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2 Acta Neurochirurgica Supplements Editor: H.-J. Reulen Assistant Editor: H.-J. Steiger

3 Advances in Stereotactic and Functional Neurosurgery 12 Proceedings of the 12th Meeting of the European Society for Stereotactic and Functional Neurosurgery, Milan 1996 Edited by C. B. Ostertag, D. G. T. Thomas, A. Bosch, B. Linderoth, G. Broggi Acta Neurochirurgica Supplement 68 Springer-Verlag Wien GmbH

4 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machines or similar means, and storage in data banks Springer-Verlag Wien Originally published by Springer-Verlag/Wien in 1997 Softcover reprint of the hardcover 1st edition 1997 Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Typesetting: ASCO Trade Typesetting Ltd., Hong Kong Printed on acid-free and chlorine free bleached paper With 59 Figures Die Deutsche Bibliothek - CIP-Einheitsaufnahme [Acta neurochirurgica / Supplement] Acta neurochirurgica. Supplement. - Wien ; New York : Springer Früher Schriftenreihe Früher u.d.t.: Acta neurochirurgica / Supplementum 68. Advances in stereotactic and functional neurosurgery Advances in stereotactic and functional neurosurgery. - Wien ; New York : Springer (Acta neurochirurgica;...) ISSN (Acta neurochirurgica ; 68) ISBN ISBN (ebook) DOI / Cataloging-in-Publication Data applied for ISSN (Acta Neurochirurgica/Suppl.) ISSN (Advances in Stereotactic and Functional Neurosurgery) ISBN

5 Foreword Neurosurgery o/the Future: Computers and Robots in Clinical Neurosurgical Practice and in Training - a Philosophical Journey into the Future Many present day neurosurgeons believe that they already obtain good results in operative surgery with the benefit of the operating microscope and other aids which have become available in the last three decades and that the introduction of computers and robots to the operating theatre is superfluous. However, it is clear from analogy with the function of the airline pilot, another profession where there are great demands on manual skill and on spatial awareness, that these devices do have much to offer neurosurgery. Classical neurosurgery, in the time of Cushing, Dandy and Scarff, was based on a three dimensional picture of the patient's brain formed in the surgeon's mind and often illustrated in elegant drawings. Such pictures were based on neuroradiological studies by pneumoencephalography, ventriculography or by angiography. Generally these studies showed the presence and position of a lesion by displacement of normal brain structures and the picture was built up by interference. This was then converted by the experienced neurosurgeon into a plan for the craniotomy site and the trajectory of the surgical approach. Once the brain was exposed further pre-operative information was obtained by visual inspection and by palpation with the brain needle. These classical forms ofneuroradiology have largely been superseded by computerised tomography and by magnetic resonance imaging. The mental process which the neurosurgeon must follow to make use of these newer forms of imaging are different. Thus, CT and MR images are conventionally presented as axial images seen viewed from the patient's feet. Occasional errors are made in planning the position of the patient's head on the operating table, on the site and trajectory ofthe approach (a 15 degree error will cause 1.5 cm displacement at a depth of 5 cm) and even on the side of the brain which is to be operated. Such errors should not be tolerated when there are now technical adjuncts available to help the neurosurgeon avoid them. Several forms ofneuro-navigation systems for computerised image directed brain surgery, including wand based, microscope based and robot based systems. The author uses the robotic "Surgiscope" system. In this the imaging data of several modalities are transmitted through Dicon compatible channels to the work station in the operating theatre. There image fusion and preplanning of the surgery is done before the equipment is used to mark out the skull entry and to guide the surgeon accurately to the deeply sited planned target. Control of the accuracy of the surgery is provided by checking on the position of fixed points in the head and by following a check list in the computer menu. A distinguished Scandinavian neurosurgeon, Professor Lars Leksell, himself a pioneer in stereotactic surgery, stated "A fool with a tool is still a fool". You have to be a master in stereotactic surgery to become a master in image-guided surgery. Education of neurosurgeons in the use of the modem computer and robotic neurosurgical equipment is clearly vital. As the pilot learns in the flight simulator so must the neurosurgeon rehearse and practice. Indeed, the equipment makes it possible for neurosurgical trainees to learn from operations by their seniors in a much more direct way than by referring to a text book. In future the possibility of tele-conferencing and tele-monitoring procedures can take this a step further. It is clear that the expectations of the public and healthcare providers are for continued improvement and progress in neurosurgery. It is also clear throughout Europe the experience and the exposure of individual neurosurgeons to clinical cases while they are training, as well as when they are independent practitioners, are diminishing. It is probable that increasing use of computers and robots will help in reconciling these two conflicting trends. Jens Haase, M. D.

6 Preface The current changes in neurosurgery are equalized historically only by the period earlier in this century when Harvey Cushing introduced the methods of modem general neurosurgery. Even the interested observer feels amazement. The last decade has seen not only the acceptance of digital imaging into the daily routine but also the incorporation of achievements in basic biologic sciences which have been termed as "molecular neurosurgery" or "reconstructive neurology". Perhaps without recognizing it stereotactic neurosurgery has played a leading role in promoting the new developments, and transforming them into useful instruments for the whole field of neurosurgery. The stereotactic methodology - not long ago considered a physiologic subspeciality for functional neurological disorders - now pervades all aspects of neurosurgery. These proceedings from the XII th Meeting of the European Society for Stereotactic and Functional Neurosurgery in Milan reflect the topics ofthe meeting and the impact on the field. The major aim of the meeting and of the publication is an update of information. This compilation of selected abstracts therefore may serve the reader for both information and judgement. The contents is subdivided into sections on Surgical Treatments of Parkinson's Disease, Pain, Psychosurgery, Epilepsy, Frameless Stereotaxy, Functional Imaging, Methodology, Gene Therapy, Radiosurgery and Tumours. Necessarily this volume contains a mixture of various topics. Although rather eclectic the series of papers, however, reflects the current status and progress in the field. Abilities do not exist in the abstract but in individual examples (M. Oakeshott). Each individual example has what maybe called a style or idiom of its own which cannot be specified in propositions. The editors are immensely indebted to Dr. Hazel Cockburn (London) for undertaking the linguistic editing and proofreading of the manuscripts. The most astounding development in neurosurgery is the general acceptance of "stereotactic space" what is now called "neuronavigation". The congress in Milan had the privilege to listen to one of the pioneers and proponents of the method namely lens Haase from Aaalborg who with great enthusiasm unifies the views of both stereotactic and general neurosurgeons. For the editors this contribution was of such high significance as to place it as a foreword of this volume. The Editors

7 Contents Surgical Treatments of Parkinson's Disease Hariz, M. I.: Controversies in Pallidal Surgery.... Siegfried, J., Wellis, G.: Chronic Electrostimulation of Ventroposterolateral Pallidum: Follow-up Schuurman, P. R., de Bie, R. M. A., Speelman, J. D., Bosch, D. A.: Posteroventral Pallidotomy in Movement Disorders Alterman, R. L., Kelly, P., Sterio, D., Fazzini, E., Eidelberg, D., Perrine, K., Beric, A.: Selection Criteria for Unilateral Posteroventral Pallidotomy Gross, R. E., Lozano, A. M., Lang, A. E., Tasker, R. R., Hutchison, W. D., Dostrovsky, J. 0.: The Effects of Pallidotomy on Parkinson's Disease: Study Design and Assessment Techniques Lehman, R. M., Kumar, R., Mezrich, R. S., Negin, S.: Frameless 3D Volume Registration ofmr Data Sets for Stereotactic Pallidotomy Meyer, C. H. A.: Unilateral Pallidotomy for Parkinson's Disease Promptly Improves a Wide Range of Voluntary Activities - Especially Gait and Trunk Movements Hariz, M. I., De Salles, A. A. F.: The Side-Effects and Complications of Posteroventral Pallidotomy Tasker, R. R., Munz, M., Junn, F. S. C. K., Kiss, Z. H. T., Davis, K., Dostrovsky, J. 0., Lozano, A. M.: Deep Brain Stimulation and Thalamotomy for Tremor Compared Pain Nguyen, J. P., Keravel, Y., Feve, A., Uchiyama, T., Cesaro, P., Le Guerinel, c., Pollin, B.: Treatment of Deafferentation Pain by Chronic Stimulation of the Motor Cortex: Report of a Series of 20 Cases 54 Psychosurgery Lippitz, B., Mindus, P., Meyerson, B. A., Kihlstrom, L., Lindquist, Ch.: Obsessive Compulsive Disorder and the Right Hemisphere: Topographic Analysis of Lesions After Anterior Capsulotomy Performed with Thermocoagulation Epilepsy Casazza, M., Avanzini, G., Ciceri, E., Spreafico, R., Broggi, G.: Lesionectomy in Epileptogenic Temporal Lobe Lesions: Preoperative Seizure Course and Postoperative Outcome Lombardi, D., Marsh, R., de Tribolet, N.: Low Grade Glioma in Intractable Epilepsy: Lesionectomy versus Epilepsy Surgery Frameless Stereotaxy Hirschberg, H., Unsgaard, G.: Incorporation of Ultrasonic Imaging in an Optically Coupled Frameless Stereotactic System... 75

8 x Contents Functional Imaging Forss, N.: Magnetoencephalography (MEG) in Epilepsy Surgery Rezai, A. R., Mogilner, A. Y., Cappell, J., Hund, M., Llinas, R. R., Kelly, P. J.: Integration of Functional Brain Mapping in Image-Guided Neurosurgery Warnke, P. c., Berlis, A., Weyerbrock, A., Ostertag, C. B.: Significant Reduction of Seizure Incidence and Increase of Benzodiazepine Receptor Density after Interstitial Radiosurgery in Low-Grade Gliomas Methodology Yeo, T. T., Nowinski, W. L.: Functional Neurosurgery Aided by Use of an Electronic Brain Atlas Gene Therapy Benedetti, S., Di Meco, F., Polio, B., Bruzzone, M. G., Cirenei, N., Spreafico, R., Solero, C. L., Broggi, G., Di Donato, St., Finocchiaro, G.: Gene Transfer of Suicide Genes for the Treatment of Malignat Gliomas: Efficacy, Limitations, and Perspectives for a Combined Immunotherapy Stratman, A., Machein, M. R., Plate, K. H.: Anti-Angiogenic Gene Therapy of Malignant Glioma Izquierdo, M., Cortes, M. L., Martin, V., de Felipe, P., Izquierdo, J. M., Perez-Higueras, A., Paz, J. F., Isla, A., Blazquez, M. G.: Gene Therapy in Brain Tumours: Implications of the Size of Glioblastoma on its Curability Radiosurgery Voges, J., Treuer, H., Lehrke, R., Kocher, M., Staar, S., MUller, R-P., Sturm, V.: Risk Analysis of LINAC Radiosurgery in Patients with Arteriovenous Malformation (A VM) Warnke, P. c., Berlis, A., Weyerbrock, A., Ostertag, C. B.: Effect of Linac Radiosurgery on Regional Cerebral Blood Flow, Glucose Metabolism and Sodium-Potassium ATP-ase in Skull Base Meningiomas and Metastasis Tumours Carapella, C. M., Carpinelli, G., Knijn, A., Raus, L., Caroli, F., Podo, F.: Potential Role of in vitro 'H Magnetic Resonance Spectroscopy in the Definition of Malignancy Grading of Human Neuroepithelial Brain Tumours Pirotte, B., Goldman, S., David, Ph., Wikler, D., Damhaut, Ph., Vandesteene, A., Salmon, 1., Brotchi, J., Levivier, M.: Stereotactic Brain Biopsy Guided by Positron Emission Tomography (PET) with [F-18]Fluorodeoxyglucose and [C-Il ]Methionine Whittle, I. R., Kimber, W. L., Li, M., Bell, H. S., Ironside, J. W.: Glioma Cells Transduced with Selection Transgenes May Not Form Gliomas in vivo and Can Also Inhibit Glioma Formation by Admixed Wild Glioma Cell Lines Index of Keywords 144 Listed in Current Contents