos Neuroquirúrgicos/efectos adversos , Trastorno Obsesivo Compulsivo/psicología , Psicocirugía/efectos adversos , Resultado del Tratamiento , Adulto JovenRESUMEN
OBJECTIVE: Measure willingness-to-accept novel Gamma knife (GK) radiosurgery of the caudate nucleus to treat tinnitus among career firefighters who are at higher risk of hearing loss because of occupational noise exposure. STUDY DESIGN: Cross-sectional survey. MATERIALS AND METHODS: A Web-based 80-item survey was distributed to 800 San Francisco firefighters and satisfactorily completed by 101 respondents. Demographic and work-related characteristics including occupational noise exposure, hearing handicap using the Hearing Handicap Inventory for Adults (HHIA), and tinnitus severity using the tinnitus functional index (TFI) were assessed. Willingness-to-accept GK radiosurgery for tinnitus was profiled using a 7-point scale for 6 decremental levels of expected tinnitus improvement. RESULTS: Respondents were a majority male (82%) and Caucasian (56%). Nearly all (95%) reported significant daily or weekly occupational noise exposure. Mean HHIA (16.3) and mean TFI (14.6) were mild. At the 100% (complete) tinnitus improvement level, more than 60% of respondents were "likely" willing-to-accept Gamma knife radiosurgery. At the 75% tinnitus improvement level, 43% of respondents were "likely" willing-to-accept GK radiosurgery. Below the 75% tinnitus improvement level, willingness-to-accept dropped off steeply. CONCLUSION: Gamma knife radiosurgery to area LC, a locus of the caudate nucleus, for tinnitus would be of interest to a large population with moderate or lower tinnitus distress. Should this innovative intervention be considered in the future, a rigorous clinical trial will be necessary to establish safety and efficacy.
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Bomberos/psicología , Aceptación de la Atención de Salud/psicología , Radiocirugia/psicología , Acúfeno/psicología , Acúfeno/cirugía , Adulto , Núcleo Caudado/cirugía , Estudios Transversales , Femenino , Pérdida Auditiva/psicología , Pérdida Auditiva/cirugía , Humanos , Masculino , Persona de Mediana Edad , Análisis de Regresión , San Francisco , Encuestas y CuestionariosAsunto(s)
Epilepsias Parciales/complicaciones , Magnetoencefalografía , Modelos Neurológicos , Convulsiones/diagnóstico , Adulto , Núcleo Caudado/cirugía , Electroencefalografía , Epilepsias Parciales/diagnóstico , Epilepsias Parciales/cirugía , Femenino , Humanos , Imagen por Resonancia Magnética , Tomografía de Emisión de Positrones , Convulsiones/clasificación , Convulsiones/etiología , Tomografía Computarizada de Emisión de Fotón Único , Adulto JovenRESUMEN
Interest in using neuromodulation to treat psychiatric disorders is rapidly increasing. The development of novel tools and techniques, such as deep brain stimulation (DBS), increases precision and minimizes risk. This article reviews the history of psychosurgical interventions and recent developments of DBS to provide a framework for understanding current options and future goals. We begin by discussing early approaches to psychosurgery, focusing on the widespread use of lobotomy and the subsequent backlash from the public and professionals in the field. Next, we discuss the development of stereotaxis. This technique allows for more targeted, precise interventions that produce discrete subcortical lesions. We focus on four stereotactic procedures that were developed using this technique: cingulotomy, capsulotomy, subcaudate tractotomy, and limbic leucotomy. We subsequently review contemporary theory and approaches with relevance to psychosurgery. We discuss the systems and neurocircuitry that are thought to be involved in psychiatric illness and provide targets for intervention. This discussion includes presentation of basal ganglia thalamocortical pathophysiology including cortico-striato-thalamo-cortical loops. We focus the discussion on two psychiatric disorders that have been targets of neurosurgical interventions: obsessive-compulsive disorder and mood disorders such as major depressive disorder. Evidence from studies of DBS in psychiatric disorders, including efficacy and tolerability, is reviewed. Finally, we look to the future, exploring the possibilities for these approaches to increase understanding, transform societal views of mental illness, and improve treatment.
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Trastornos Mentales/cirugía , Psiquiatría/historia , Psicocirugía/historia , Núcleo Caudado/cirugía , Estimulación Encefálica Profunda , Manual Diagnóstico y Estadístico de los Trastornos Mentales , Giro del Cíngulo/cirugía , Historia del Siglo XIX , Historia del Siglo XX , Humanos , Cápsula Interna/cirugía , Sistema Límbico/cirugía , Trastornos Mentales/psicología , Trastornos del Humor/psicología , Trastornos del Humor/cirugía , Vías Nerviosas/cirugía , Trastorno Obsesivo Compulsivo/psicología , Trastorno Obsesivo Compulsivo/cirugía , Técnicas EstereotáxicasRESUMEN
Admissions for irreversible psychosurgical treatment of obsessive-compulsive disorder (OCD) by the Working Group for Indication Psychosurgery in the Netherlands were analyzed, and the postsurgical effects on symptom severity and quality of life were evaluated. The data were extracted from patient records in the period 2001-2008, and there was a postoperative assessment with a semistructured interview. Fourteen patients applied, having severe OCD with mostly one or more comorbid disorders. The mean Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was 32 points. Four of seven patients in whom psychosurgery was deemed useful were operated on. The decrease of the Y-BOCS score from registration to after surgery was 9 points (range, 3-17 points). An improvement in social function was present in three of four patients. In conclusion, psychosurgery can be a valuable treatment option for patients with severe OCD in whom other treatments fail.
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Encéfalo/cirugía , Vías Nerviosas/cirugía , Trastorno Obsesivo Compulsivo/cirugía , Psicocirugía/métodos , Adulto , Núcleo Caudado/cirugía , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Países Bajos , Trastorno Obsesivo Compulsivo/fisiopatología , Psicocirugía/efectos adversos , Calidad de Vida , Índice de Severidad de la Enfermedad , Factores de Tiempo , Resultado del TratamientoRESUMEN
OBJECT: Recent neuroimaging and surgical results support the crucial role of white matter in mediating motor and higher-level processing within the frontal lobe, while suggesting the limited compensatory capacity after damage to subcortical structures. Consequently, an accurate knowledge of the anatomofunctional organization of the pathways running within this region is mandatory for planning safe and effective surgical approaches to different diseases. The aim of this dissection study was to improve the neurosurgeon's awareness of the subcortical anatomofunctional architecture for a lateral approach to the frontal region, to optimize both resection and postoperative outcome. METHODS: Ten human hemispheres (5 left, 5 right) were dissected according to the Klingler technique. Proceeding lateromedially, the main association and projection tracts as well as the deeper basal structures were identified. The authors describe the anatomy and the relationships among the exposed structures in both a systematic and topographical surgical perspective. Structural results were also correlated to the functional responses obtained during resections of infiltrative frontal tumors guided by direct cortico-subcortical electrostimulation with patients in the awake condition. RESULTS: The eloquent boundaries crucial for a safe frontal lobectomy or an extensive lesionectomy are as follows: 1) the motor cortex; 2) the pyramidal tract and premotor fibers in the posterior and posteromedial part of the surgical field; 3) the inferior frontooccipital fascicle and the superior longitudinal fascicle posterolaterally; and 4) underneath the inferior frontal gyrus, the head of the caudate nucleus, and the tip of the frontal horn of the lateral ventricle in the depth. CONCLUSIONS: Optimization of results following brain surgery, especially within the frontal lobe, requires a perfect knowledge of functional anatomy, not only at the cortical level but also with regard to subcortical white matter connectivity.
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Mapeo Encefálico , Neoplasias Encefálicas/cirugía , Encéfalo/anatomía & histología , Encéfalo/fisiología , Estimulación Encefálica Profunda , Glioma/cirugía , Monitoreo Intraoperatorio/métodos , Fibras Nerviosas Mielínicas , Vías Nerviosas/cirugía , Procedimientos Neuroquirúrgicos/efectos adversos , Procedimientos Neuroquirúrgicos/métodos , Trastornos del Habla/prevención & control , Adulto , Ganglios Basales/anatomía & histología , Ganglios Basales/fisiología , Ganglios Basales/cirugía , Encéfalo/cirugía , Mapeo Encefálico/métodos , Neoplasias Encefálicas/patología , Neoplasias Encefálicas/fisiopatología , Cadáver , Núcleo Caudado/anatomía & histología , Núcleo Caudado/fisiología , Núcleo Caudado/cirugía , Estimulación Encefálica Profunda/métodos , Disección , Femenino , Lóbulo Frontal/anatomía & histología , Lóbulo Frontal/fisiología , Lóbulo Frontal/cirugía , Glioma/patología , Glioma/fisiopatología , Humanos , Ventrículos Laterales/anatomía & histología , Ventrículos Laterales/fisiología , Ventrículos Laterales/cirugía , Masculino , Corteza Motora/anatomía & histología , Corteza Motora/fisiología , Corteza Motora/cirugía , Vías Nerviosas/anatomía & histología , Vías Nerviosas/fisiología , Pruebas Neuropsicológicas , Tractos Piramidales/anatomía & histología , Tractos Piramidales/fisiología , Tractos Piramidales/cirugía , Resultado del Tratamiento , VigiliaRESUMEN
AIM: The balance of excitation and inhibition of neurons and neuronal network is very important to perform complete neuronal function. Damage or loss of inhibitory γ-aminobutyric acid (GABA)-ergic interneuron is associated with impaired inhibitory control of cortical pyramidal neurons, leading to hyperexcitability and epileptogenesis. Ectopic neurons in the basal ganglia are to be one of the pathological features of epileptogenesis. In the present study, we investigated distribution of interneuron subtypes between neocortex and caudate nucleus. METHODS: We performed immunohistochemistry of GABA, glutamic acid decarboxylase (GAD), calretinin (CR), calbindin (CB), parvalbumin (PV) and neuropeptide. We used surgical materials of four focal cortical dysplasia (FCD) cases, having lesions of neocortex and caudate nucleus, and eight age-matched autopsy controls. RESULTS: The pathology showed three FCD IIa, containing dysmorphic neurons, and one FCD IIb, balloon cells. In the neocortex, the concentrations (each positive cell number/all cell numbers in the evaluated field) of GAD+, CR+ and CB+ cells were significantly lower in FCD than in controls. On the contrary, in the caudate nucleus those of CR+ and CB+ cells were significantly more in FCD than in controls. CONCLUSION: The interneuron imbalance between the neocortex and basal ganglia may affect the epileptogenesis of FCD.
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Encefalopatías/patología , Núcleo Caudado/patología , Epilepsias Parciales/etiología , Neuronas GABAérgicas/patología , Interneuronas/patología , Malformaciones del Desarrollo Cortical/patología , Neocórtex/patología , Adolescente , Encefalopatías/complicaciones , Encefalopatías/fisiopatología , Encefalopatías/cirugía , Calbindina 2 , Calbindinas , Estudios de Casos y Controles , Núcleo Caudado/cirugía , Recuento de Células , Niño , Preescolar , Epilepsias Parciales/fisiopatología , Epilepsias Parciales/cirugía , Epilepsia , Femenino , Neuronas GABAérgicas/química , Glutamato Descarboxilasa/análisis , Humanos , Lactante , Recién Nacido , Interneuronas/química , Interneuronas/clasificación , Imagen por Resonancia Magnética , Masculino , Malformaciones del Desarrollo Cortical/complicaciones , Malformaciones del Desarrollo Cortical/fisiopatología , Malformaciones del Desarrollo Cortical/cirugía , Malformaciones del Desarrollo Cortical de Grupo I , Neocórtex/cirugía , Proteínas del Tejido Nervioso/análisis , Neuropéptidos/análisis , Parvalbúminas/análisis , Proteína G de Unión al Calcio S100/análisis , Ácido gamma-Aminobutírico/análisisRESUMEN
OBJECT: For several decades, clinicians have predicted intraparenchymal brain pressure or brain tissue compression indirectly based on the degree of distortion of the midline structures (midline shift) and ventricle wall (ventriculomegaly) observed on conventional MRI. However, this method has several limitations. Diffusion tensor imaging (DTI) is a novel MRI technique that can provide information about the microstructural properties of compressed tissue. In this study, the authors evaluated whether DTI can precisely define the degree of tissue compression in patients with chronic subdural hematoma (CSDH). METHODS: The study sample consisted of 18 patients (mean age 71 years, 10 men and 8 women) with unilateral CSDH and 12 age-matched volunteers. Diffusion tensor imaging results were acquired before and after the surgical irrigation in the CSDH group. Subdural pressure during the operation was also measured. Fractional anisotropy (FA) values were evaluated at several locations, including the gray matter. RESULTS: The FA values of the gray matter, especially in the caudate nucleus and putamen, were increased in the patients with CSDH compared with the control group. The change in FA data before and after surgery (ΔFA) correlated with the degree of tissue compression evaluated by measurement of the subdural pressure. Furthermore, the increased FA values in patients with CSDH decreased after surgery. CONCLUSIONS: These findings indicate that FA values of the gray matter, especially in the caudate nucleus and putamen, may be important markers of tissue compression. The assessment of FA values of the gray matter will result in a new, less-invasive diagnostic technique to evaluate the degree of brain compression.
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Encéfalo/fisiopatología , Imagen de Difusión por Resonancia Magnética/métodos , Hematoma Subdural Crónico/fisiopatología , Aumento de la Imagen/métodos , Interpretación de Imagen Asistida por Computador/métodos , Presión Intracraneal/fisiología , Anciano , Anciano de 80 o más Años , Anisotropía , Encéfalo/cirugía , Núcleo Caudado/fisiopatología , Núcleo Caudado/cirugía , Demencia/fisiopatología , Demencia/cirugía , Dominancia Cerebral/fisiología , Femenino , Trastornos Neurológicos de la Marcha/fisiopatología , Trastornos Neurológicos de la Marcha/cirugía , Hematoma Subdural Crónico/cirugía , Humanos , Masculino , Persona de Mediana Edad , Paresia/fisiopatología , Paresia/cirugía , Complicaciones Posoperatorias/fisiopatología , Estudios Prospectivos , Putamen/fisiopatología , Putamen/cirugía , TrepanaciónRESUMEN
Tinnitus is an auditory disorder characterized by perception of internally generated phantom auditory sensations without corresponding mechanical stimuli arising from the body or external environment. Current auditory based treatment approaches, sometimes in conjunction with nonauditory based strategies, such as Tinnitus Retraining Therapy and Cognitive Behavioral Therapy, have been helpful in mitigating symptoms for the majority of patients. Yet there are over 1 million tinnitus sufferers who still endure troublesome chronic, continuous head noises that are debilitating and interfere with activities of daily living. Here we show that application of deep brain stimulation (DBS) therapy to a locus of caudate neurons (area LC) in the body of the nucleus, a subsite of the striatum that is not part of the classical auditory pathway, can decrease or increase tinnitus loudness perception. The DBS lead traversed through or was adjacent to area LC in six Parkinson's disease and essential tremor subjects with concomitant tinnitus who underwent implantation of the subthalamic or ventral intermediate nucleus. In five subjects where the DBS lead tip traversed area LC, tinnitus loudness in both ears was suppressed to a nadir of level 2 or lower on a 0-10 rating scale. In one subject where the DBS lead was outside area LC, tinnitus was not modulated. In three subjects with preoperative and postoperative audiograms, hearing thresholds were unchanged by area LC stimulation. Neuromodulation of area LC may be interrupting perceptual integration of phantom sensations generated in the central auditory system. This new, basal ganglia based approach to tinnitus modulation warrants further investigation and may be ultimately refined to treat patients with refractory symptoms.