Pre-and post-surgical non-functional pituitary adenomas and their relationship with high levels of serum glucose.

OBJECTIVES: This clinical, analytical, retro-prospective, auto-controlled, not randomized, and not blinded study, aimed to investigate the association of changes in the serum glucose levels with the pre-and-post changes in the size tumor in mm3 in the Non-Functional pituitary adenomas. METHODS: Pre-and post-surgical MRI, as well as the measurements in the serum glucose levels and immunohistochemical techniques were performed in all the patients in the study, with a mean followed-up until 208.57 days. A comparison was made between the reductions in tumor size of hormonally active pituitary adenomas (HSPAs) vs NFPAs. RESULTS: Seventy-four patients were included in this study, of whom, 46 were NFPAs. The decrease in the NFPAs tumor size after surgery was statistically significant (P ≤ 0.0001). The Mean of the differences of both type of tumors in mm3 were -9552 ± 10287. Pre-surgery, the mean of the HSPAs were 8.923 ± 2.078; and the NFPAs were 14.161 ± 1.912. The differences in the tumor size were statistically significant (p = 0.039). Post-surgical, the mean of the HSPAs were 2.079 ± 971, with a (p = 0.14): and the NFPAs were 4.609 ± 1.205. After surgery of the NFPAs, most of the patients-maintained serum levels ≤ 100 mg/dL, with a statistical significance (P ≤ 0.0003). CONCLUSION: This study demonstrates for the first time the correlation between the presence of pre-and post- surgical changes in the NFPAs, with modifications in the levels of serum glucose, and the comparison, pre- and post-surgical between the tumor size of HSPAs and NFPAs.

Improvement of metabolic syndrome and its components in patients who underwent transsphenoidal resection for pituitary adenoma.

BACKGROUND: Pituitary adenomas (PA) are neoplasms of pituitary adenohypophyseal cell lineage, which are the third most common cause of brain tumors among adults. Due to hormone secretion, PAs are closely related to metabolic syndrome (MetS). However, the relationship between these two entities has been scarcely studied to date. PURPOSE: This paper aims to evaluate changes in the metabolic status of patients with PA before and after surgical treatment and to look for differences in metabolic outcomes among patients according to the adenoma type and the surgery success rate. METHODS: We assessed patients with PA who went through transsphenoidal surgery for its treatment, documenting metabolic parameters before and after surgery, analyzed whole sample changes, and then stratified them according to adenoma type (nonfunctioning, somatotroph, lactotroph, and corticotroph), and surgery success (total resection, near-total resection, partial resection, subtotal resection). RESULTS: A total of 214 patients were enrolled for this study. The prevalence of MetS with AACE criteria went from 51.52% before surgery to 28.99% after surgery (P < 0.001). Hyperglycemia (HG) was the most beneficial component; it went from 56% pre-surgery to 40.51% post-surgery (P = 0.03). The total resection group had the best improvement, with a significant decrease of prevalence in MetS from 83 to 16% (P < 0.001), and every component, except hypoalphalipoproteinemia (HA): obesity went from 96 to 67% (P < 0.001), arterial hypertension (AH) 59 to 24% (P < 0.001), HG 74 to 23% (P < 0.001), and hypertriglyceridemia (HTG) from 81 to 54% (P < 0.001). According to MetS prevalence, there was no difference in the improvement according to PA type. CONCLUSION: Surgical treatment in patients with PA is associated with MetS improvement.

Pre- and post-clinical-radiological and surgical evaluation of patients with pituitary adenoma and metabolic syndrome.

BACKGROUND: Pituitary adenomas are benign tumors located in the anterior hypophysis. Its appearance is associated with the development of parameters related to metabolic syndrome; therefore, surgical treatment could reduce associated morbimortality. METHODS: Pre- and post-surgical MRI, using the Hardy-Wilson and Knosp classification, and clinical data according to the American Association of Clinical Endocrinology (AACE) criteria for metabolic syndrome: all the patients were followed-up until 208.57 days were reviewed on 217 consecutive patients with pituitary surgery. RESULTS: Seventy-four patients were included in this study. There was a significant reduction in tumor size in mm3 [average pre- and post-surgery respectively: 12,362 mm3 (±12,397); 3,910 mm3 (±7,160)], (p < 0.0001). This was confirmed by the Hardy-Wilson and Knosp classification, where most patients went from grade IV C (33.7%) to grade 0 (12.1%), IA (20.2%), IIB (21.36%), and IIC (16.2%); as well as from grade 4 (24.3%) to grade 0 (45.9%), respectively. After surgery, there were statistically significant reductions in total serum levels of glucose [average pre- and post-surgery, respectively: 116 mg/dL (±26.9); 90 mg/dL (±10.2)], (p < 0.001), triglycerides [average pre- and post-surgery, 240 mg/dL (±102); 171 mg/dL (±60.5)], (p = 0.001); and HDL-c [average pre- and post-surgery, respectively: 39 mg/dL (±11.8); 44.6 mg/dL (±8.4)], (p = 0.029). The other parameters remained unchanged. CONCLUSION: This is the first study to demonstrate the relationship between the presence of pituitary adenoma and significative changes in serum glucose, triglycerides and c-HDL related to metabolic syndrome.

Biochemical blood profile in water buffaloes: alterations related to natural infection by Trypanosoma spp / Perfil bioquímico do sangue em búfalos: alterações relacionadas à infecção natural por Trypanosoma spp

ABSTRACT Blood and biochemical profiles of animals can be used to evaluate the physiological state of an individual and relate it to that individual's health. In many countries, water buffaloes are currently evaluated using blood parameters from other bovine species. To accurately interpret the biochemical results from individual animals, species-specific reference ranges should be established. One hundred and twenty-eight water buffaloes, without clinical signs of disease and of different ages, were analyzed, and reference intervals were calculated (95% CI; p < 0.05). The data were analyzed according to three age groups (calves, young animals, and adults) and the infection status (infected or uninfected with Trypanosoma spp.). All the biochemical values of total serum proteins, aspartate aminotransferase, gamma globulin, urea nitrogen, calcium, and phosphorus were included; these are parameters that are generally affected by parasites or by infection with hemotropic agents. Natural infection with Trypanosoma spp. gave rise to differences (p < 0.05) in terms of increased calcium and decreased total protein, alkaline phosphatase, and aspartate aminotransferase. Thus, it can be inferred that the infection follows a chronic course in the affected animals, in this case, young animals or young animals.

RESUMO Introdução: Os perfis sanguíneos e bioquímicos de animais podem ser usados para avaliar o estado fisiológico de um indivíduo e relacioná-lo com a saúde desse indivíduo. Em muitos países, os búfalos são atualmente avaliados usando parâmetros sanguíneos de outras espécies bovinas. Para interpretar com precisão os resultados bioquímicos de animais individuais, os intervalos de referência específicos da espécie devem ser estabelecidos. Método: Foram analisados 128 búfalos, sem sinais clínicos da doença e de diferentes idades, e calculados os intervalos de referência (IC 95%; p < 0,05). Os dados foram analisados de acordo com três faixas etárias (bezerros, novilhos e adultos) e o estado de infecção (infectado ou não por Trypanosoma spp.). Todos os valores bioquímicos de proteínas séricas totais, aspartato aminotransferase, gamaglobulina, nitrogênio ureico, cálcio e fósforo foram incluídos; estes são parâmetros que geralmente são afetados por parasitas ou por infecção com agentes hemotrópicos. Resultados: A infecção natural por Trypanosoma spp. originaram diferenças (p < 0,05) em termos de aumento de cálcio e diminuição de proteína total, fosfatase alcalina e aspartato aminotransferase. Com isso, pode-se inferir que a infecção segue um curso crônico nos animais acometidos, neste caso, animais jovens ou novilhos.

Clinical outcomes report in different brachial plexus injury surgeries: a systematic review.

Brachial plexus injury is a lesion that results in loss of function of the arm, and there are multiple ways of surgically approaching its treatment. Controlled trials that compare all surgical repair strategies and their clinical outcomes have not been performed. A systematic review was conducted to identify all articles that reported clinical outcomes in different surgeries (nerve transfer, nerve graft, neurolysis, end-to-end, multiple interventions, and others). Advanced search in PubMed was performed using the Mesh terms "brachial plexus injury" as the main topic and "surgery" as a subtopic, obtaining a total of 2153 articles. The clinical data for eligibility extraction was focused on collecting motor, sensory, pain, and functional recovery. A statistical analysis was performed to find the superior surgical techniques in terms of motor recovery, through the assessment of heterogeneity between groups, and of relationships between surgery and motor recovery. The frequency and the manner in which clinical outcomes are recording were described. The differences that correspond to the demographics and procedural factors were not statistically significant among groups (p > 0.05). Neurolysis showed the highest proportion of motor recovery (85.18%), with significant results between preoperative and post-operative motor assessment (p = 0.028). The proportion of motor recovery in each group according to the surgical approach differed significantly (X2 = 82.495, p = 0.0001). The motor outcome was the most reported clinical outcome (97.56%), whereas the other clinical outcomes were reported in less than 15% of the included articles. Unexpectedly, neurolysis, a technique displaced by new surgical alternatives such as nerve transfer/graft, demonstrated the highest proportion of motor recovery. Clinical outcomes such as pain, sensory, and functional recovery were infrequently reported. These results introduce the need to re-evaluate neurolysis through comparative clinical trials, as well as to standardize the way in which clinical outcomes are reported.

Evaluación de algunos factores de riesgo para la presentación de síndrome de úlcera gástrica (SUGE) en el caballo criollo colombiano en el Valle de Aburrá, Antioquia (Colombia) / Evaluation of some risk factors for the presentation of equine gastric ulcer syndrome (EGUS) in colombian creole horse in Valle de Aburrá, Antioquia (Colombia)

RESUMEN Las úlceras gástricas se definen como la pérdida de continuidad de la mucosa gástrica. Se originan principalmente por desequilibrio entre factores injuriantes y de protección del estómago. Generalmente se manifiestan con signos como pérdida de peso, cólico, bruxismo e inapetencia, conllevando al bajo rendimiento del animal y pérdidas económicas. El objetivo del presente estudio fue determinar la prevalencia y factores de riesgo para la presentación de SUGE en CCC del Valle de Aburra. Se realizó gastroscopia a 100 animales de diferentes pesebreras, entre dos y 25 años de edad; cada estómago se caracterizó macro y microscópicamente. Las lesiones macroscópicas se valoraron de acuerdo con el grado de lesión según el Equine Gastric Ulcer Council, y la clasificación microscopica se basó en una adaptación hecha por patrones de descripción de lesiones más utilizados como: The sidney system y Equine gastritis grading system (EGGS). Para el análisis de los resultados, se tuvieron en cuenta variables como la intensidad del ejercicio, alojamiento, tipo y frecuencia de alimentación, transporte y frecuencia del mismo. El 65% de los equinos evaluados presentaron lesiones compatibles con SUGE. Macroscópicamente el grado 2 de severidad fue el más común (38%), con mayor presentación en la región aglandular. Microscópicamente el edema en la región fundica y pilórica fue la lesión más frecuente (35,2% y 30,7%, respectivamente). Los principales factores de riesgo asociados a la presentación de las lesiones fueron el transporte de los animales y la intensidad del ejercicio.

ABSTRACT Gastric ulcers are defined as the loss of continuity of the gastric mucosal. They are mainly caused by an imbalance between harmful and protective factors of the stomach. It generally manifests itself with signs such as weight loss, colic, bruxism and inappetence, which can lead to low performance and economic losses. The objective of the present study was to determine the prevalence and risk factors for the presentation of SUGE in CCC of the Valle del Aburra. Gastroscopy was made to 100 animals from different stables, between two and 25 years of age; each stomach characterized, macro and microscopically. Lesions are evaluate depending on the degree of injury to the "Equine Gastric Ulcer Council". Microscopic lesions classification was based on an adaptation by patterns most commonly used description of injuries such as: the Sidney System and the equine gastritis grading system (EGGS). For the analysis of the results, variables such as exercise intensity, accommodation, type and frequency of feeding, transportation and its frequency were taken into account. 65% of the equines evaluated presented SUGE-compatible lesions, of which the most common degree of severity macroscopically was grade 2 (38%), with grater presentation in the non-glandular region. Microscopically, edema in the fundic and pyloric region was the most frequent (35.2% and 30.7%, respectively). The main risk factors associated with the presentation of the lesions were the transport of the animals and the intensity of the exercise.

[Treatment of refractory aggressiveness by amygdalotomy and posteromedial hypothalamotomy by radiofrequency]. / Tratamiento de la agresividad refractaria mediante amigdalotomia e hipotalamotomia posteromedial por radiofrecuencia.

INTRODUCTION: Since, under certain circumstances, defensive or attacking behaviours display a pattern of motor dominance, as observed in subjects who participate in contact or fighting sports, aggressive behaviour was considered to have a dominant motor pattern. With the aim of preventing the functional problems reported with bilateral lesion procedures involving both the central nucleus of the amygdala and the posteromedial hypothalamus, the decision was made to combine them; thus, an amygdalotomy of the central nucleus of the amygdala and a posteromedial hypothalamotomy were to be performed simultaneously and unilaterally, on the basis of the motor dominance of the patient determined by means of the Edinburgh test. PATIENTS AND METHODS: This study describes the surgical experience in a series of nine patients diagnosed with refractory neuroaggressive syndrome. As part of the study protocol, a magnetic resonance brain scan was performed to rule out the presence of neoplasms, vascular diseases, infections and degenerative disorders. The degree of aggressiveness was quantified using Yudofsky's Overt Aggression Scale. Additionally, manual dominance was determined by means of the Edinburgh test. RESULTS AND CONCLUSIONS: Good control of aggressiveness was seen immediately. In some cases it was necessary to reduce the antipsychotic or benzodiazepine medication, as it was seen to increase aggressiveness. Only one case required a second surgical intervention. Follow-up was achieved in 100% of the cases at 24 months and 78% at 36 months.

TITLE: Tratamiento de la agresividad refractaria mediante amigdalotomia e hipotalamotomia posteromedial por radiofrecuencia.Introduccion. Dado que, en algunas circunstancias, las conductas defensivas o de ataque muestran un patron de dominancia motora, tal como se observa en los sujetos dedicados a los deportes de contacto o de lucha, se considero que la conducta agresiva tiene un patron motor dominante. Con el fin de evitar los problemas funcionales descritos con los procedimientos de lesion bilateral tanto del nucleo central de la amigdala como del hipotalamo posteromedial, se decidio combinarlos; es decir, realizar amigdalotomia del nucleo central de la amigdala e hipotalamotomia posteromedial de manera unilateral y simultanea, basandose en la dominancia motora del paciente mediante la prueba de Edimburgo. Pacientes y metodos. Este estudio muestra la experiencia quirurgica en una serie de nueve pacientes con el diagnostico de sindrome neuroagresivo resistente al tratamiento farmacologico. Dentro del protocolo de estudio, se les realizo resonancia magnetica cerebral para descartar la presencia de neoplasias, enfermedades vasculares, infecciones y trastornos degenerativos. El grado de agresividad se cuantifico mediante la escala global de agresividad de Yudofsky. Adicionalmente, se determino la dominancia manual a traves de la prueba de Edimburgo. Resultados y conclusiones. El buen control de la agresividad se observo de modo inmediato. En algunos casos fue necesario reducir la medicacion de antipsicoticos o benzodiacepinas, ya que aumentaban la agresividad. Solo un caso requirio una segunda cirugia. Se logro seguimiento del 100% de los casos en 24 meses y del 78% en 36 meses.

Sistema Vestible para la Detección Simultánea y No Invasiva del ECG y el Flujo Sanguíneo / Wearable System for Simultaneous and Noninvasive Detection of ECG and Blood Flow

Resumen Se desarrolló un sistema vestible para la detección simultánea y no invasiva de dos señales provenientes de la actividad cardiaca: el ECG y el flujo sanguíneo. Se utilizaron dos electrodos secos para detectar la derivación I del ECG. La detección del flujo sanguíneo se realizó de forma no invasiva mediante un sensor magnetorresistivo tipo Túnel (TMR) basándose en la firma magnética de la sangre sobre un campo magnético constante proveniente de un imán permanente. Los electrodos, el sensor TMR y el imán se montaron en un brazalete tipo pulsera para la comodidad del usuario. La instrumentación desarrollada para detectar el ECG y el flujo sanguíneo se diseñó en base a una configuración diferencial con una relación de rechazo en modo común superior a 87 dB a 60 Hz y con una tensión de ruido de tal forma que las señales cardiacas presentaron una relación señal a ruido superior a 41 dB, siempre y cuando el sujeto no se mueva durante la medida. La calidad de las señales fue suficiente como para extraer información de dichas señales mediante algoritmos sencillos de implementar. El sistema propuesto es una alternativa a los sistemas vestibles presentados hasta ahora, del cual es posible valorar la salud cardiovascular del sujeto en ambientes no hospitalarios.

Abstract A wearable system was developed for the simultaneous and non-invasive detection of two signals from cardiac activity: the ECG and blood flow. Two dry electrodes were used to detect the lead I of the ECG. The detection of blood flow was performed non-invasively using a tunnel-magnetoresistance (TMR) sensor based on the magnetic signature of the blood over a constant magnetic field from a permanent magnet. The electrodes, the TMR sensor and the magnet were mounted on a wristband-type bracelet for the user comfort. The instrumentation developed to detect the ECG and blood flow was designed based on a differential configuration with a common-mode rejection ratio higher than 87 dB at 60 Hz and with a noise voltage in such a way that the cardiac signals presented a signal-to-noise ratio greater than 41 dB, as long as the subject stays still during the measurement. The quality of the signals was enough to extract information from these signals by means of simple to implement algorithms. The proposed system is an alternative to the wearable systems presented so far, from which it is possible to assess the cardiovascular health of the subject in non-hospital environments.

Skull stab wound from a metal railroad nail perforating the right frontal lobe.

STUDY DESIGN: Case report and review of literature. OBJECTIVE: To present the rare case of a 70-year-old man with a punctured cranial lesion, who was treated with surgery and had a positive recovery. SUMMARY OF BACKGROUND DATA: Cerebral trauma as the serious consequence of urban aggressiveness. METHOD: Clinical and imagery review of a cranial puncture trauma caused by a metal railroad nail, which penetrated the cranium, dura mater, frontal cerebral parenchyma and deep structures, lodging itself next to the midline, without damaging the superior sagittal sinus. RESULTS: The patient underwent a frontal craniotomy to remove the metal nail. He was hospitalized 2 weeks post-surgery and discharged. During external consultations, he manifested no neurologic deficit. A post-surgical CT ruled-out a brain abscess or other complications. CONCLUSIONS: Skull and brain stab wound lesions are highly infrequent, but evaluating the mechanism of injury and the successful medical and surgical treatment employed is illustrative of how post-traumatic recovery of this severe head injury can be achieved. The site of the injury and the position of the object were decisive for establishing an adequate diagnosis and prognosis. The patient reported an exemplary recovery without any secondary complications.

Sedación y analeesia con bolos de xilazina y mofina en infusión continua en unna yegua criolla Colombiana sometida a ovarioectomía en estación / Sedation and analgesia with xylazine bolus and morphine in continuous infusion in a mare standing subjected to ovariectomy: case report

En el acto quirúrgico la anestesia es un proceso que siempre conlleva riesgos. Un procedimiento común en equinos es realizar cirugías en estación para disminuir el riesgo de la anestesia general. Para los procedimientos anestésicos en estación en equinos se han utilizado las combinaciones de bolos de xilazina y anestesia local; sin embargo, la analgesia irregular y la marcada ataxia son complicaciones frecuentes. En el presente caso clínico se evaluó un protocolo de bolos de xilazina 0,6 mg/kg I.V. y morfina en infusión I.V. continua a 30 µg/kg/hora, con aplicación de anestesia local para la extraccción de un tumor de células de la granulosa en una yegua. Durante el procedimiento quirúrgico se observó una buena analgesia, sedación moderada y ataxia leve, sin alteraciones cardiovasculares o respiratorias, lo que favoreció el procedimiento quirúrgico; solamente se observó un corto periodo de amotilidad intestinal el cual fue superado espontáneamente. La yegua se recuperó totalmente del procedimiento quirúrgico y presentó evidencia de estro en dos ocasiones dentro del año siguiente a la intervención. Los procedimeintos anestésico y quirúrgico empleados en esta yegua fueron apropiados y la llevaron a su normalidad reproductiva.

Anesthesia is always a procedure that leads many risks in the quirurgical act. A common procedure in horses is to make standing surgeries to decrease the general anesthesia risks. For standing anesthetic procedures in horses there have been used combinations of xilazine bolus and local anesthesia; however, irregular analgesia and marked ataxia are frequent complications. In this clinical case it was evaluate a protocol of xilazine bolus 0,6 mg/kg I.V. and a constant rate infusion of morphine 30 µg/kg/h I.V., with local anesthesia for the extraction of a granulosa cell tumor in one mare. In general, during the surgical procedure it was observed good analgesia, moderate sedation and slight ataxia, without cardiovascular or respiratory problems which favored the surgical procedure; it was observed only a short period without intestinal motility that returned to normality spontaneously. The mare recovered fully from the surgical procedure and presented evidence of estrus twice within one year after the intervention. The anesthetic and surgical procedures used in this case were appropriate and lead recovery of the normal reproductive behavior of this mare.

[Central nervous system neuromodulation for the treatment of epilepsy. II. Mechanisms of action and perspectives]. / Neuromodulation du système nerveux central dans le traitement des épilepsies. II . Mécanismes d'action et perspectives.

OBJECTIVES: Review of available evidence of the mechanisms of action underlying the anticonvulsant effect of current applied to various CNS structures. MATERIAL AND METHODS: Studies were conducted from observations of patients with drug-resistant seizures and treated with neuromodulation. Seizures originated from various cortical areas with secondary generalization or were initially generalized without a focal origin, either clinically or on EEG or SEEG. Intracranial recordings and SEEG were performed using subdural grids or depth electrodes implanted either for recordings or therapeutic deep brain stimulation (DBS). In a group of mesial temporal lobe epilepsy patients investigated with subdural or SEEG electrodes, the epileptogenic focus area was stimulated for 15 days before anterior temporal lobectomy. The surgical specimen was examined using standard and electronic microscopy and autoradiography in order to identify several neurotransmitter receptors. They also were compared to other surgical specimens from epileptic patients who had intracerebral recordings but without stimulation (epileptic controls) and to autopsy specimens from subjects with no history of epilepsy (nonepileptic controls). RESULTS: High-frequency (HF) stimulation increases the after-discharge threshold of the stimulated site and alters the cycles of potentials evoked by a test stimulation using a paradigm of coupled stimulations. HF stimulation also decreases local cerebral blood flow in the stimulated area as demonstrated on SPECT. Parahippocampal cortex HF stimulation significantly increases the GABAergic benzodiazepine receptor density in the stimulated area. In addition, centromedianum (CM) thalamic nucleus HF stimulation suppresses thalamic and cortical spike-waves, as well as secondary synchronous discharges visible on EEG. Conversely, low-frequency (3-Hz) bilateral CM stimulation induces a typical absence clinically and on EEG. CONCLUSION: High-frequency stimulation is responsible for an inhibition of local and propagated epileptogenesis. Low-frequency stimulation may trigger or enhance epileptogenesis when applied on epileptogenic regions.

[Central nervous system neuromodulation for the treatment of epilepsy]. / Neuromodulation du système nerveux central dans le traitement des épilepsies I-Efficacité et sécurité de la méthode.

We present here a review of the work on neuromodulation - defined as application of an inhibitory or excitatory current - on intracranial structures for the treatment of drug-resistant epilepsy. Near 250 patients were treated using a neuromodulation technique of the cerebellum (paravermian cortex), the CM-pf nucleus of the thalamus, the hippocampus, epileptogenic foci, and anterior ventral nucleus of the thalamus, with a one- to 15-year follow-up. Four contact strips were used for cerebellar and functional region neuromodulation, and DBS-type depth electrodes were stereotactically implanted for CM-pf and anterior nuclei of the thalamus and hippocampal neuromodulation. Electric stimulation was cyclic in almost all trials, using low frequency (10-40 Hz) for excitation and high frequency (60-185 Hz) for inhibition. Seizure frequency reduction was variable, depending on the neuromodulation site and patient selection, although seizure duration decreased in most patients. Cerebellar neuromodulation was followed by a 78% reduction in tonic and tonic-clonic seizures, CM-pf neuromodulation by an 83% reduction in tonic-clonic seizures and atypical absence of Lennox-Gastaut syndrome, with a 17.2% seizure-free and drug-free patient rate. Hippocampal neuromodulation was followed by a 73% reduction in partial complex seizures, with a 33% seizure-free patient rate. Anterior ventral nucleus of the thalamus was followed by a 63% reduction in tonic-clonic, tonic and atonic seizures. Several prognostic factors were identified in order to improve future results. There was no mortality and morbidity was limited to skin erosion at the neurostimulator site. Seizure reduction was associated with improved neuropsychological performance and better quality of life. Neuromodulation is safe and effective for the treatment of epileptic seizures of various origins. Several targets may be associated in a single patient, especially when bilateral hippocampal seizure foci are present.

Neuromodulation of prelemniscal radiations in the treatment of Parkinson's disease.

In patients with Parkinson's disease (PD), tetrapolar electrodes were implanted in the prelemniscal radiations (RAPRL) to treat tremor, rigidity and bradykinesia. Fifteen patients were implanted unilaterally and five patients bilaterally and followed-up for one year. The selection criteria included the presence of unilateral pronounced tremor and rigidity in patients implanted unilaterally or bilateral symptoms including severe bradykinesia in patients implanted bilaterally. In the operating room, the tremor decreased significantly or was abolished following the insertion of the electrode in the RAPRL. This effect was temporary and subsided when the stimulation was off. However, when the stimulator was turned on, the severity of the symptoms and signs decreased significantly. The post-implantation MRI confirmed that the electrode contacts used for stimulation were inserted in RAPRL, a group of fibers located between the red nucleus and subthalamic nucleus, above the substantia nigra, medially to the zona incerta and below the thalamus. The patients were evaluated using the UPDRS part III, before implantation and every 3 months during the first year. Global scores decreased significantly. The pre- and postoperative median values (range in round brackets) were as follows: tremor improved from 3 (2-16) to 1 (2-3) (p<0.001); rigidity was either abolished or decreased markedly from 2 (1-16) to 0 (0-4) (p< 0.001); bradykinesia improved from 2 (0-4) to 1 (0-2) (p<0.001). We conclude that RAPRL, an area anatomically different from STN, is a good target for electrical stimulation in order to treat effectively all the main symptoms of PD.

The role of neuromodulation of the hippocampus in the treatment of intractable complex partial seizures of the temporal lobe.

We present the results of chronic electrical stimulation of the hippocampus (ESH) in 9 patients with complex partial seizures and at least 18 months follow-up. The magnetic resonance imaging (MRI) scan was normal in 5 while in 4 patients it showed hippocampal sclerosis. The seizure frequency ranged from 10 to 50 seizures per month. All patients were submitted to implantation of diagnostic 8-contact bilateral hippocampal depth electrodes to determine the location of epileptic foci. Once the focus was located, the diagnostic electrodes were replaced by deep brain stimulation (DBS) electrodes. Following DBS, all patients improved. With respect to outcome, patients were divided in two groups, one seizure-free (5 patients) and the other with residual seizures (4 patients). Both groups shared similar clinical features. However, the patients who were seizure free had normal MRI scan while those who had residual seizures were being stimulated on a sclerotic hippocampus. We conclude that electrical stimulation of the epileptic hippocampal formation can control mesial temporal seizures. Best results are obtained if we stimulate a hippocampus which does not show sclerosis in the MRI. In these cases, seizures are stopped and the recent memory tests improve even in patients with bilateral foci. This result is of extreme importance to patients who have either intractable seizures and normal MRI or bilateral epileptogenic foci, are excluded as candidates for temporal lobectomy and are left with no other alternative.

Deep brain stimulation for treatment of the epilepsies: the centromedian thalamic target.

Electrical stimulation (ES) of the thalamic centromedian nucleus (CMN) has been proposed as a minimally invasive alternative for the treatment of difficult-to-control seizures of multifocal origin and seizures that are generalized from the onset. ES intends to interfere with seizure propagation in a non-specific manner through the thalamic system. By adopting a frontal parasagittal approach and based on anterior-posterior (AC-PC) commissure intersection, deep brain stimulation (DBS) electrodes are stereotactically inserted. Electrophysiologic confirmation of electrodes position is accomplished by eliciting cortical recruiting responses and direct current (DC) shifts by low- and high-frequency stimulation through the electrodes. Cycling mode of bipolar stimulation has been used at 60-130 Hz, 0.45 msec, 2.5-3.5 V, 1 min ON in one side 4 min OFF, 1 min ON in the other side and 4 min OFF forward and back for 24h. ES of CMN significantly decreases generalized seizures of cortical origin and focal motor seizures. Best results are obtained in non-focal generalized tonic clonic seizures and atypical absences of the Lennox-Gastaut syndrome. Experience has indicated that the most effective target for seizure control is the thalamic parvocellular centromedian subnucleus.