Takaomi Taira

Introduction: Deep brain stimulation (DBS) is an established therapy for movement disorders. However, conventional DBS often involves complete scalp shaving and a visible subclavicular incision for implantable pulse generator (IPG) placement, which may cause cosmetic and psychological burden, particularly in younger or female patients. To address these issues, we developed a cosmetic-oriented DBS technique combining a no-shave cranial approach with trans-axillary fossa IPG implantation. Methods: In this single-center retrospective series, we analyzed 60 consecutive patients who underwent DBS implantation using a no-shave cranial approach with trans-axillary fossa IPG placement. Procedural characteristics and postoperative complications were reviewed retrospectively. Results: Sixty patients underwent DBS implantation with this cosmetic-oriented protocol. The mean age at surgery was 50.4 ± 14.7 years, and the mean follow-up was 31.6 ± 18.3 months. The mean operative time, including IPG placement, was 159.1 ± 64.4 min (range 70–353). Early postoperative infection occurred in 2 patients (3.3%), both confined to the axillary IPG pocket within 1 month; no cranial infections or hematomas were observed. Non-infectious complications occurred in 3 patients (5.0%) (one cervical extension foreign-body reaction, one cranial insertion-site reaction, and one lateral IPG displacement requiring revision). Mild transient axillary tightness was reported in 10 patients (16.7%) and resolved without intervention. Conclusion: This cosmetic-oriented DBS method demonstrated a low infection rate and consistent concealment of cranial and axillary incisions, with no apparent signal of increased risk in this series. The approach appears technically feasible across different ages and in both sexes, although patient satisfaction was not formally evaluated.

Objective Globus pallidus internus deep brain stimulation (GPi-DBS) is an established treatment for dystonia, but its specific efficacy for tardive dystonia (TD) remains insufficiently documented. To evaluate the long-term clinical outcomes of GPi-DBS and to identify optimal stimulation sites in patients with medically refractory TD.Methods We retrospectively analyzed data from 26 patients with TD who underwent bilateral GPi-DBS. Clinical outcomes were assessed using the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS). Optimal stimulation sites were identified using voxelwise sweet spot analysis.Results At an average follow-up time of 42 months (range 12–4 months), the mean BFMDRS score improvement was 81.5%. The optimal stimulation sites were located in the posteroventral region of the GPi. Two patients experienced sustained symptom remission after DBS cessation. Complications included device-related infection (n=2), dysarthria (n=4), and gait imbalance (n= 1); no severe permanent complications occurred.Conclusion GPi-DBS is effective and safe for patients with medically refractory TD, providing significant long-term symptom relief. The optimal stimulation sites were located in the posteroventral GPi, which is consistent with those reported for patients with other dystonia types.

Introduction: Dystonia is a movement disorder characterized by involuntary, sustained, and patterned muscle contractions, which cause twisting and repetitive movements. Dystonia includes various types of movement disorders such as cervical, generalized, task specific focal hand dystonia. Several potential stereotactic targets have been suggested for the treatment of dystonia such as GPi and PTT. Materials and methods: All the patients of generalized dystonia who underwent surgical interventions in Annapurna Neurological Institute and Allied Sciences since January 2015 till December 2023 were included in our study. We performed unilateral pallidotomy/ pallidothalamic tractotomy for cervical dystonia and bilateral pallidotomies or unilateral pallidotomy and contralateral pallidothalamic tractotomy for generalized dystonia. We used ZD Fishers frame and the thermal lesioning machine of Cosman Radiofrequency (RF) generator with the lesioning electrode of 0.75 mm internal diameter and 2 mm exposed tip was used. Results: There were altogether 16 cases of generalized dystonia. There was overall 70 percent decrease in the symptoms of dystonia. The mean age was 41.49 years±12 years. The male: female ratio was 3:1. The mean percentage change in BFMDRS was 70 percent (p value<0.05) in postoperative period. There was relapse of symptoms in 3 cases of generalized dystonia. One case of tardive dystonia with repeated bilateral pallidotomy had status dystonicus and finally she got better with intrathecal baclofen pump. One case had transient hemiparesis, three cases had transient dysarthria and two cases had dysphagia. Conclusion: Lesioning surgery is quite rewarding for generalized dystonia. However, tardive dystonia and some cases of generalized dystonias have higher relapse rate. Recurrent cases may need DBS or further potential targets. Unilateral PTT and contralateral Gpi lesioning in generalised dystonia is rewarding.

Introduction: Dystonia is a movement disorder characterized by involuntary, sustained, and patterned muscle contractions, which cause twisting and repetitive movements. Dystonia includes various types of movement disorders such as cervical, generalized and task specific focal hand dystonia. Several potential stereotactic targets have been suggested for the treatment of dystonia such as GPi ( Globus pallidus internus) and PTT (Pallidothalamic tract) for generalized and cervical dystonia and Thalamotomy for task specific focal hand dystonia. Materials and Methods: All the patients of cervical dystonia who underwent surgical interventions in Annapurna Neurological Institute and Allied Sciences since January 2015 till December 2023 were included in our study. We performed unilateral pallidotomy or pallidothalamic tractotomy for cervical dystonia. We used ZD Fishers frame and the thermal lesioning machine of Cosman Radiofrequency (RF) generator with the lesioning electrode of 0.75 mm internal diameter and 2 mm exposed tip was used. Results: There were altogether 42 cases of cervical dystonia. Twenty nine cases had unilateral Pallidotmy and thirteen cases had unilateral pallidothalamic tract (PTT) lesioning. The mean age was 41.49 years±12 years. The male: female ratio was 3:1. The mean percentage change in BFMDRS was 70 percent (p value<0.05) in pallidotomy group and 75% (p value<0.05) in PTT lesioning group in postoperative period. Similarly there was 60 % improvement in TWSTRSs score in pallidotomy group (p value<0.05) and 70% improvement in PTT group (p value<0.05). One case had hemiparesis, three cases had transient dysarthria and one case had hypophonia. Conclusion: Lesioning surgery is rewarding for cervical dystonia. It is less time consuming and cheaper and it should not be abandoned. Both unilateral PTT lesioning or unilateral pallidotomy is equally effective in cervical dystonia. Though some recurrent cases may benefit from Deep brain stimulation (DBS) surgery we believe lesioning surgery is effective with good outcome. Conclusion:

Successful Treatment with Posterior Subthalamic Area-Deep Brain Stimulation in a patient with tremor and extensive brain lesion

Introduction: Parkinson’s disease (PD) is a neurodegenerative disorder characterized primarily by loss of dopamine neurons in the Substantia Nigra Pars compacta resulting in various symptoms like bradykinesia, rigidity and tremor. Surgical treatments like lesioning procedure (Pallidotomy) and Deep brain stimulation surgery are well established surgical treatment for drug resistant PD Materials & Methods: All the patients who underwent surgical treatment of Parkinsons Disease in Annapurna Neurological Institute And allied Sciences from 2016 January to December 2022 have been included in this study. Patients undergoing DBS versus lesioning in the treatment of Parkinson disease with more than two years follow up were reviewed retrospectively. Results: Eighty cases were included in this study with 50 cases of Pallidotomy and 30 cases of DBS. The male to female ratio was 2:1 in both groups. There was no difference in mean duration of illness. However, the surgical timing, hospital stay and frequency of follow ups and surgical expenses were more in DBS group. Mean change in Unified Parkinsons Disease Rating Score (UPDRS) III at the immediately after surgery was 70 percent in Pallidotomy group and 65 % in DBS group(P=0.4). However it was not statistically significant. In long term follow up period after two years, we found that the mean change in off period of UPDRS score in Lesioning vs DBS was 46.6 % vs 46.5% .(p=0.8) There was only 10 percent reduction on the dose of dopamine in pallidotomy group whereas there was 30 percent reduction in DBS group. Similarly there was significant reduction in Dyskinesia both in Pallidotomy and DBS group. Conclusion: Both lesioning and DBS procedures are equally effective surgical treatment of Parkinsons Disease. Lesioning procedure are more feasible in our context due to its cost effectiveness and long term benefit.

Thalamic deep brain stimulation for SPG-56 related focal hand dystonia

Background: The thalamic ventral intermediate nucleus (Vim) and globus pallidus internus are far apart and cannot be captured using a single electrode. Case Description: We describe our experience with a patient with dystonic tremors of the head and upper and lower extremities who showed symptomatic improvement after radiofrequency (RF) ablation using a parietal lobe approach with a single trajectory to capture the pallidothalamic tract and Vim. A 46-year-old man developed head tremors at 41 and a right-sided neck tilt three years later. Five years after the onset of the head tremors, tightness of the larynx during speech and tremors in both the upper and lower limbs also appeared. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) score was 24, and the Fahn-Tolosa-Marin Tremor Rating Scale (FTM) score was 48. We captured the pallidothalamic tract and Vim along a single trajectory by locating the entry point in the inferior parietal lobule. One week after treatment, the TWSTRS and FTM scale scores were 9 (62.5%) and 30 (37.5%), respectively. No adverse events were observed. Conclusion: This case suggests that in dystonic tremors involving abnormalities of the basal ganglia-thalamo-cortical and cerebello-thalamo-cortical circuits, a single electrode can be used to approach both circuits through the parietal lobe approach.

Background: Neurosurgical treatment for pistol shooting dystonia has not been studied. Case report: The patient was a 41-year-old woman who participated in the Olympic Games four times as a shooting player. Five months after the final Tokyo Olympic trials, she developed dystonia of the right index finger when shooting. Stereotactic thalamotomy was performed, and a complete resolution of dystonia was achieved. She garnered her personal best score and placed fifth in the Tokyo Olympics. Discussion: Thalamotomy along with deep brain stimulation can be a surgical modality for patients with task-specific dystonia who fail oral medications or botulinum toxin therapy.