- Email: [email protected]
Trigeminal neuralgia: a challenge of diagnosis and treatment
In Context
Books Deep brain stimulation: management of patients after surgery
Deep Brain Stimulation Management Edited by William J Marks Jr. Cambridge University Press, 2010. Pp 180. £50. ISBN 978-0-521-51415-6
Deep brain stimulation has evolved from an experimental therapy to a routine treatment for patients with medically refractory movement disorders. More than 60 000 patients worldwide have received deep brain stimulation for chronic neurological disorders, such as Parkinson’s disease, which typically requires lifelong medical care. Therefore, management of patients with implanted neurostimulation devices will become an increasingly common task for neurologists and allied professions. This readership is targeted by Deep Brain Stimulation Management, a well organised and up-to-date textbook on the various neurological aspects of this complex surgical treatment. The book is divided into ten chapters covering the various stages of treatment: preoperative selection of patients, intraoperative clinical and neurophysiological assessment, programming of neurostimulation devices, troubleshooting, and long-term management of stimulation and medication. One chapter is dedicated to the basic physiological mechanisms of deep brain stimulation. In particular, the chapters on programming, troubleshooting, and long-term management of neurostimulation in Parkinson’s disease, tremor, and dystonia provide structured and balanced introductions to the standard clinical approach. Flow charts of treatment algorithms and anatomical graphs supplement the text in a useful and didactic way. However, as with many other books with several authors, the structure, style, and quality of the chapters varies greatly. Some
chapters provide a rather personal and self-referenced view without citing relevant reports, such as the text on principles of neurostimulation, whereas other chapters excellently synthesise existing knowledge and add practical recommendations for care of patients wherever evidence is scarce. A remarkable shortcoming of this book is the absence of neurosurgical input in a text dealing with a surgical therapy. A basic knowledge of the surgical procedure, anatomical targeting, and surgical troubleshooting is, in my opinion, essential for neurologists to advise patients and identify problems in management of deep brain stimulation requiring neurosurgical attention. Although neurologists in Europe usually participate in the surgical procedure and assist the neurosurgeon with the intraoperative clinical and neurophysiological assessment, they seldom do so in the USA. This cultural difference might explain the neurological focus of this book of US origin. Despite these deficiencies, overall I recommend this textbook, which is, to my knowledge, the first of its kind to provide a practical guide to the clinical management of movement disorders in patients with implanted neurostimulators. The book will make a useful addition to the libraries of specialists in movement disorders and general neurologists, and help to train residents and nurses in this specialty.
Jens Volkmann [email protected]
Trigeminal neuralgia: a challenge of diagnosis and treatment
Trigeminal Neuralgia Edited by Peter Jannetta Oxford University Press, 2010. Pp 304. £50. ISBN 978-0-19-534283-3
412
Trigeminal neuralgia is a severe and excruciating pain that causes intense distress and often complete isolation of the patient because attacks are triggered by activities involving facial movements. It is aggravated by the fact that patients often undergo inadequate treatments, including teeth extractions and oral surgeries, before the correct diagnosis is made. Trigeminal Neuralgia is a pleasure to read, and is edited by Peter Jannetta, a neuroscientist who has dedicated his life to the disease and developed one of the most widely used neurosurgical techniques for trigeminal neuralgia—microvascular decompression for trigeminal neuralgia. The book, written by several distinguished collaborators, covers all aspects of trigeminal neuralgia, from history to treatments, and passes through the variable clinical presentations, diagnosis, and outcomes, with an increased focus on neurosurgical treatments that are available.
A detailed description of anatomy and physiology of the trigeminal nerve is also included, and will help readers to understand the surgical techniques and the pathophysiological aspects, which remain obscure in this specialty. Trigeminal neuralgia has some particularities in comparison with all other chronic orofacial pains—for example, the location is restricted to the territory of the trigeminal branch affected, a trigger zone is present, and patients have brief but extremely intense attacks with intervals of no pain. Furthermore, the cause remains unclear, although, in many patients, the trigeminal root is compressed by a blood vessel. Orofacial peripheral and central sensitisations, the central processing of motor and sensory information, and voltage-gated sodium channels also play a part in trigeminal neuralgia and provide pathophysiological evidence about the possible cause, according to recent reports. www.thelancet.com/neurology Vol 10 May 2011
In Context
Evidence for the variable clinical presentations (including associated constant pain) and the sensorial deficits in the trigeminal territory are well described and will help new classifications and diagnosis of trigeminal neuralgia. Trained specialists should be aware that trigeminal neuralgia can often be associated with temporomandibular disorders or toothache. Notably, patients with trigeminal neuralgia who have had one or more surgical procedures can present with complications involving the masticatory system and oral tissues, and these patients need follow-up and treatment of these outcomes. This book is quite focused on neurosurgical treatments of trigeminal neuralgia, and a later edition would
benefit from expansion on the pathophysiology of the disease, clinical diagnosis of orofacial pains that can be associated with the disease, the complications of surgery, drug treatments and other potential therapies, the psychological and emotional aspects of the disease, and directions for future research. Nevertheless, this book will help clinicians, specialists, and students of several specialties to identify, diagnose, treat, and refer these patients, alleviating the distress of patients and enabling the adequate assessment and treatment of trigeminal neuralgia.
Silvia Regina Dowgan Tesseroli de Siqueira [email protected]
Post-pump mysteries: linking the brain and the heart For half a century, life-saving cardiac surgery has been complicated by postoperative delirium, which is far more prominent in cardiac surgery than in other major operations, and stroke. Moreover, whether coronary artery bypass graft induces long-term cognitive decline is under debate. Brain Protection in Cardiac Surgery is a collection of chapters, written by well known researchers in the specialty, representing the perspectives of specialists in surgery, cardiotechnics, anaesthesiology, neurology, radiology, and pathology. Thus, this book uniquely provides a multidisciplinary approach to the existing knowledge of brain damage and protective measures in cardiac surgery. Although we are still far away from fully understanding what happens to the brain in cardiac surgery, many aspects have been widely elucidated in the past 10 years. Clearly, gaseous and non-gaseous microembolism, hypoperfusion, and a systemic inflammatory response play a part. The extracorporeal circuit contributes to focal brain damage, and developments in technology and anaesthesiological management together with brain monitoring do reduce mortality and the risk of stroke. However, mysteriously, off-pump surgery has no better outcome than does onpump surgery with regard to the frequency and severity of postoperative encephalopathy, which can have substantial recovery time. Surgeons, perfusionists, and anaesthesiologists have already done great work to improve the biocompatibility of cardiac surgery, but this book also indicates a lack of innovative ideas for future improvements. These improvements will crucially depend on how the course of postoperative cognitive abilities is measured. Several chapters address the difficulties of testing in diffuse brain injury, drawing different conclusions regarding the optimum psychometric methods. This topic remains unresolved, demanding increased neurological interest in future research. www.thelancet.com/neurology Vol 10 May 2011
Another open issue in this specialty is the assumption that further late cognitive decline is induced by cardiac surgery. Fortunately, this association was not confirmed in several studies of patients with strict control of vascular risk factors. A possible hypothesis could be that in patients undergoing cardiac surgery, factors contributing to short-term and long-term outcome, and even factors independent from surgery such as vascular dementia, need to be better defined in terms of premorbid brain function, vascular and microvascular brain lesions, and the best general medical treatment. These factors could include predisposing genetic factors, the presence of which, however, would not affect the indication for surgery. Such a holistic approach seems to be out of the scope of most of the specialists contributing to the book. Obviously, creation of new ideas for prevention of postoperative encephalopathy should also include cerebrovascular atherosclerosis and dementia research. Overall, this book comprehensively summarises the proven and postulated mechanisms of brain damage caused by cardiac surgery and the methods to identify risky situations and document sequelae. Therefore, the book seems near-mandatory reading for all clinicians and researchers caring for such patients. Regrettably, the editors did not take the opportunity to open up vistas on further brain protection, and, according to the foreward, they did not aim to do so. However, the material should stimulate interest in test methodology, which is also conferrable to other types of encephalopathy, and research on genetics and inflammatory processes in patients undergoing cardiac surgery might help to improve understanding of delirium or long-term depression and anxiety in all critically ill patients.
Brain Protection in Cardiac Surgery Edited by Robert S Bonser, Domenico Pagano, and Axel Haverich. Springer, 2011. Pp 246. €139·95. ISBN 978-1-84996-292-6
Wolfgang Müllges [email protected]
413
Books Deep brain stimulation: management of patients after surgery
Deep Brain Stimulation Management Edited by William J Marks Jr. Cambridge University Press, 2010. Pp 180. £50. ISBN 978-0-521-51415-6
Deep brain stimulation has evolved from an experimental therapy to a routine treatment for patients with medically refractory movement disorders. More than 60 000 patients worldwide have received deep brain stimulation for chronic neurological disorders, such as Parkinson’s disease, which typically requires lifelong medical care. Therefore, management of patients with implanted neurostimulation devices will become an increasingly common task for neurologists and allied professions. This readership is targeted by Deep Brain Stimulation Management, a well organised and up-to-date textbook on the various neurological aspects of this complex surgical treatment. The book is divided into ten chapters covering the various stages of treatment: preoperative selection of patients, intraoperative clinical and neurophysiological assessment, programming of neurostimulation devices, troubleshooting, and long-term management of stimulation and medication. One chapter is dedicated to the basic physiological mechanisms of deep brain stimulation. In particular, the chapters on programming, troubleshooting, and long-term management of neurostimulation in Parkinson’s disease, tremor, and dystonia provide structured and balanced introductions to the standard clinical approach. Flow charts of treatment algorithms and anatomical graphs supplement the text in a useful and didactic way. However, as with many other books with several authors, the structure, style, and quality of the chapters varies greatly. Some
chapters provide a rather personal and self-referenced view without citing relevant reports, such as the text on principles of neurostimulation, whereas other chapters excellently synthesise existing knowledge and add practical recommendations for care of patients wherever evidence is scarce. A remarkable shortcoming of this book is the absence of neurosurgical input in a text dealing with a surgical therapy. A basic knowledge of the surgical procedure, anatomical targeting, and surgical troubleshooting is, in my opinion, essential for neurologists to advise patients and identify problems in management of deep brain stimulation requiring neurosurgical attention. Although neurologists in Europe usually participate in the surgical procedure and assist the neurosurgeon with the intraoperative clinical and neurophysiological assessment, they seldom do so in the USA. This cultural difference might explain the neurological focus of this book of US origin. Despite these deficiencies, overall I recommend this textbook, which is, to my knowledge, the first of its kind to provide a practical guide to the clinical management of movement disorders in patients with implanted neurostimulators. The book will make a useful addition to the libraries of specialists in movement disorders and general neurologists, and help to train residents and nurses in this specialty.
Jens Volkmann [email protected]
Trigeminal neuralgia: a challenge of diagnosis and treatment
Trigeminal Neuralgia Edited by Peter Jannetta Oxford University Press, 2010. Pp 304. £50. ISBN 978-0-19-534283-3
412
Trigeminal neuralgia is a severe and excruciating pain that causes intense distress and often complete isolation of the patient because attacks are triggered by activities involving facial movements. It is aggravated by the fact that patients often undergo inadequate treatments, including teeth extractions and oral surgeries, before the correct diagnosis is made. Trigeminal Neuralgia is a pleasure to read, and is edited by Peter Jannetta, a neuroscientist who has dedicated his life to the disease and developed one of the most widely used neurosurgical techniques for trigeminal neuralgia—microvascular decompression for trigeminal neuralgia. The book, written by several distinguished collaborators, covers all aspects of trigeminal neuralgia, from history to treatments, and passes through the variable clinical presentations, diagnosis, and outcomes, with an increased focus on neurosurgical treatments that are available.
A detailed description of anatomy and physiology of the trigeminal nerve is also included, and will help readers to understand the surgical techniques and the pathophysiological aspects, which remain obscure in this specialty. Trigeminal neuralgia has some particularities in comparison with all other chronic orofacial pains—for example, the location is restricted to the territory of the trigeminal branch affected, a trigger zone is present, and patients have brief but extremely intense attacks with intervals of no pain. Furthermore, the cause remains unclear, although, in many patients, the trigeminal root is compressed by a blood vessel. Orofacial peripheral and central sensitisations, the central processing of motor and sensory information, and voltage-gated sodium channels also play a part in trigeminal neuralgia and provide pathophysiological evidence about the possible cause, according to recent reports. www.thelancet.com/neurology Vol 10 May 2011
In Context
Evidence for the variable clinical presentations (including associated constant pain) and the sensorial deficits in the trigeminal territory are well described and will help new classifications and diagnosis of trigeminal neuralgia. Trained specialists should be aware that trigeminal neuralgia can often be associated with temporomandibular disorders or toothache. Notably, patients with trigeminal neuralgia who have had one or more surgical procedures can present with complications involving the masticatory system and oral tissues, and these patients need follow-up and treatment of these outcomes. This book is quite focused on neurosurgical treatments of trigeminal neuralgia, and a later edition would
benefit from expansion on the pathophysiology of the disease, clinical diagnosis of orofacial pains that can be associated with the disease, the complications of surgery, drug treatments and other potential therapies, the psychological and emotional aspects of the disease, and directions for future research. Nevertheless, this book will help clinicians, specialists, and students of several specialties to identify, diagnose, treat, and refer these patients, alleviating the distress of patients and enabling the adequate assessment and treatment of trigeminal neuralgia.
Silvia Regina Dowgan Tesseroli de Siqueira [email protected]
Post-pump mysteries: linking the brain and the heart For half a century, life-saving cardiac surgery has been complicated by postoperative delirium, which is far more prominent in cardiac surgery than in other major operations, and stroke. Moreover, whether coronary artery bypass graft induces long-term cognitive decline is under debate. Brain Protection in Cardiac Surgery is a collection of chapters, written by well known researchers in the specialty, representing the perspectives of specialists in surgery, cardiotechnics, anaesthesiology, neurology, radiology, and pathology. Thus, this book uniquely provides a multidisciplinary approach to the existing knowledge of brain damage and protective measures in cardiac surgery. Although we are still far away from fully understanding what happens to the brain in cardiac surgery, many aspects have been widely elucidated in the past 10 years. Clearly, gaseous and non-gaseous microembolism, hypoperfusion, and a systemic inflammatory response play a part. The extracorporeal circuit contributes to focal brain damage, and developments in technology and anaesthesiological management together with brain monitoring do reduce mortality and the risk of stroke. However, mysteriously, off-pump surgery has no better outcome than does onpump surgery with regard to the frequency and severity of postoperative encephalopathy, which can have substantial recovery time. Surgeons, perfusionists, and anaesthesiologists have already done great work to improve the biocompatibility of cardiac surgery, but this book also indicates a lack of innovative ideas for future improvements. These improvements will crucially depend on how the course of postoperative cognitive abilities is measured. Several chapters address the difficulties of testing in diffuse brain injury, drawing different conclusions regarding the optimum psychometric methods. This topic remains unresolved, demanding increased neurological interest in future research. www.thelancet.com/neurology Vol 10 May 2011
Another open issue in this specialty is the assumption that further late cognitive decline is induced by cardiac surgery. Fortunately, this association was not confirmed in several studies of patients with strict control of vascular risk factors. A possible hypothesis could be that in patients undergoing cardiac surgery, factors contributing to short-term and long-term outcome, and even factors independent from surgery such as vascular dementia, need to be better defined in terms of premorbid brain function, vascular and microvascular brain lesions, and the best general medical treatment. These factors could include predisposing genetic factors, the presence of which, however, would not affect the indication for surgery. Such a holistic approach seems to be out of the scope of most of the specialists contributing to the book. Obviously, creation of new ideas for prevention of postoperative encephalopathy should also include cerebrovascular atherosclerosis and dementia research. Overall, this book comprehensively summarises the proven and postulated mechanisms of brain damage caused by cardiac surgery and the methods to identify risky situations and document sequelae. Therefore, the book seems near-mandatory reading for all clinicians and researchers caring for such patients. Regrettably, the editors did not take the opportunity to open up vistas on further brain protection, and, according to the foreward, they did not aim to do so. However, the material should stimulate interest in test methodology, which is also conferrable to other types of encephalopathy, and research on genetics and inflammatory processes in patients undergoing cardiac surgery might help to improve understanding of delirium or long-term depression and anxiety in all critically ill patients.
Brain Protection in Cardiac Surgery Edited by Robert S Bonser, Domenico Pagano, and Axel Haverich. Springer, 2011. Pp 246. €139·95. ISBN 978-1-84996-292-6
Wolfgang Müllges [email protected]
413