7 functional neurosurgery

الرحمن الله بسمالرحيم

الرحيم الرحمن الله بسمالرحمن الله بسم

الرحيم

الرحمن الله بسمالرحيم

الرحيم الرحمن الله بسم

Dr. Yahya Al-MuazenConsultant Neurosurgery & Radiosurgery

&Functional Neurosurgery

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 .

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.

The segmental Cutaneous innervation of the body

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.

Functional Neurosurgery

• Parkinsonism -Anatomy

- Clinical Featur- Diagnosis

-Treatment

VPL-Pallidotomy-Rationale-

Dopamine )-( Putamen )+( )+( VPL-Pallidum )+( SubthalamicNucleus

)-(

Medial Pallidum - vop/Voa - Area 6 a

Indication Target

Tremor Vim,)Rigor( Suvthalamus

)dentato-thalamic fibres

Rigor Vop / Vim,)Tremor( Subthalamus

)pallido-thalamic fibres(

Thalamotomy-Present state-

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

Dopamine )-( Putamen )+( )+( VPL-Pallidum )+( SubthalamicNucleus

)-(

Medial Pallidum - vop/Voa - Area 6 a

VPL-Pallidotomy-Rationale-

VPL-Pallidotomy

Indication Target

- Akinesia, Bradykinesia VPL Pallidum- Dopamine induced dyskinesias- Rigor - Tremor

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%

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%

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-

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

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

Future Prospects

- Grafting of stem – cells - Microinfusion of growth – factors- VPL – Pallidotomy

Surgical Treatmentin Parkinson’s Disease

Vim, Subthalamus

- Motor neglect 7%

- Speech impairment 0% )unilateral(

- Bilateral 15%

Thalamotomy in Parkinson’s Disease -Side effects-

Target:- Striatum

Grafts:- Adrenal tissue- Embyonal midbrain - tissue

Tissue - Transplantation

Radiosurgery

Brain tumor AVM Epilepsy Parkinsonism

Indication:

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

30Gy 11Gy 8GyAcoustic Neuroma

Dose Gradient Shaping

__________________________________

Optic pathways 8 Gy 3rd, 4th and 6th cranial nerve. 20 Gy 5th nerve. 15 Gy__________________________________

Tolerable Single Dose

Organs at Risk

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(

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__________________________________

__________________________________

__________________________________

RS for Benign Skull - Base Tumors-Strategies

Early series__________________________________

__________________________________

__________________________________

1st priority: Dose homogeneity )few isocenters(

2nd priority: Dose conformation

Peripheral Dose: Higher

_________________________________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:

Treatment Planning in AVM’s

20Gy

AVMa. – p. view

Stereotactic Angiography

Meningioma

12 Gy10 Gy

Dose Gradient Shaping

Linac – RS in a Pituitary Adenoma

18 Gy12 Gy 8 Gy