Neurosurgery
-
124 Endoscopic Trigeminal Nucleus Caudalis Doral Root Entry Zone Lesioning for Atypical Facial Pain.
While many chronic pain conditions are challenging to treat, atypical facial pain including conditions such as anesthesia dolorosa and trigeminal deafferentation are among the most difficult. Patients experience numbness in facial areas that also have constant severe, burning pain. The condition results from traumatic or surgical deafferentation injuries of the first-order trigeminal nerve. Anesthesia dolorosa occurs in up to 4% of patients who have undergone prior trigeminal procedures. Deafferentation releases second-order neurons along the trigeminal pain pathway to generate spontaneous pain signals, without a nociceptive stimulus. Medications used for neuropathic pain are first-line but often ineffective. ⋯ Endoscopic NC DREZ lesioning is a safe, effective, and minimally invasive approach for reducing neural hyper-excitability in second order neurons in patients with intractable atypical facial pain. Longer-term studies and follow-up are needed for these challenging types of craniofacial pain.
-
Activity-induced blood flow increases make up the basis for functional brain imaging and are central to normal brain function. Conventionally, cerebral blood flow is thought to be controlled by arterioles that alter brain intraparenchymal vascular tone to subsequently increase or decrease blood flow through downstream capillaries. We present data that challenge the concept that capillaries are merely passive players in blood flow regulation, and propose that not only do capillaries participate in functional hyperemia, they also help maintain brain vascular resistance. ⋯ These findings support the hypothesis that brain capillaries can regulate local blood flow during neuronal activity. In addition, the preservation of capillary RBC flow velocities and hyperemic responsiveness during mild hypercapnia indicates that capillaries possess intrinsic vascular tone and that arterial vasodilation neither drives nor is required for functional hyperemia. Capillaries are not only able to actively participate in functional hyperemia, but may also serve as a site of vascular autoregulation in the brain, potentially providing an additional layer of protection against extremes in cerebral blood supply produced by physiological systemic blood flow fluctuations.
-
Anatomic and functional hemispherectomies are relatively infrequent and technically challenging. The literature is limited by small samples and single institution data. ⋯ This is the largest study to date examining hemispherectomy and associated in-hospital complication rates. This study supports early surgery in patients with medically intractable epilepsy and severe hemispheric disease.
-
The Massachusetts Healthcare Policy of 2006 has many similarities to the Affordable Care Act (ACA). There are concerns the ACA will negatively impact case volume and reimbursement for physicians. Analyzing neurosurgical cases and patient insurance status before and after the Massachusetts policy change can provide insight into the future of neurosurgery in the American health care system. ⋯ After the Massachusetts Healthcare Reform, the number of uninsured individuals undergoing surgeries significantly decreased for all categories of neurosurgical procedures, but more importantly, the total number of cases did not change dramatically. To the extent that Massachusetts predicts the overall US experience, some aspects of reimbursement may be positively impacted by the ACA. Neurosurgery, which treats patients with more urgent conditions, may be affected differently than other specialties.
-
Up to 80% of von Hippel-Lindau disease (VHL) patients develop central nervous system hemangioblastomas (HBs) during the disease course. Treatment of choice for symptomatic HBs remains surgery. VHL-related HBs show avid DOTATATE uptake on PET imaging, suggesting the presence of somatostatin receptors (SSTRs). Neuroendocrine tumors and renal cell carcinoma expressing SSTRs have shown clinical response to somatostatin analogues. For the first time, we describe the presence of SSTRs on VHL HBs and demonstrate a possible tumoral response to somatostatin analogues. ⋯ VHL-associated HBs consistently show stromal-cell expression of SSTR2a, SSTR4, and SSTR5. Activation of these receptors using Octreotide leads to decreased stromal-cell survival. Further work is necessary to elucidate the mechanism of this response, possibly mediated by the SSTR downstream targets SHP-1 or HIF-2. This study is suggestive of the potential use of Octreotide in the management of VHL HBs.