Progress in neurological surgery
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Hematogeneous spread of primary neoplasm can result in central nervous system (CNS) disease burden in various anatomically distinct regions; calvarial, pachymeningeal, leptomeningeal, and intraparenchymal. The choice of imaging modality is dependent on the individual clinical situation, but, largely depends on the patients overall clinical status and the information needed to make treatment decisions. Contrast-enhanced magnetic resonance (MR) imaging is the preferred imaging modality of choice; however, computed tomography (CT) is often utilized as the first-pass screening modality for CNS disease. ⋯ Proton magnetic resonance spectroscopic and dynamic susceptibility contrast-enhanced perfusion-weighted imaging are two physiologic sequences which add additional diagnostic information allowing for improved tumor characterization. Common pitfalls in evaluating for metastatic disease burden include the misidentification of non-neoplastic hematomas, remote microvascular ischemia, and acute onset of ischemic stroke. In the pediatric population, CNS metastases are rare; however, the onset of acute neurological symptoms in a child with known primary tumor should prompt imaging of the neuroaxis.
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We evaluated the role of Gamma Knife stereotactic radiosurgery in the multidisciplinary management of brain metastases ovarian and endometrial, prostate, thyroid, sarcoma, or unknown primary cancers. From a series of over 3,000 patients who had Gamma Knife radiosurgery for brain metastases we reviewed indications and outcomes in patients with less common cancer types. ⋯ Patients with thyroid metastases appear to live much longer with a more indolent course. Radiosurgery is an effective and safe minimally invasive option for patients with brain metastases from these less common primary origins.
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The field of peripheral nerve stimulation (PNS) is now experiencing a phase of rapid growth in number of patients, number of implanters, number of indications, and procedure types. This, however, appears to be only a beginning of major developments that could revolutionize the field of PNS. It is expected that the progress in PNS will continue simultaneously in several directions as new indications, new stimulation targets and new device designs evolve in the foreseeable future. ⋯ Expanding the number of applications will without question strengthen the field of PNS. The turning point, however, will not occur until sufficient scientific evidence is gathered to unequivocally prove its safety, clinical efficacy and cost-effectiveness, and when PNS applications become officially endorsed through regulatory approval of each indication. Such changes will allow implanters to use approved devices for approved indications--instead of the contemporary 'off-label' use--and at the same time give device manufacturers a chance to market these devices and support education on their appropriate use.
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Cluster headache is well known as one of the most painful primary neurovascular headache. Since 1% of chronic cluster headache patients become refractory to all existing pharmacological treatments, various invasive and sometimes mutilating procedures have been tempted in the last decades. Recently, neurostimulation methods have raised new hope for drug-resistant chronic cluster headache patients. ⋯ Other peripheral nerve stimulation approaches used for this indication are also reviewed in detail. Although available studies are limited to a relatively small number of patients and placebo-controlled trials are lacking, existent clinical data suggest that occipital nerve stimulation should nonetheless be recommended for intractable chronic cluster headache patients before more invasive deep brain stimulation surgery. More studies are needed to evaluate the usefulness of supraorbital nerve stimulation and of vagus nerve stimulation in management of cluster headaches.
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Subcutaneous occipital nerve region stimulation is becoming an important part of the overall treatment regimen for a number of chronic headache syndromes refractory to nonsurgical, medical management. A combination of improved device technology and methodology, further understanding about appropriate indications and achievement of on-label FDA status should support continued use and success of this neuromodulation modality.