7 Functional Neurosurgery
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Transcript of 7 Functional Neurosurgery
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الرحمن الله بسمالرحيم
الرحيم الرحمن الله بسمالرحمن الله بسم
الرحيم
الرحمن الله بسمالرحيم
الرحيم الرحمن الله بسم
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Dr. Yahya Al-MuazenConsultant Neurosurgery & Radiosurgery
&Functional Neurosurgery
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CT scan cut through the level of the anterior horns of the lateral ventricles.
Anterior horn of lateral ventricle
Septum pellucidum
Calcified pineal
Calcified choroid plexus in occipital horn of lateral
ventricle .
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Caudatenucleus
Corpuscallosum
Lateralventricle
Calcified choroid
plexus
Frontal lobe
Septum pellucidum
Skull
CT scan of skull through the level of the bodies of the lateral ventricles.
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The segmental Cutaneous innervation of the body
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Deformities of the hand.(a )Radial palsy-wrist drop.(b )Ulnar nerve palsy Main
en griffe' or claw hand.(c )Median nerve
palsy – 'Monkey's hand'. )d( Volkmann's contracture - another claw hand deformity. The pink areas represent the usual distribution of anaesthesia.
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Functional Neurosurgery
• Parkinsonism -Anatomy
- Clinical Featur- Diagnosis
-Treatment
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VPL-Pallidotomy-Rationale-
Dopamine )-( Putamen )+( )+( VPL-Pallidum )+( SubthalamicNucleus
)-(
Medial Pallidum - vop/Voa - Area 6 a
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Indication Target
Tremor Vim,)Rigor( Suvthalamus
)dentato-thalamic fibres
Rigor Vop / Vim,)Tremor( Subthalamus
)pallido-thalamic fibres(
Thalamotomy-Present state-
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Indication Target
Tremor Vim,Uni - and bilateral
Stim – Parameter: 100-200 Hz, 0,5-1msec2-5 V
Side –Effects: Tingling-sensations contralateral)occasional, usually mild(
Elektrostimulation
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Dopamine )-( Putamen )+( )+( VPL-Pallidum )+( SubthalamicNucleus
)-(
Medial Pallidum - vop/Voa - Area 6 a
VPL-Pallidotomy-Rationale-
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VPL-Pallidotomy
Indication Target
- Akinesia, Bradykinesia VPL Pallidum- Dopamine induced dyskinesias- Rigor - Tremor
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Thalamotomy in Parkinson’s Disease-Results-
Vim, Subthalamus
Tremor Complete relief initially 75%
long term 66%
Partial relief initially 18%long term 13%
Rigor Significant relief initially 80%
long term 71%
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Thalamotomy in Parkinson’s Disease-Results-
Vop, Subthalamus
Tremor Complete relief initially 44%
long term 35%
Partial relief initially 30%long term 25%
Unchanged 26%
Rigor Significant relief initially 82%
long term 65%
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Patients n=215Follow-up 6m – 8y
ResultsImprovement 93%Akinesia +++Dopamine induced dyskinesias +++Rigor ++Tremor +
ComplicationsHomonymous scotoma 7%In central lower visual field )early series
VPL-Pallidotomy-Laitinen, L., 1993-
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RelationsmaBeModellhimRontgenhim(rP)rP/M
(1) Basisline )a( AC PC
)b( Formen Monroi-PC
(2) Thalamushohe in ½ Basislinie
)a( AC – PC
)b( Foramen Monroi – PC
3) Hemispharenbreite
re/li
)a( 25,0
)b( 23,5
)a( 15,2
)b( )b( 14,0
63,5
28,0
76.5 – 1.5 =75
1.12
1.2
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AbstandsmaBe des Zielpunktes
(ZP)
Modellhim
(M)
rP berechnet
Mit rP/M
rP berechnet
Mit RV
Koordinaten
RoRo.Op.
(a)
Von Mitte AC PC ZP
Von FM auf Basislinie ZP
Von PC auf Basislinie ZP
(b)
Oberhalb (+)
Unterhalb (- )
Basislinie
(c)
Mitte III Ventrikel ZP re/li
Sagittal
Vertikal
Frontal re/li
7.0 Pe
14.5 M.D,II.V
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Future Prospects
- Grafting of stem – cells - Microinfusion of growth – factors- VPL – Pallidotomy
Surgical Treatmentin Parkinson’s Disease
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Vim, Subthalamus
- Motor neglect 7%
- Speech impairment 0% )unilateral(
- Bilateral 15%
Thalamotomy in Parkinson’s Disease -Side effects-
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Target:- Striatum
Grafts:- Adrenal tissue- Embyonal midbrain - tissue
Tissue - Transplantation
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Radiosurgery
Brain tumor AVM Epilepsy Parkinsonism
Indication:
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Linac Isocenter Check: + 0.32 mm+ isocenter and laser+ positioning to laser+ densitometric measurement
Displacement of Dose Center: + 0.62.mm+ stereotactic localization+ positioning device
Displacement of 80% Isodose: + 0.34 mm
+ dosimetry
__________________________________________________________Overall Accuracy: +0.78 mm
Accuracy in Linac Radiosurgery
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30Gy 11Gy 8GyAcoustic Neuroma
Dose Gradient Shaping
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__________________________________
Optic pathways 8 Gy 3rd, 4th and 6th cranial nerve. 20 Gy 5th nerve. 15 Gy__________________________________
Tolerable Single Dose
Organs at Risk
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RS for Benign Skull - Base Tumors-Earl Series
Indications Dose__________________________________
__________________________________
__________________________________
Acoustic Neuromas 14 - 20 Gy)Stockholm, Heidelberg, Cologne(
Meningiomas)Heidelberg, Cologne(
Pituitary Adenomas 20 - 60 Gy)Stockholm, Boston(
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Acoustic Neuromas 10 - 13 Gy)mean 11 Gy(
Meningiomas 9 - 14 Gy)mean 12 Gy(
Pituitary Adenomas 10 - 14 Gy)mean 12 Gy(
RS for Skull - Base Tumors-Ongoing Series
Indications Dose__________________________________
__________________________________
__________________________________
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RS for Benign Skull - Base Tumors-Strategies
Early series__________________________________
__________________________________
__________________________________
1st priority: Dose homogeneity )few isocenters(
2nd priority: Dose conformation
Peripheral Dose: Higher
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_________________________________1st priority: Optimal Dose Conformation
( more isocenters)
_________________________________2nd priority: Dose homogeneity
__________________________________Peripheral Dose: Lower.
( limited by burden to organs at risk)
RS for Benign Skull - Base Tumors - Strategies
Ongoing Series:
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Treatment Planning in AVM’s
20Gy
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AVMa. – p. view
Stereotactic Angiography
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Meningioma
12 Gy10 Gy
Dose Gradient Shaping
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Linac – RS in a Pituitary Adenoma
18 Gy12 Gy 8 Gy
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