Intraoperative imaging in the neurosurgery operating theatre: A review of the most commonly used techniques for brain tumour surgery. / Imagen intraoperatoria en el quirófano de neurocirugía: revisión de las técnicas más empleadas para la cirugía de los tumores cerebrales.

INTRODUCTION: New intraoperative imaging techniques, which aim to improve tumour resection, have been implemented in recent years in brain tumour surgery, although they lead to an increase in resources. In order to carry out an update on this topic, this manuscript has been drafted by a group from the Sociedad Española de Neurocirugía (Spanish Society of Neurosurgery). MATERIAL AND METHODS: Experts in the use of each one of the most-used intraoperative techniques in brain tumour surgery were presented with a description of the technique and a brief review of the literature. Indications for use, their advantages and disadvantages based on clinical experience and on what is published in the literature will be described. RESULTS: The most robust intraoperative imaging technique appears to be low- and high-field magnetic resonance imaging, but this is the technique which results in the greatest expenditure. Intraoperative ultrasound navigation is portable and less expensive, but it provides poorer differentiation of high-grade tumours and is observer-dependent. The most-used fluorescence techniques are 5-aminolevulinic acid for high-grade gliomas and fluorescein, useful in lesions which rupture the blood-brain barrier. Last of all, intraoperative CT is more versatile in the neurosurgery operating theatre, but it has fewer indications in neuro-oncology surgery. CONCLUSIONS: Intraoperative imaging techniques are used with increasingly greater frequency in brain tumour surgery, and the neurosurgeon should assess their possible use depending on their resources and the needs of each patient.

Duodenal Levodopa Infusion for Long-Term Deep Brain Stimulation-Refractory Symptoms in Advanced Parkinson Disease.

OBJECTIVES: This study assesses the effect of levodopa/carbidopa intestinal infusion gel (LCIIG) as an additional treatment in patients with advanced idiopathic Parkinson disease (PD) previously treated with deep brain stimulation (DBS). METHODS: Prospective study of advanced PD patients, satisfactorily treated with bilateral DBS of the subthalamic nucleus, who had developed refractory symptoms and LCIIG was added. Controls were advanced PD patients treated with LCIIG. Measurements included the Unified Parkinson Disease Rating Scale (UPDRS)-III and the UPDRS axial compound. RESULTS: There were 19 patients in the DBS-LCIIG therapy group and 21 in the control group. The DBS-LCIIG patients were younger and had disease duration longer than controls. The median time from DBS to gastrostomy was 7.8 years (range, 2-12 years). In both study groups, the mean scores of the UPDRS-III and UPDRS axial subscales improved significantly after LCIIG treatment (DBS-LCIIG group: UPDRS-III, 62.0 [15.7] vs 30.9 [12.1]; UPDRS axial, 24.7 [4.9] vs 10.2 [2.7]; P < 0.0005 for all comparisons). There were no differences in adverse events between the groups. In the follow-up of the DBS-LCIIG group. 5 patients discontinued DBS-LCIIG therapy and returned to DBS, 5 discontinued DBS and were maintained with LCIIG, and the remaining 9 continued with DBS-LCIIG therapy. Mean time until discontinuation in the double DBS-LCIIG group was 891 days. The main risk factors for discontinuation were age at the beginning of LCIIG and severity of the UPDRS axial subscale. CONCLUSIONS: Levodopa/carbidopa intestinal infusion gel therapy may be a valuable option in selected patients with advanced PD who develop refractory symptoms after long-term subthalamic nucleus-DBS.

Long-Term Effective Thalamic Deep Brain Stimulation for Neuropathic Tremor in Two Patients with Charcot-Marie-Tooth Disease.

BACKGROUND: It has been described that many Charcot-Marie-Tooth syndrome type 2 patients are affected by a very disabling type of tremor syndrome, the pathophysiology of which remains unclear. Deep brain stimulation (DBS) has been successfully applied to treat most types of tremors by implanting electrodes in the ventral intermediate nucleus of the thalamus (Vim). METHODS: We used DBS applied to the Vim in 2 patients with severe axonal inherited polyneuropathies who developed a disabling tremor. RESULTS: Both patients responded positively to stimulation, with a marked reduction of the tremor and with an improvement of their quality of life. CONCLUSION: We report 2 cases of tremor associated with a hereditary neuropathy with a good response to DBS.

Deep Brain Stimulation in Posttraumatic Tremor: A Series of Cases and Literature Review.

BACKGROUND: Posttraumatic tremor (PTT) is the most frequent movement disorder secondary to cranioencephalic trauma and can be persistent and disabling. OBJECTIVES: We review and assess the efficacy of deep brain stimulation (DBS) at the VIM/VOP/ZI (ventralis intermedius/ventrooralis posterior/zona incerta) complex level for the treatment of PTT. METHODS: During the period from 1999 to 2014, 5 patients diagnosed with PTT were selected who had experienced a major deterioration in their quality of life without improvement during medical treatment for more than 1 year. They underwent surgery for DBS at the VIM/VOP/ZI complex level, and the modified tremor scale before and after surgery was used for their follow-up. RESULTS: Each patient showed improvements in their symptoms after DBS compared with baseline, which was moderate (II) in 2 cases and marked (III) in the other cases. All of the improvements were maintained with chronic DBS, without tremor rebound. CONCLUSIONS: Stimulation of the contralateral VIM/VOP/ZI complex resulted in a noticeable improvement in tremor and recovery of independence in basic daily activities in patients with PTT.