Dr.

Yahya Al-Muazen
Consultant Neurosurgery & Radiosurgery & Functional Neurosurgery

Septum pellucidum

Anterior horn of lateral ventricle

Calcified pineal

Calcified choroid plexus in occipital horn of lateral ventricle.

CT scan cut through the level of the anterior horns of the lateral ventricles.

Frontal lobe

Corpus callosum Caudate nucleus Lateral ventricle Calcified choroid plexus

Septum pellucidum

Skull

CT scan of skull through the level of the bodies of the lateral ventricles.

The segmental Cutaneous innervation of the body

Deformities of the hand. (a) Radial palsy-wrist drop. (b) Ulnar nerve palsyMain en griffe' or claw hand. (c) Median nerve palsy 'Monkey's hand'. (d) Volkmann's contracture another claw hand deformity. The pink areas represent the usual distribution of anaesthesia.

Functional Neurosurgery

Parkinsonism
- Anatomy - Clinical Featur - Diagnosis - Treatment

VPL-Pallidotomy -RationaleDopamine (-)

(+) (+) VPL-Pallidum (+) SubthalamicNucleus

Putamen

(-)
Medial Pallidum - vop/Voa - Area 6 a

Thalamotomy -Present state-

Indication
Tremor (Rigor)

Target
Vim, Suvthalamus (dentato-thalamic fibres Vop / Vim, Subthalamus (pallido-thalamic fibres)

Rigor (Tremor)

Elektrostimulation

Indication
Tremor Uni - and bilateral

Target
Vim,

Stim Parameter: 100-200 Hz, 0,5-1msec 2-5 V Side Effects: Tingling-sensations contralateral (occasional, usually mild)

VPL-Pallidotomy -RationaleDopamine (-)

(+) (+) VPL-Pallidum (+) SubthalamicNucleus

Putamen

(-)
Medial Pallidum - vop/Voa - Area 6 a

VPL-Pallidotomy

Indication
- Akinesia, Bradykinesia - Dopamine induced dyskinesias - Rigor - Tremor

Target
VPL Pallidum

Thalamotomy in Parkinsons Disease -ResultsVim, Subthalamus

Tremor Complete relief Partial relief initially 75% long term 66% initially 18% long term 13% initially 80% long term 71%

Rigor Significant relief

Thalamotomy in Parkinsons Disease -ResultsVop, Subthalamus

Tremor Complete relief Partial relief initially 44% long term 35% initially 30% long term 25%

Unchanged
Rigor Significant relief

26%
initially 82% long term 65%

VPL-Pallidotomy -Laitinen, L., 1993Patients Follow-up n=215 6m 8y

Results
Improvement Akinesia +++ Dopamine induced dyskinesias +++ Rigor ++ Tremor + 93%

Complications
Homonymous scotoma In central lower visual field 7% (early series

RelationsmaBe

Modellhim
(a) (b) 25,0 23,5

Rontgenhim(rP)
28,0

rP/M
1.12

(1)

Basisline
(a) AC PC (b) Formen Monroi-PC

(2)

Thalamushohe in Basislinie
(a) AC PC (b) Foramen Monroi PC (a) (b) 15,2 (b) 14,0

3)

Hemispharenbreite
re/li 63,5 76.5 1.5 =75 1.2

AbstandsmaBe des Zielpunktes (ZP)

Modellhim (M)

rP berechnet Mit rP/M

rP berechnet Mit RV

Koordinaten Ro Sagittal Ro.Op.

7.0 Pe

(a) Von Mitte AC PC ZP Von FM auf Basislinie ZP Von PC auf Basislinie ZP (b) Oberhalb (+) Unterhalb (- ) Basislinie (c) Mitte III Ventrikel ZP re/li

Vertikal

Frontal re/li

14.5 M.D,II.V

Surgical Treatment in Parkinsons Disease Future Prospects

- Grafting of stem cells
- Microinfusion of growth factors - VPL Pallidotomy

Thalamotomy in Parkinsons Disease -Side effects-

Vim, Subthalamus
- Motor neglect
- Speech impairment (unilateral) - Bilateral

7%
0%

15%

Tissue - Transplantation

Target:
- Striatum

Grafts:
- Adrenal tissue - Embyonal midbrain - tissue

Radiosurgery
Indication:
Brain tumor AVM Epilepsy Parkinsonism

Accuracy in Linac Radiosurgery

Linac Isocenter Check: + 0.32 mm + isocenter and laser + positioning to laser + densitometric measurement
Displacement of Dose Center: + 0.62.mm + stereotactic localization + positioning device Displacement of 80% Isodose: + 0.34 mm

+ dosimetry
__________________________________________________________

Overall Accuracy: +0.78 mm

Dose Gradient Shaping

Acoustic Neuroma

30Gy

11Gy

8Gy

Organs at Risk

Tolerable Single Dose __________________________________

Optic pathways 3rd, 4th and 6th cranial nerve. 5th nerve.

8 Gy 20 Gy 15 Gy

__________________________________

RS for Benign Skull - Base Tumors -Earl Series

Indications Dose __________________________________
Acoustic Neuromas
(Stockholm, Heidelberg, Cologne)

14 - 20 Gy

__________________________________
Meningiomas
(Heidelberg, Cologne)

__________________________________
Pituitary Adenomas
(Stockholm, Boston)

20 - 60 Gy

RS for Skull - Base Tumors -Ongoing Series

Indications Dose __________________________________
Acoustic Neuromas
(mean 11 Gy)

10 - 13 Gy 9 - 14 Gy 10 - 14 Gy

__________________________________
Meningiomas
(mean 12 Gy)

__________________________________
Pituitary Adenomas
(mean 12 Gy)

RS for Benign Skull - Base Tumors -Strategies

Early series __________________________________

1st priority:
2nd priority:

Dose homogeneity
Dose conformation

(few isocenters) __________________________________

__________________________________
Peripheral Dose: Higher

RS for Benign Skull - Base Tumors - Strategies Ongoing Series: _________________________________

1st priority: Optimal Dose Conformation
(more isocenters)

_________________________________
Dose homogeneity 2nd priority:

__________________________________
Peripheral Dose: Lower.
(limited by burden to organs at risk)

Treatment Planning in AVMs

20Gy

Stereotactic Angiography

AVM
a. p. view

Dose Gradient Shaping

Meningioma
12 Gy 10 Gy

Linac RS in a Pituitary Adenoma

18 Gy 12 Gy 8 Gy