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Franzini A.,Fondazione Istituto Nazionale Neurologico Carlo Besta
Neurosurgical focus | Year: 2010

OBJECT: The aim of this study was to review the indications for and results of deep brain stimulation (DBS) of the posterior hypothalamus (pHyp) in the treatment of drug-refractory and severe painful syndromes of the face, disruptive and aggressive behavior associated with epilepsy, and below-average intelligence. The preoperative clinical picture, functional imaging studies, and overall clinical results in the literature are discussed. METHODS: All patients underwent stereotactic implantation of deep-brain electrodes within the pHyp. Data from several authors have been collected and reported for each clinical entity, as have clinical results, adverse events, and neurophysiological characteristics of the pHyp. RESULTS: The percentage of patients with chronic cluster headache who responded to DBS was 50% in the overall reported series. The response rate was 100% for short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing and for chronic paroxysmal hemicrania, although only 2 patients and 1 patient, respectively, have been described as having these conditions. None of the 4 patients suffering from refractory neuropathic trigeminal pain benefited from the procedure (0% response rate), whereas all 5 patients (100%) affected with refractory trigeminal neuralgia (TN) due to multiple sclerosis (MS) and undergoing pHyp DBS experienced a significant decrease in pain attacks within the first branch of cranial nerve V. Six (75%) of 8 patients presenting with aggressive behavior and mental retardation benefited from pHyp stimulation; 6 patients were part of the authors' series and 2 were reported in the literature. CONCLUSIONS: In carefully selected patients, DBS of the pHyp can be considered an effective procedure for the treatment of refractory trigeminal autonomic cephalalgias, aggressive behavior, and MS-related TN in the first trigeminal branch. Only larger and prospective studies along with multidisciplinary approaches (including, by necessity, neuroimaging studies) can lead us to better patient selection that would reduce the rate of nonresponders.


Leone M.,Headache Center and Pain Neuromodulation Unit | Franzini A.,Fondazione Istituto Nazionale Neurologico Carlo Besta | Proietti Cecchini A.,Headache Center and Pain Neuromodulation Unit | Bussone G.,Headache Center and Pain Neuromodulation Unit
Pain | Year: 2013

Drug-resistant chronic cluster headache (CH) is an unremitting illness with excruciatingly severe headaches that occur several times daily. Starting in 2000, a total of 19 patients with long-lasting chronic CH, with multiple daily attacks unresponsive to all known prophylactics, received stimulation of the posterior inferior hypothalamic area ipsilateral to the pain as treatment. We report long-term follow-up (median 8.7 years, range 6-12 years) in 17 patients. Long-lasting improvement occurred in 70% (12 of 17): 6 are persistently almost pain-free; another 6 no longer experience daily attacks but rather episodic CH interspersed with long-lasting remissions. In 5 of 6 almost pain-free patients, the stimulators have been off for a median of 3 years (range 3-4 years). Five patients did not improve: 4 had bilateral CH, and 3 developed tolerance after experiencing relief for 1-2 years. Adverse events are electrode displacement (n = 2), infection (electrode n = 3; generator n = 1), electrode malpositioning (n = 1), transient nonsymptomatic third ventricle hemorrhage (n = 1), persistent slight muscle weakness on one side (n = 1), and seizure (n = 1). This exceptionally long follow-up shows that hypothalamic stimulation for intractable chronic CH produces long-lasting improvement in many patients. Previous experience was limited to a median of 16 months. Important new findings are as follows: stimulation is well tolerated for many years after implantation; after several years during which stimulation was necessary for relief, a persistent almost pain-free condition can be maintained when stimulation is off, suggesting that hypothalamic stimulation can change disease course; tolerance can occur after marked long-lasting improvement; and bilateral chronic CH seems to predict poor response to hypothalamic stimulation. © 2012 International Association for the Study of Pain. All rights reserved.


Rosa M.,Centro Clinico Per la Neurostimolazione | Fumagalli M.,Centro Clinico Per la Neurostimolazione | Fumagalli M.,University of Milan | Giannicola G.,Centro Clinico Per la Neurostimolazione | And 11 more authors.
Movement Disorders | Year: 2013

Pathological gambling develops in up to 8% of patients with Parkinson's disease. Although the pathophysiology of gambling remains unclear, several findings argue for a dysfunction in the basal ganglia circuits. To clarify the role of the subthalamic nucleus in pathological gambling, we studied its activity during economics decisions. We analyzed local field potentials recorded from deep brain stimulation electrodes in the subthalamic nucleus while parkinsonian patients with (n=8) and without (n=9) pathological gambling engaged in an economics decision-making task comprising conflictual trials (involving possible risk-taking) and non conflictual trials. In all parkinsonian patients, subthalamic low frequencies (2-12 Hz) increased during economics decisions. Whereas, in patients without gambling, low-frequency oscillations exhibited a similar pattern during conflictual and non conflictual stimuli, in those with gambling, low-frequency activity increased significantly more during conflictual than during non conflictual stimuli. The specific low-frequency oscillatory pattern recorded in patients with Parkinson's disease who gamble could reflect a subthalamic dysfunction that makes their decisional threshold highly sensitive to risky options. When parkinsonian patients process stimuli related to an economics task, low-frequency subthalamic activity increases. This task-related change suggests that the cognitive-affective system that drives economics decisional processes includes the subthalamic nucleus. The specific subthalamic neuronal activity during conflictual decisions in patients with pathological gambling supports the idea that the subthalamic nucleus is involved in behavioral strategies and in the pathophysiology of gambling. © 2013 Movement Disorder Society.


Messina G.,Fondazione Istituto Nazionale Neurologico Carlo Besta | Rizzi M.,Fondazione Istituto Nazionale Neurologico Carlo Besta | Cordella R.,Fondazione Istituto Nazionale Neurologico Carlo Besta | Caraceni A.,Fondazione Istituto Nazionale Dei Tumori | And 4 more authors.
Cephalalgia | Year: 2013

Introduction: Deep brain stimulation (DBS) of the posterior hypothalamus (pHyp) has been reported as an effective treatment for primary, drug-refractory and chronic cluster headache (CCH). We here describe the use of such a procedure for the treatment of secondary CCH due to a neoplasm affecting the soft tissues of the right hemiface. Methods: A 27-year-old man affected by infiltrating angiomyolipoma of the right hemiface who subsequently developed drug refractory homolateral CCH underwent DBS of the right pHyp region at the Fondazione IRCCS Istituto Nazionale Neurologico Carlo Besta. Results: After surgery, the patient presented a significant reduction in frequency of pain bouts. However, because of a subsequent infection, the entire system was removed. After re-implantation of the system, successful outcome was observed at 2 years follow-up. Discussion: This brief report shows the feasibility of pHyp DBS in secondary drug-refractory CCH syndromes; future reports are needed in order to confirm our positive result. © International Headache Society 2012 Reprints and permissions.


Angelo F.,Fondazione Istituto Nazionale Neurologico Carlo Besta | Giuseppe M.,Fondazione Istituto Nazionale Neurologico Carlo Besta | Eliana M.,Fondazione Istituto Nazionale Neurologico Carlo Besta | Luisa C.,Fondazione Istituto Nazionale Neurologico Carlo Besta | Gennaro B.,Fondazione Istituto Nazionale Neurologico Carlo Besta
Neurological Sciences | Year: 2011

Spontaneous intracranial hypotension syndrome (SIH) is a complex pathological entity due to reduction of cerebrospinal fluid (CSF) volume and results into a variegated symptomatology, ranging from orthostatic headache to more severe conditions, such as stupor and coma; several attempts have been done in the past to understand the exact pathophysiological mechanisms which underlie its phenomenology, as well as different therapeutic approaches to relieve symptoms and reverse the reduction of overall CSF volume, both focally (in the case of a clear localized CSF leak) or by reversing the pressure gradient between the venous system and the subdural and epidural compartments (in the case of idiopathic SIH). The Authors' experience is here reported, along with some pathophysiological and neuroradiological implications and considerations. © Springer-Verlag 2011.

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