History and evolution of surgical treatment for spasticity: a journey from neurotomy to selective dorsal rhizotomy.

The evolution of neurosurgical approaches to spasticity spans centuries, marked by key milestones and innovative practitioners. Probable ancient descriptions of spasmodic conditions were first classified as spasticity in the 19th century through the interventions of Dr. William John Little on patients with cerebral palsy. The late 19th century witnessed pioneering efforts by surgeons such as Dr. Charles Loomis Dana, who explored neurotomies, and Dr. Charles Sherrington, who proposed dorsal rhizotomy to address spasticity. Dorsal rhizotomy rose to prominence under the expertise of Dr. Otfrid Foerster but saw a decline in the 1920s due to emerging alternative procedures and associated complications. The mid-20th century saw a shift toward myelotomy but the revival of dorsal rhizotomy under Dr. Claude Gros' selective approach and Dr. Marc Sindou's dorsal root entry zone (DREZ) lesioning. In the late 1970s, Dr. Victor Fasano introduced functional dorsal rhizotomy, incorporating electrophysiological evaluations. Dr. Warwick Peacock and Dr. Leila Arens further modified selective dorsal rhizotomy, focusing on approaches at the cauda equina level. Later, baclofen delivered intrathecally via an implanted programmable pump emerged as a promising alternative around the late 1980s, pioneered by Richard Penn and Jeffrey Kroin and then led by A. Leland Albright. Moreover, intraventricular baclofen has also been tried in this matter. The evolution of these neurosurgical interventions highlights the dynamic nature of medical progress, with each era building upon and refining the work of significant individuals, ultimately contributing to successful outcomes in the management of spasticity.

Signaling Pathways in the Relapse of Glioblastoma.

BACKGROUND: Glioblastoma is the most common primary neoplasm of the central nervous system. Standard treatment includes surgery with maximum safe resection and radiotherapy plus concomitant and adjuvant chemotherapy; however, almost invariably, tumor relapse occurs. We aimed to describe signaling pathways and molecular mechanisms present in tumor relapse of glioblastoma. METHODS: This systematic review followed the PRISMA guidelines. We searched the PubMed, EMBASE and Web of Science databases. We included studies that enrolled patients 15 years or older with a diagnosis of glioblastoma according to Louis criteria and focused on signaling pathways and molecular mechanisms present in tumor relapse of glioblastoma. The outcome of interest was progression-free survival. RESULTS: We identified 1470 articles; 31 met the inclusion criteria. From each publication, we obtained the associated markers O-6-methylguanine-DNA methyltransferase, isocitrate dehydrogenase, mRNA, epidermal growth factor receptor (EGFR), p53, and others. All publications were evaluated with the Q-Genie checklist tool for quality assessment. CONCLUSIONS: We identified a wide variety of signaling pathways and molecular processes that are involved in glioblastoma relapse. This diversity would explain intra- and intertumor heterogeneity, treatment evasion, and relapse. However, only a few molecular processes have robust evidence for clinical utility.

A Case Series of Stereotactic Biopsy of Brainstem Lesions through the Transfrontal Approach.

Background and Importance Brainstem lesions may be unresectable or unapproachable. Regardless, the histopathological diagnosis is fundamental to determine the most appropriate treatment. We present our experience with transfrontal stereotactic biopsy technique for brainstem lesions as a safe and effective surgical route even when contralateral transhemispheric approach is required for preservation of eloquent tissue. Clinical Presentation Twenty-five patients underwent surgery by transfrontal approach. Medical records were reviewed for establishing the number of patients who had postoperative histopathological diagnosis and postoperative complications. Twenty-four patients (18 adults and 7 children) had histopathological diagnosis. There were 18 astrocytomas documented, of which 12 were high grade and 6 low grade. The other diagnoses included viral encephalitis, post-renal transplant lymphoproliferative disorder, nonspecific chronic inflammation, Langerhans cell histiocytosis, and two metastases. No case was hindered by cerebrospinal fluid loss or ventricular entry. Complications included a case of mesencephalic hemorrhage with upper limb monoparesis and a case of a partially compromised third cranial nerve in another patient without associated bleeding. Conclusion Stereotactic biopsy of brainstem lesions by transfrontal ipsilateral or transfrontal transhemispheric contralateral approaches is a safe and effective surgical approach in achieving a histopathological diagnosis in both pediatric and adult populations.

Deep Brain Stimulation for Severe and Intractable Aggressive Behavior.

Aggressive behavior in patients with intellectual disability can be resistant to pharmacological treatment and have detrimental consequences to themselves, family members, and caregivers. Hypothalamic deep brain stimulation (DBS) has been used to improve this type of behavior in severe and refractory cases. Here, we present the description and analysis of DBS of the posteromedial hypothalamus (PMH) and its long-term impact as treatment to improve severe and refractory aggressive behaviors, even with previous bilateral hypothalamotomy without improvement in patients with intellectual disability. Eleven patients underwent bilateral DBS of the PMH. Their medical records were reviewed, and the impact on behavior was measured using preoperative and postoperative Modified Overt Aggression Scale (MOAS) during the last follow-up medical visit. Nine of 11 patients presented a significant decrease in the severity of aggressive behavior, with a preoperative and postoperative MOAS average value of 50.5 and 18.7, respectively. An overall improvement of 63% was seen with a mean follow-up time of 4 years. A patient who previously underwent a bilateral hypothalamotomy via radiofrequency was included in this group. During follow-up, 3 patients presented deterioration of symptoms subsequent to pulse generator depletion but made a full clinical recovery after battery replacement. We posit that DBS of the PMH may be a safe and effective in improving severe and refractory aggressive behavior in patients with long-term intellectual disability.