- Email: [email protected]
Aesthetically optimal deep brain stimulation technique in patients with alopecia
206
n e u r o c i r u g i a . 2 0 1 5;2 6(4):205–208
Figura 1 – Corte coronal a) y sagital b) de RMN potenciada en T1 con gadolinio que muestra una lesión selar que capta contraste, invadiendo el seno cavernoso derecho a) y erosionando el suelo de la silla, ocupando el seno esfenoidal b).
et al.2 , de exacerbación del asma en un paciente intervenido de un adenoma hipofisario. Por todo ello, es imprescindible realizar una anamnesis detallada para identificar los pacientes que puedan requerir la administración de dosis mayores de corticoides para prevenir el agravamiento de patologías previas silentes.
bibliograf í a
5. Uthman I, Senecal JL. Onset of rheumatoid arthritis after surgical treatment of Cushing’s disease. J Rheumatol. 1995;22:1964–6.
Nicolás Samprón a , José Undabeitia a,∗ , Sergio Torres-Bayona a y Enrique Úrculo a,b a Servicio de Neurocirugía, Hospital Universitario Donostia, San ˜ Sebastián, Guipúzcoa, Espana b
1. Quirce S, Bobolea I, Barranco P. Asma Actualización terapéutica. Med Clin (Barc). 2014;142:317–22. 2. Krysiak R, Kedzia A, Okopien B. Relapse of asthma after surgical treatment of Cushing’s syndrome. Acta Clin Belg. 2013;68:218–9. 3. Newell-Price J, Bertagna X, Grossman AB, Nieman LK. Cushing’s syndrome. Lancet. 2006;367:1605–17. 4. Yakushiji F, Kita M, Hiroi N, Ueshiba H, Monma I, Miyachi Y. Exacerbation of rheumatoid arthritis after removal of adrenal adenoma in Cushing’s syndrome. Endocr J. 1995;42: 219–23.
Departamento de Cirugía y Radiología y Medicina Física, Facultad de Medicina y Odontología, Universidad del País Vasco (UPV/EHU), ˜ San Sebastián, Espana
∗ Autor
para correspondencia. Correo electrónico: [email protected] (J. Undabeitia). http://dx.doi.org/10.1016/j.neucir.2014.12.001 ˜ 1130-1473/© 2014 Sociedad Espanola de Neurocirugía. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.
Aesthetically optimal deep brain stimulation technique in patients with alopecia Técnica para optimizar el resultado estético de pacientes con alopecia sometidos a neuromodulación por estimulación cerebral profunda Dear Editor, The effectiveness of DBS is related to chronic stimulation of specific deep-seated targets in the brain1 . Electrode fixation is one of the important issues in the effectiveness of this therapy2,3 . It is also noted that burrhole caps yield unaesthetic elevations over the skull bone of about 0,5 cm, which
can be clearly observed under the skin in hairless patients (Figure 1). Herein, the authors present two illustrative DBS cases operated according to the routine technique used in this center4 , proposing the use of the tissue adhesive Histoacryl® (Aesculap, Tuttlingen, Germany) as a simple electrode fixation method. This adhesive is a low cost biocompatible woundclosing agent that, in our experience, saves time during
207
n e u r o c i r u g i a . 2 0 1 5;2 6(4):205–208
A
Burr hole and cyanoacrilate
Burr hole cap and ring
B Skin Bone Dura
6 mm
14 mm
DBS LEAD
5 mm
Figure 1 – (A and B) Illustration of the lead fixation with the ring-cap anchoring device on the left vs. the proposed method with sealing adhesive (Histoacryl®) on the right using a smaller bur hole.
Figure 2 – (A and B) Illustration of esthetic results of DBS implants in two hairless patients. Arrowheads point to the position of bilateral burr holes thephination sites. (C) DBS Lead in place seconds after the application of the adhesive, sealing the 6mm-burrhole and fixing the lead.
surgery because of its fast polymerization property when in contact with CSF or distilled water. Once the surgeon has determined the target site, he irrigates the burr hole in order to fill the intracranial compartment. This fact also prevents the glue from entering the skull, avoiding direct contact with the brain. This simplified method provides a reliable stabilization, firmly attaching the DBS lead onto the skull (Figure 2 C). It additionally seals the burrhole and rules out elevations over the skull with outstanding esthetic results (Figure 2 A/B). This method has been used for many years in our service in over 250 DBS implants with less than 0.5% electrode migration. The proposed technique also permits a smaller burrhole around 6 mm what also helps to prevent CSF leak and consequently less brain shifting5 . The adhesive is also easily removable with blunt instruments spearing the silicon coated lead in reoperations.
Conflict of interest The authors declare that they have no conflicts of interests.
Acknowledgments Figure 1 conception: William Omar Contreras Lopez and Erich T. Fonoff. Drawing: Danilo Costa Barbosa.
bibliograf í a
1. Wagle Shukla A, Okun MS. Surgical treatment of Parkinson’s disease: patients, targets, devices, and approaches. Neurother J Am Soc Exp Neurother 11:47-59. 2014. 2. Chan DTM, Zhu XL, Yeung JHM, Mok VCT, Wong E, Lau C, et al. Complications of deep brain stimulation: a collective review. Asian J Surg Asian Surg Assoc. 2009;32:258–63. 3. Contarino MF, Bot M, Speelman JD, de Bie RMA, Tijssen MA, Denys Det al. Postoperative displacement of deep brain stimulation electrodes related to lead-anchoring technique. Neurosurgery 73:681–688; discussion 188. 2013. 4. Fonoff ET, Campos WK, Mandel M, Alho EJL, Teixeira MJ. Bilateral subthalamic nucleus stimulation for generalized dystonia after bilateral pallidotomy. Mov Disord. 2012;27:1559–63.
208
n e u r o c i r u g i a . 2 0 1 5;2 6(4):205–208
∗ Corresponding
˜ 5. Figueira-Mendez R, Magarinos-Ascone C, Regidor I, et al. ˜ Estimulación cerebral profunda: 12 anos de experiencia y 250 ˜ pacientes intervenidos con un seguimiento de más de un ano. Rev Neurol. 2009;49:511–6.
author: Division of Functional Neurosurgery Department of Neurology–University of Sao Paulo School of Medicine; São Paulo, Brazil. Rua Dr. Ovídio Pires de Campos, 785, 01060-970, São Paulo–SP–Brasil.
Erich Talamoni Fonoff ∗ , Manoel Jacobsen Teixeira, Clarissa Nóbrega Gambarra Nascimento, William Omar Lopez Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of São Paulo School of Medicine, São Paulo, Brazil
E-mail address: [email protected] (E.T. Fonoff). http://dx.doi.org/10.1016/j.neucir.2015.02.004 ˜ 1130-1473/© 2015 Sociedad Espanola de Neurocirugía. Published by Elsevier España, S.L.U. All rights reserved.
n e u r o c i r u g i a . 2 0 1 5;2 6(4):205–208
Figura 1 – Corte coronal a) y sagital b) de RMN potenciada en T1 con gadolinio que muestra una lesión selar que capta contraste, invadiendo el seno cavernoso derecho a) y erosionando el suelo de la silla, ocupando el seno esfenoidal b).
et al.2 , de exacerbación del asma en un paciente intervenido de un adenoma hipofisario. Por todo ello, es imprescindible realizar una anamnesis detallada para identificar los pacientes que puedan requerir la administración de dosis mayores de corticoides para prevenir el agravamiento de patologías previas silentes.
bibliograf í a
5. Uthman I, Senecal JL. Onset of rheumatoid arthritis after surgical treatment of Cushing’s disease. J Rheumatol. 1995;22:1964–6.
Nicolás Samprón a , José Undabeitia a,∗ , Sergio Torres-Bayona a y Enrique Úrculo a,b a Servicio de Neurocirugía, Hospital Universitario Donostia, San ˜ Sebastián, Guipúzcoa, Espana b
1. Quirce S, Bobolea I, Barranco P. Asma Actualización terapéutica. Med Clin (Barc). 2014;142:317–22. 2. Krysiak R, Kedzia A, Okopien B. Relapse of asthma after surgical treatment of Cushing’s syndrome. Acta Clin Belg. 2013;68:218–9. 3. Newell-Price J, Bertagna X, Grossman AB, Nieman LK. Cushing’s syndrome. Lancet. 2006;367:1605–17. 4. Yakushiji F, Kita M, Hiroi N, Ueshiba H, Monma I, Miyachi Y. Exacerbation of rheumatoid arthritis after removal of adrenal adenoma in Cushing’s syndrome. Endocr J. 1995;42: 219–23.
Departamento de Cirugía y Radiología y Medicina Física, Facultad de Medicina y Odontología, Universidad del País Vasco (UPV/EHU), ˜ San Sebastián, Espana
∗ Autor
para correspondencia. Correo electrónico: [email protected] (J. Undabeitia). http://dx.doi.org/10.1016/j.neucir.2014.12.001 ˜ 1130-1473/© 2014 Sociedad Espanola de Neurocirugía. Publicado por Elsevier España, S.L.U. Todos los derechos reservados.
Aesthetically optimal deep brain stimulation technique in patients with alopecia Técnica para optimizar el resultado estético de pacientes con alopecia sometidos a neuromodulación por estimulación cerebral profunda Dear Editor, The effectiveness of DBS is related to chronic stimulation of specific deep-seated targets in the brain1 . Electrode fixation is one of the important issues in the effectiveness of this therapy2,3 . It is also noted that burrhole caps yield unaesthetic elevations over the skull bone of about 0,5 cm, which
can be clearly observed under the skin in hairless patients (Figure 1). Herein, the authors present two illustrative DBS cases operated according to the routine technique used in this center4 , proposing the use of the tissue adhesive Histoacryl® (Aesculap, Tuttlingen, Germany) as a simple electrode fixation method. This adhesive is a low cost biocompatible woundclosing agent that, in our experience, saves time during
207
n e u r o c i r u g i a . 2 0 1 5;2 6(4):205–208
A
Burr hole and cyanoacrilate
Burr hole cap and ring
B Skin Bone Dura
6 mm
14 mm
DBS LEAD
5 mm
Figure 1 – (A and B) Illustration of the lead fixation with the ring-cap anchoring device on the left vs. the proposed method with sealing adhesive (Histoacryl®) on the right using a smaller bur hole.
Figure 2 – (A and B) Illustration of esthetic results of DBS implants in two hairless patients. Arrowheads point to the position of bilateral burr holes thephination sites. (C) DBS Lead in place seconds after the application of the adhesive, sealing the 6mm-burrhole and fixing the lead.
surgery because of its fast polymerization property when in contact with CSF or distilled water. Once the surgeon has determined the target site, he irrigates the burr hole in order to fill the intracranial compartment. This fact also prevents the glue from entering the skull, avoiding direct contact with the brain. This simplified method provides a reliable stabilization, firmly attaching the DBS lead onto the skull (Figure 2 C). It additionally seals the burrhole and rules out elevations over the skull with outstanding esthetic results (Figure 2 A/B). This method has been used for many years in our service in over 250 DBS implants with less than 0.5% electrode migration. The proposed technique also permits a smaller burrhole around 6 mm what also helps to prevent CSF leak and consequently less brain shifting5 . The adhesive is also easily removable with blunt instruments spearing the silicon coated lead in reoperations.
Conflict of interest The authors declare that they have no conflicts of interests.
Acknowledgments Figure 1 conception: William Omar Contreras Lopez and Erich T. Fonoff. Drawing: Danilo Costa Barbosa.
bibliograf í a
1. Wagle Shukla A, Okun MS. Surgical treatment of Parkinson’s disease: patients, targets, devices, and approaches. Neurother J Am Soc Exp Neurother 11:47-59. 2014. 2. Chan DTM, Zhu XL, Yeung JHM, Mok VCT, Wong E, Lau C, et al. Complications of deep brain stimulation: a collective review. Asian J Surg Asian Surg Assoc. 2009;32:258–63. 3. Contarino MF, Bot M, Speelman JD, de Bie RMA, Tijssen MA, Denys Det al. Postoperative displacement of deep brain stimulation electrodes related to lead-anchoring technique. Neurosurgery 73:681–688; discussion 188. 2013. 4. Fonoff ET, Campos WK, Mandel M, Alho EJL, Teixeira MJ. Bilateral subthalamic nucleus stimulation for generalized dystonia after bilateral pallidotomy. Mov Disord. 2012;27:1559–63.
208
n e u r o c i r u g i a . 2 0 1 5;2 6(4):205–208
∗ Corresponding
˜ 5. Figueira-Mendez R, Magarinos-Ascone C, Regidor I, et al. ˜ Estimulación cerebral profunda: 12 anos de experiencia y 250 ˜ pacientes intervenidos con un seguimiento de más de un ano. Rev Neurol. 2009;49:511–6.
author: Division of Functional Neurosurgery Department of Neurology–University of Sao Paulo School of Medicine; São Paulo, Brazil. Rua Dr. Ovídio Pires de Campos, 785, 01060-970, São Paulo–SP–Brasil.
Erich Talamoni Fonoff ∗ , Manoel Jacobsen Teixeira, Clarissa Nóbrega Gambarra Nascimento, William Omar Lopez Department of Neurology, Division of Functional Neurosurgery of the Institute of Psychiatry, University of São Paulo School of Medicine, São Paulo, Brazil
E-mail address: [email protected] (E.T. Fonoff). http://dx.doi.org/10.1016/j.neucir.2015.02.004 ˜ 1130-1473/© 2015 Sociedad Espanola de Neurocirugía. Published by Elsevier España, S.L.U. All rights reserved.