Neurosurgery clinics of North America
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Neurosurg. Clin. N. Am. · Jan 2014
ReviewLimbic neuromodulation: implications for addiction, posttraumatic stress disorder, and memory.
Deep brain stimulation, a technique whereby electrodes are implanted into specific brain regions to modulate their activity, has been mainly used to treat movement disorders. More recently this technique has been proposed for the treatment of drug addiction, posttraumatic stress disorder (PTSD), and dementia. The nucleus accumbens, amygdala, and hippocampus, central nuclei within the limbic system, have been studied as potential targets for neuromodulation for the treatment of drug addiction, PTSD, and dementia, respectively. As the scope of neuromodulation grows to include disorders of mood and thought, new ethical and philosophic challenges that require multidisciplinary discussion and cooperation are emerging.
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Current DBS therapy delivers a train of electrical pulses at set stimulation parameters. This open-loop design is effective for movement disorders, but therapy may be further optimized by a closed loop design. ⋯ Neuronal oscillations may represent or facilitate the cooperative functioning of brain ensembles, and may provide critical information to customize neuromodulation therapy. This review addresses advances to date, not of the technology per se, but of the strategies to apply neuronal signals to trigger or modulate stimulation systems.
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Surgical neuromodulation has emerged as the primary method to treat the medically refractory symptoms of essential tremor and Parkinson disease. With reversible manipulation of CNS neurons, neuromodulation can be used to intraoperatively localize and verify a stereotactic target, and to chronically treat movement disorders. ⋯ Electrical neuromodulation, or deep brain stimulation, is emphasized as the major surgical intervention with a discussion of the technique, surgical targets, and clinical outcomes. A comparison of neuromodulation techniques is presented.
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Neurosurg. Clin. N. Am. · Oct 2013
ReviewStereotactic radiosurgery of intracranial cavernous malformations.
Despite increasing worldwide experience, the role of stereotactic radiosurgery (SRS) in the management of cerebral cavernous malformations (CMs) remains controversial. Microsurgical excision of easily accessible CMs is typically safe; therefore, removal remains the gold standard for most of the symptomatic hemispheric lesions. ⋯ Waiting for the cumulative morbidity of the natural history to justify intervention does not serve the patient's interest, therefore, we argue for early radiosurgical intervention. Carefully designed randomized controlled trials might resolve controversies concerning the role of SRS in treating cerebral CMs.
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Neurosurg. Clin. N. Am. · Oct 2013
ReviewStereotactic radiosurgery of intracranial arteriovenous malformations.
Stereotactic radiosurgery for intracranial arteriovenous malformations (AVMs) has been performed since the 1970s. When an AVM is treated with radiosurgery, radiation injury to the vascular endothelium induces the proliferation of smooth muscle cells and the elaboration of extracellular collagen, which leads to progressive stenosis and obliteration of the AVM nidus. Obliteration after AVM radiosurgery ranges from 60% to 80%, and relates to the size of the AVM and the prescribed radiation dose. The major drawback of radiosurgical AVM treatment is the risk of bleeding during the latent period (typically 2 years) between treatment and AVM thrombosis.