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  • Endovascular treatment of intracranial aneurysms: a minimally invasive approach with advantages for elderly patients.

    12 December 2017

    An endovascular approach, embolizing intracranial aneurysms with electrolytically detachable coils, is a new minimally invasive treatment of aneurysms. Reviewing our experience with 13 patients aged 70 years or more, 12 patients were treated successfully. Over an average follow-up period of 8 months, there was only one death which might be attributed to an intracranial aneurysm. This compares favourably with mortality rates approaching 50% for either conservative or traditional surgical management of aneurysms presenting with subarachnoid haemorrhage in this age group. Coil embolization, avoiding craniotomy, may offer particular advantages in managing intracranial aneurysms in the elderly patient.

  • Neurosurgery at the Radcliffe Infirmary, Oxford: a history.

    12 December 2017

    Neurosurgery started in Oxford in 1938. In this article, we commence the story of Oxford neurosurgery with Thomas Willis and trace the historical thread through William Osler, Charles Sherrington, John Fulton, and Harvey Cushing to Hugh Cairns. The department in Oxford is renowned for the training of neurosurgeons. The initial stimulus for this was the abundance of neurosurgical and neurological expertise in Oxford during World War II with Cairns, and this tradition continued with Joe Pennybacker and his successors. The large and ever increasing work load ensures trainees a wide exposure to challenging neurosurgical problems. An increasing emphasis placed on research has resulted in the creation of two posts; each consists of half-time clinical neurosurgery and half-time research. Hugh Cairns organized the department along "Cushing lines." This organization still exists, allowing us to treat a large number of patients with relatively few beds and an average length of patient stay less than 6 days. We look to the future with confidence.

  • The saccade-related local field potentials of the superior colliculus: a functional marker for localizing the periventricular and periaqueductal gray.

    29 November 2017

    This study was intended to investigate the neural signals related to oculomotor and visual activity during horizontal saccades in humans and to explore the potential of using such signals as a functional marker for localizing the periventricular and periaqueductal gray. We recorded the local field potentials (LFPs) via implanted electrodes in the rostrolateral part of the periventricular and periaqueductal gray in four patients (six electrodes) who underwent deep brain stimulation for treatment of neuropathic pain. The functional composition of the saccade-related LFPs under different visual conditions was characterized using time-frequency analysis, and it was correlated with the anatomic placement of the electrodes on the postoperative magnetic resonance images. The magnitude of oculomotor signals varied predictably with the proximity of the recording electrode to the superior colliculus; the oculomotor activity was represented specifically in the alpha (8-13 Hz) and theta (4-8 Hz) bands for saccades and in the alpha band for fixation, whereas the visual activity was represented in the delta band (1-3 Hz) of the LFPs. The compound LFP signals of the superior colliculus embrace the synchronized population activity of multimodalities, which can be differentiated in the frequency domain. This is the first time LFP signals of the human superior colliculus have been characterized. Such signals may be used as a functional marker for electrode placement in the periventricular and periaqueductal gray for modulation of pain.

  • Translational principles of deep brain stimulation.

    13 December 2017

    Deep brain stimulation (DBS) has shown remarkable therapeutic benefits for patients with otherwise treatment-resistant movement and affective disorders. This technique is not only clinically useful, but it can also provide new insights into fundamental brain functions through direct manipulation of both local and distributed brain networks in many different species. In particular, DBS can be used in conjunction with non-invasive neuroimaging methods such as magnetoencephalography to map the fundamental mechanisms of normal and abnormal oscillatory synchronization that underlie human brain function. The precise mechanisms of action for DBS remain uncertain, but here we give an up-to-date overview of the principles of DBS, its neural mechanisms and its potential future applications.

  • A dominant bursting electromyograph pattern in dystonic conditions predicts an early response to pallidal stimulation.

    12 December 2017

    Although chronic pallidal deep brain stimulation (DBS) is effective in the treatment of medically intractable dystonia, there is no way of predicting the variations in clinical outcome, partly due to our limited understanding of the pathophysiological mechanisms underlying this condition. We recorded electromyographic (EMG) activity from the most severely affected muscle groups in seven dystonia patients before and after pallidal DBS. Patient EMG recordings could be classified into two groups: one consisting of patients who at rest demonstrated a dominant low frequency component of activity on power spectral analysis (ranging from 2 to 5 Hz), and one group in which this dominant pattern was absent. Early postoperative improvements (within 2-3 days) were observed in the former group, whereas the latter group benefited more gradually (over several months). Analysis of EMG activity may provide a sensitive means of identifying dystonic patients who are likely to be most responsive to functional neurosurgical intervention.

  • Thalamotomy versus thalamic stimulation for multiple sclerosis tremor.

    12 December 2017

    Disabling intractable tremor occurs frequently in patients with multiple sclerosis (MS). There is currently no effective medical treatment available, and the results of surgical intervention have been variable. Thalamotomy has been the mainstay of neurosurgical therapy for intractable MS tremor, however the popularisation of deep brain stimulation (DBS) has led to the adoption of chronic thalamic stimulation in an attempt to ameliorate this condition. With the goal of examining the relative efficacy and adverse effects of these two surgical strategies, we studied twenty carefully selected patients with intractable MS tremor. Thalamotomy was performed in 10 patients, with chronic DBS administered to the remaining 10. Both thalamotomy and thalamic stimulation produced improvements in postural and intention tremor. The mean improvement in postural tremor at 16.2 months following surgery was 78%, compared with a 64% improvement after thalamic stimulation (14.6 month follow-up) (P > 0.05). Intention tremor improved by 72% in the group undergoing thalamotomy, a significantly larger gain than the 36% tremor reduction following DBS (P < 0.05). Early postoperative complications were common in both groups. Permanent complications related to surgery occurred in four patients overall. Following thalamotomy, long-term adverse effects were observed in three patients (30%), and comprised hemiparesis and seizures. Only one patient in the thalamic stimulation group experienced a permanent deficit (monoparesis). We conclude that thalamotomy is a more efficacious surgical treatment for intractable MS tremor, however the higher incidence of persistent neurological deficits in patients receiving lesional surgery may support the use of DBS as the preferred surgical strategy.