Surgical quadriceps lengthening can reduce quadriceps spasticity in chronic stroke patients. A case-control study

For me surgery for spasticity is absolutely the last resort. But since I'm not medically trained my opinion has no value.

Surgical quadriceps lengthening can reduce quadriceps spasticity in chronic stroke patients. A case-control study

Andrea Merlo¹, Martina Galletti^1*, Paolo Zerbinati², Paolo Prati¹, Francesca Mascioli¹, Giacomo Basini¹, Chiara Rambelli^1,3, Stefano Masiero³ and Davide Mazzoli¹

• ¹Gait and Motion Analysis Laboratory, Sol et Salus Hospital, Rimini, Italy
• ²Neuro-Orthopedic Unit, Sol et Salus Hospital, Rimini, Italy
• ³Section of Rehabilitation, Department of Neuroscience, University of Padova, Padua, Italy

Background: Muscle overactivity is one of the positive signs of upper motor neuron lesions. In these patients, the loss of muscle length and extensibility resulting from soft tissue rearrangement has been suggested as a contributing cause of muscle overactivity in response to stretching.

Objective: To assess the effects of surgical lengthening of the quadriceps femoris (QF) muscle-tendon unit by aponeurectomy on muscle spasticity.

Methods: This is a case-control study on chronic stroke patients with hemiparesis that have undergone lower limb functional surgery over a 8-year period. CASEs underwent corrective surgery for both the foot and knee deviations, inclusive of a QF aponeurectomy. Controls (CTRLs) underwent corrective surgery for foot deviations only. QF spasticity was assessed with the Modified Tardieu Scale (MTS) before and 1 month after surgery. The Wilcoxon test was used to assess MTS variations over time and the Mann–Whitney test was used to verify the presence of group differences at the 1 month mark.

Results: Ninety-three patients were included: 57 cases (30F, 1–34 years from lesion) and 36 controls (12F, 1–35 years from lesion). Before surgery, both CASEs and CTRLs had similar MTS scores (median MTS = 3) and functional characteristics. One month after surgery, QF spasticity was significantly lower in the CASEs compared to CTRLs (p = 0.033) due to a significant reduction of the median MTS score from 3 to 0 in the CASE group (p < 0.001) and no variations in the CTRL group (p = 0.468). About half of the cases attained clinically significant MTS reductions and complete symptom relief even many years from the stroke.

Conclusions: Functional surgery inclusive of QF aponeurectomy can be effective in reducing or suppressing spasticity in chronic stroke patients. This is possibly a result of the reduction in neuromuscular spindle activation due to a decrease in muscle shortening, passive tension, and stiffness.

Introduction

In patients with upper motor neuron lesions (UMNL), weakness consequent to paresis leaves the affected muscles immobilized. The prolonged maintenance in the shortened position produces changes in soft tissues, with a progressive modifications of the muscle rheologic properties (1), leading to muscle contracture (2). UMNL and muscle contracture are the cause of a form of muscle overactivity that is often referred to as non-reflex hypertonia, intrinsic hypertonia (3, 4), or spastic dystonia (5–7). Regardless of the trigger—pain, gravity, etc.—this muscle overactivity can be present in completely flaccid muscles and can last for several hours a day (8, 9) resulting in an even further shortening, thus aggravating muscle contracture, in a vicious cycle (2).

Muscle immobilization also impairs post-activation depression, which is key in the progressive development of spasticity (3), and one of the positive signs occurring after UMNL. This is characterized by an abnormal reflex muscle activation in response to a fast stretch, at rest, and by impaired derecruitment (3, 5, 6, 10). More in general, hyperexcitability of the stretch reflex produces spasticity, clonus, and the increase of deep tendon reflexes (3).

The link between these two different types of muscle overactivity has been highlighted in recent literature (3, 5, 6). The reduced extensibility—i.e., the muscle's ability to absorb part of the applied stretch through its own elongation—because of muscle shortening, increased stiffness and increased internal viscosity (2, 11), might cause “any pulling force to be transmitted more readily to the spindles,” thus increasing spasticity (2, 3, 12).

Following this reasoning, a recovery in muscle length and ability to elongate should result in a reduction of spindle activation during muscle stretch, and should in turn result in a reduction of spasticity. We hypothesized that surgical muscle lengthening should result in reduced spasticity at least in those patients whose hyperreflexia is determined by excessive spindles activity (3).

Surgical muscle lengthening is a common procedure used with neurological patients during neuro-orthopedic surgery in order to correct joint deviations (13–15). Two recent and independent studies on children affected by cerebral palsy (CP) have reported a significant decrease in muscle spasticity after muscle lengthening surgery (16, 17). However, interesting these findings may be, we still have no comparable results reported in adult stroke survivors. Only one preliminary report, seems to confirm this hypothesis (18). Nevertheless, this was a single-arm study with a limited sample size. A case-control study would be the appropriate design in order to test whether surgical muscle lengthening of a target muscle group, performed with a standardized procedure, could lead to a decrease in spasticity.

In this case-control study, we compared the effects of lower limb functional surgery on quadriceps femoris (QF) spasticity in two parallel groups of stroke patients who underwent surgery including or not including QF aponeurectomy.

More at link.

Silent Strokes Common After Surgery in Elderly Patients, Linked to Cognitive Decline

You'll have to ask your doctor how they will guarantee that you won't have silent strokes. If they don't know why those strokes are occurring ask what research they are working on to find out why and how to prevent them. OR, you could just let them be incompetent and DO NOTHING.  Up to you if you want good doctors or not. 

Silent Strokes Common After Surgery in Elderly Patients, Linked to Cognitive Decline

Silent strokes are common in elderly patients after they have elective, non-cardiac surgery and double their risk of cognitive decline 1 year later, according to a study published in The Lancet.

While an overt stroke causes obvious symptoms, such as weakness in 1 arm or speech problems that last more than a day, a covert stroke is not obvious except on brain scans.

“We’ve found that ‘silent’ covert strokes are actually more common than overt strokes in people aged 65 or older who have surgery,” said PJ Devereaux, MD, McMaster University, Hamilton, Ontario.

The researchers found that 1 in 14 people aged older than 65 years who had elective, non-cardiac surgery had a silent stroke, suggesting that as many as 3 million people in this age category globally suffer a covert stroke after surgery each year.

The NeuroVISION study involved 1,114 patients aged 65 years and older from 12 centres in North and South America, Asia, New Zealand, and Europe. All patients received an MRI within 9 days of their surgery to look for imaging evidence of silent stroke. The researchers followed the patients for 1 year after their surgery to assess their cognitive capabilities.

Results showed that people who had a silent stroke after surgery were more likely to experience cognitive decline, perioperative delirium, overt stroke or transient ischaemic attack within 1 year compared with patients who did not have a silent stroke.

“Over the last century, surgery has greatly improved the health and the quality of life of patients around the world,” said Marko Mrkobrada, MD, University of Western Ontario, London, Ontario. “Surgeons are now able to operate on older and sicker patients thanks to improvements in surgical and anaesthetic techniques. Despite the benefits of surgery, we also need to understand the risks.”

“The NeuroVISION Study provides important insights into the development of vascular brain injury after surgery, and adds to the mounting evidence of the importance of vascular health on cognitive decline,” said Brian Rowe, Institute of Circulatory and Respiratory Health, Canadian Institutes of Health Research, Ottawa, Ontario. “The results of NeuroVISION are important and represent a meaningful discovery that will facilitate tackling the issue of cognitive decline after surgery.”

Reference: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31795-7/fulltext

SOURCE: McMaster University

New Treatment Approaches on the Horizon for Spastic Hemiparesis

I don't think that my spasticity is bad enough to even consider surgery. We need less drastic solutions. May have to look into hyaluronidase.

New Treatment Approaches on the Horizon for Spastic Hemiparesis

Author links open overlay panelNathaniel H.MayerMD^a

https://doi.org/10.1016/j.pmrj.2018.07.006Get rights and content

Abstract

This article presents 2 recent articles that propose novel interventions for treating spastic hemiparesis by changing biological infrastructure. In 18 patients with unilateral spastic arm paralysis due to chronic cerebral injury greater than 5 years’ duration, Zheng et al transferred the C7 nerve from the nonparalyzed side to the side of the arm that was paralyzed. Over a follow-up period of 12 months, they found greater improvement in function and a reduction of spasticity compared to rehabilitation alone. Using functional magnetic resonance imaging, they also found evidence for physiological connectivity between the ipsilateral cerebral hemisphere and the paralyzed hand. In the second article, Raghavan et al examine the concept of stiffness, a common symptom in patients with spastic hemiparesis, as a physical change in the infrastructure of muscle. Raghavan’s non-neural hyaluronan hypothesis postulates that an accumulation of hyaluronan within spastic muscles promotes the development of muscle stiffness in patients with an upper motor neuron syndrome (UMNS). In a case series of 20 patients with spastic hemiparesis, Raghavan et al report that upper limb intramuscular injections of hyaluronidase increased passive and active joint movement and reduced muscle stiffness. Interventions that change biological infrastructure in UMNS is a paradigm on the horizon that bears watching.

Nerve Transfer May Restore Function in Stroke Victims

Read the caveats carefully, I wouldn't do this except as a very last resort, my spasticity is not bad enough to consider this. 
https://www.medpagetoday.com/neurology/generalneurology/70030?

Significant improvements seen for spastic arm hemiplegia in Chinese study

• by Scott Harris, Contributing Writer, MedPage Today December 20, 2017

Action Points

• Note that this small trial suggests that contralateral C7 nerve transfer may improve function in the upper arm of those with spastic hemiparesis.
• Be aware that the large effect size and short time-frame should engender some skepticism; larger trials are needed.

A promising but controversial nerve transfer technique can help treat spastic hemiplegia, the paralysis caused by stroke and conditions like cerebral palsy, in the arm and hand.
That's according to a study published Wednesday in The New England Journal of Medicine.
"Transfer of the C7 nerve from the nonparalyzed side to the side of the arm that was paralyzed was associated with a greater improvement in function and reduction of spasticity than rehabilitation alone over a period of 12 months," wrote Mou-Xiong Zheng, MD, PhD, a hand surgeon with Huashan Hospital in Shanghai, China, and colleagues. "Physiological connectivity developed between the ipsilateral cerebral hemisphere and the paralyzed hand."
But in an accompanying editorial, Robert Spinner, MD, a neurosurgeon and orthopedic surgeon with the Mayo Clinic, and two colleagues urged caution.
They called the results "exciting" but questioned whether "connectivity" occurred as a direct result of the procedure.
"The time frame for improvement is the major question: that distal muscles are functionally reinnervated in such a short time seems unlikely to us," Spinner and colleagues wrote. "An alternative hypothesis to explain the functional improvement is that there was reduction in limb spasticity and improved function through the normal motor pathways of the C5, C6, C8, and T1 nerves, and the effect may have been augmented by rehabilitation ... An improvement in function at 10 months cannot be readily explained as being predominantly a result of the contralateral nerve transfer, because nerves do not regenerate that quickly, fully or consistently."
Zheng and colleagues said a more extensive study might help shed more light on the initial findings.
"A larger cohort, followed for a longer period, would be necessary to determine whether cervical nerve transfer results in safe, consistent, and long-term improvements in the function of an arm that is chronically paralyzed as a result of a cerebral lesion," Zheng and colleagues wrote.
Spastic limb hemiplegia typically results from stroke, traumatic brain injury, or a condition like cerebral palsy. According to estimates, 30-60 percent of stroke survivors suffer from spastic limb hemiplegia. The C7 nerve accounts for approximately 20 percent of the nerve fibers comprising the brachial plexus. The C7 nerve transfer procedure uses a healthy C7 nerve as a "donor" to restore function in the injured plexus.
For approximately 5 years, Zheng and colleagues studied 36 spastic hemiplegia patients between 12-45 years old, in whom power and sensitivity were decreased but not absent in the affected hand. Half of the patients underwent C7 nerve transfer plus rehabilitation; half underwent only rehabilitation. Patients were excluded if they had systemic diseases such as diabetes mellitus or cardiopulmonary disease, developmental delay, or severe deformities.
Analyzing functional MRI test results, the mean changes in Fugl-Meyer Assessment (motor recovery) scores from baseline to 12 months were 17.7±5.6 in the surgery group and 2.6±2.0 in the control group, indicating significant improvement in the surgery group (difference 15.1; 95% CI 12.2 to 17.9; P<0.001). The score increases occurred at months 10 and 12 in the surgery group, Zheng and colleagues concluded.
Significant improvements in spasticity from baseline to 12 months were seen in all relevant joints with surgery, including elbow extension, forearm rotation, wrist extension, thumb extension, and extension of fingers two through five. For the surgery group, mean changes in active range of motion from baseline to 12 months was 23±13 degrees at the elbow, 36±19 degrees in forearm rotation, and 49±21 degrees at the wrist. In the control group, the changes were 0±3, 1±5, and 1±5 degrees (P<0 .001="" all="" between-group="" comparisons="" for="" p=""> At 12 months, 16 of the 18 surgery patients could use the affected hand to perform three or more basic tasks. In the control group, seven of the 18 patients could perform two tasks, three could perform one, and eight could perform none.
"The paralyzed arm showed improved power, function, and reduced spasticity at month 12 in the surgery group, whereas there was significantly less improvement in the control group, in which patients received only physical therapy," Zheng and colleagues wrote.

The work had no commercial funding. All study authors declared they had no relevant financial interests other than government research grants. Spinner declared he had no relevant financial interests. His co-authors reported relationships with the Musculoskeletal Transplant Foundation, Acumed, Aptis Medical, and Synthes.

• Reviewed by F. Perry Wilson, MD, MSCE Assistant Professor, Section of Nephrology, Yale School of Medicine and Dorothy Caputo, MA, BSN, RN, Nurse Planner

• Primary Source

  New England Journal of Medicine

  Source Reference: Zheng M-X, et al "Trial of contralateral seventh cervical nerve transfer for spastic arm paralysis" New Engl J Med 2017; DOI: 10.1056/NEJMoa1615208.

• Secondary Source

  New England Journal of Medicine

  Source Reference: Spinner R, et al "Rewiring to regain function in patients with spastic hemiplegia" New Engl J Med 2017; DOI: 10.1056/NEJMe1713313.

Taking an anticlotting drug? If you need a procedure, be prepared

Be careful out there, your doctor has a lot to think about when doing this. And getting it wrong will hurt you, not the doctor. 
https://www.health.harvard.edu/blog/anticlotting-drug-procedure-safety-2017110112659

Posted November 01, 2017, 10:30 am

Julie Corliss, Executive Editor, Harvard Heart Letter

Millions of people with cardiovascular disease take drugs that help prevent blood clots, which can lodge in a vessel and choke off the blood supply to part of a leg, lung, or the brain. These potentially lifesaving medications include warfarin (Coumadin) and a class of drugs called non-vitamin K antagonist oral anticoagulants or NOACs. Examples include dabigatran (Pradaxa) and rivaroxaban (Xarelto).
However, if you’re taking one of these drugs and need an invasive procedure — anything from a tooth extraction to a hip replacement — managing the risks can be tricky, says cardiologist Dr. Gregory Piazza, assistant professor of medicine at Harvard Medical School. “There’s a higher-than-normal risk of bleeding during and after the procedure, because your blood doesn’t clot as easily,” he says.
But stopping an anticlotting drug is also risky. Doing so increases the chance of a blood clot, especially if you have surgery, which also leaves you more prone to a clot. “Walking the tightrope between these two extremes can be a challenge for clinicians,” says Dr. Piazza. They need to consider if, when, and how long a person might need to stop taking their anticlotting medication. And the answer hinges on many different factors.

Different risk levels

Each year, about one in 10 people taking a NOAC requires a planned invasive procedure. These include diagnostic tests and treatments that require a doctor to use an instrument to enter the body. Some are more risky than others, of course. Minor procedures such as a skin biopsy aren’t very worrisome, because you can compress and bandage the wound, says Dr. Piazza.
Tooth extractions can bleed a fair amount. Compresses and topical treatments are usually sufficient for controlling the bleeding, although your doctor might suggest skipping your anticoagulant the day of the procedure.

Biopsies, injections, and surgeries

Deciding to stop an anticoagulant for a colonoscopy is more complicated. A diagnostic colonoscopy isn’t likely to cause bleeding. But if the doctor has to remove any polyps from the colon, the risk of bleeding rises. Other procedures that require careful planning for people on anticoagulants include breast and prostate biopsies, as well biopsies of internal organs, such as the kidney or liver, which can lead to hard-to-detect internal bleeding.
Another common procedure (especially in older people) is a steroid injection in the spinal column to treat back pain. This, too, may cause undetected and potentially dangerous bleeding around the spinal column in people taking anticoagulants.
People nearly always have to stop taking anticlotting medications a few days prior to any type of elective surgery. Sometimes, doctors will use injectable, short-acting anticlotting drugs right before and immediately after the operation. This technique, called bridging, helps them better balance the degree of blood clotting during that critical window of time.

A key conversation

In addition to the procedure itself, other factors that affect anticoagulant decisions include a person’s age, any other health problems or medications they take, and whether they’re taking warfarin (which stays in the body for days) or a NOAC (which may lose some of its effect after about 12 hours). Because of all these variables, the best strategy is to make sure that the doctor slated to perform your procedure talks directly with the doctor who prescribed your anticoagulant, says Dr. Piazza. “If that conversation doesn’t take place, patients can have problems with either bleeding or clotting,” he says. Many physicians who do procedures aren’t as familiar with NOAC prescribing guidelines, so they may mistakenly keep people off these medications for a week or more, putting them at risk for a clot.

Migraine Tied to Perioperative Stroke Risk 30-day ischemic stroke risk higher for those with migraine with aura

Be careful out there.
http://www.medpagetoday.com/Neurology/Strokes/62453?

• This article is a collaboration between MedPage Today® and:
  

Action Points

• Migraine patients had nearly twice the risk of an ischemic stroke within the first month after surgery than those without the headache disorder.
• Note that the study suggests that in patients with migraine with aura undergoing surgery, steps should be investigated to reduce the heightened risk of stroke.

Migraine patients had nearly twice the risk of an ischemic stroke within the first month after surgery than those without the headache disorder, researchers reported.
That risk was higher for those who had migraine with aura, but was elevated regardless of whether patients had aura or not (aOR 2.61 and aOR 1.62, respectively), Matthias Eikermann, MD, PhD, of Massachusetts General Hospital (MGH), and colleagues reported online in The BMJ.
"There are 60 million surgeries every year, and the baseline stroke risk is one in 1,000," Eikermann told MedPage Today. "If migraine [with aura] increases that risk almost three-fold ... you're talking about thousands of strokes each year. This is a relevant observation that needs to be explored further."
Richard Lipton, MD, of Albert Einstein College of Medicine in New York, a migraine specialist who was not involved in the study, called it "well-designed" and suggested that migraineurs needing surgery should not panic about the findings.
"The study suggests that, in patients with migraine with aura undergoing surgery, steps should be investigated to reduce the heightened risk of stroke," Lipton told MedPage Today. "People with migraine undergoing surgery should be reassured that although the relative risk is high, the absolute risk of post-operative stroke is modest."
Migraine is already a known risk factor for ischemic stroke, especially if a patient has aura. Eikermann and colleagues wanted to investigate whether that risk also carries to the perioperative period.
They looked at data on nearly 125,000 surgical patients (mean age 53; 55% female) who had surgery at MGH, or two satellite sites, from January 2007 to August 2014. About 8% of the patients had any migraine diagnosis, and 13% of migraineurs had aura.
Overall, there were 771 cases of perioperative ischemic stroke (0.6%). About 12% of these patients had a diagnostic code for migraine.
In controlled analyses, the researchers found that patients with migraine were at an increased risk of perioperative ischemic stroke compared with patients without migraine (aOR 1.75, 95% CI 1.39-2.21), and that risk was higher in those who had aura (aOR 2.61, 95% CI 1.59-4.29), though it was still elevated for migraineurs without aura (aOR 1.62, 95% CI 1.26-2.09).
The researchers calculated a predicted absolute risk of 2.4 perioperative ischemic strokes for every 1,000 surgical patients, which rises to 4.3 for every 1,000 patients with any migraine diagnosis.
That separates into rates of 3.9 per 1,000 patients for migraine without aura, and 6.3 per 1,000 for migraine with aura, they added.
Eikermann's group also found a higher rate of hospital readmission within 30 days of discharge among those with migraine (aOR 1.31, 95% CI 1.22-1.41).
"We see that patients with migraine are not only readmitted for stroke, but for other conditions associated with migraine, such as GI symptoms like nausea and vomiting, and pain," he told MedPage Today. "We should not only look at stroke, but other factors that contribute to more frequent readmission in migraine patients. Those things may be just as important to focus on."
Migraine patients may have a genetic predisposition that puts them at heightened risk of stroke during surgery, as well as an increased perioperative vulnerability to cerebral ischemia. One major mechanism may be an increased susceptibility to spreading depolarization, particularly in migraine with aura, they noted.
Eikermann said there are "two things that we feel pretty certain about" with regard to managing perioperative stroke risk in migraineurs: use of vasopressors, and right-left shunt, such as patent foramen ovale (PFO).
"High-dose vasopressin puts them at higher risk, and the same is true for right-left shunt, blood flowing from the right part of the heart to the left part," he said, noting that much more work would need to be done before recommending something like PFO closure to lower the risk of perioperative stroke in migraineurs.
He added that his group plans to use their data to create a new prediction instrument for perioperative stroke, which includes migraine and other risk factors, and that they would ultimately like to do an intervention study to see if that tool could decrease the risk of perioperative stroke.
Matthew Robbins, MD, of Montefiore Medical Center, who was not involved in the study, said it would “lead me to counsel patients with migraine differently.”
“Common sense measures include stroke education to such patients to promote awareness, early stroke diagnosis and treatment,” Robbins told MedPage Today. “Surgeons and anesthesiologists should also take note of this study’s results as the use of higher doses of vasopressors in patients with migraine could be a modifiable perioperative stroke risk factor, as the authors suggest.”
He noted that open questions still remain — “Does having chronic migraine or a higher migraine attack frequency elevate the perioperative stroke risk? Do those with more optimally treated migraine have a diminished risk?” — but concluded that the study “should further heighten our awareness that having migraine is not ‘benign.’”

The study was funded by Jeff and Judy Buzen.
Eikermann disclosed relevant relationships with Calabash Bioscience, Merck, and the Buzen Fund. Co-authors disclosed relevant relationships with Merck, Depomed, Anesthesiology, Annals of Surgery, and Headache, the NIH, the Else-Kröner-Fresenius-Stiftung/German Scholars Organization, the French National Research Agency, Amgen, BMJ, Cephalalgia, and the International Headache Society.

Rate of Death and MI After Non-Cardiac Surgery Decreases, But Risk of Stroke Increases

If you need this type of surgery ask your doctor how they are reducing these post operative events.
Rate of Death and MI After Non-Cardiac Surgery Decreases, But Risk of Stroke Increases
Cardiovascular complications after non-cardiac surgery remain a major source of morbidity and mortality, according to a study published online by JAMA Cardiology.
Despite the significant burden perioperative events place on the national healthcare system, recent data are lacking on trends in perioperative major adverse cardiovascular and cerebrovascular events (MACCE) among patients hospitalised for major non-cardiac surgery.
Using the National Inpatient Sample, Sripal Bangalore, MD, New York University School of Medicine, New York, New York, and colleagues identified patients who underwent major non-cardiac surgery from January 2004 to December 2013.
Among 10,581,621 hospitalisations (mean age, 66 years; 57% female) for major non-cardiac surgery, perioperative MACCE -- defined as in-hospital, all-cause death, acute myocardial infarction (MI) or acute ischaemic stroke -- occurred in 317,479 hospitalisations (3%), corresponding to an annual incidence of approximately 150,000 events.
MACCE occurred most frequently in patients undergoing vascular (7.7%), thoracic (6.5%), and transplant surgery (6.3%).
Between 2004 and 2013, the frequency of MACCE declined from 3.1% to 2.6%, driven by a decline in frequency of perioperative death and acute MI, but there was an increase in perioperative ischaemic stroke from 0.52% in 2004 to 0.77% in 2013.
Men had higher risk of perioperative MACCE than women. In analyses of perioperative events by race and ethnicity, non-Latino black patients had the highest rates of perioperative death and ischaemic stroke compared with other racial groups.
“Perioperative MACCE occurs in 1 of every 33 hospitalisations for non-cardiac surgery,” the authors wrote. “Despite improvements in perioperative outcomes over the past decade, the significant increase in the rate of ischaemic stroke in this analysis requires confirmation and further study. Additional efforts are necessary to improve perioperative cardiovascular care of patients undergoing non-cardiac surgery.”
SOURCE: JAMA Cardiology

Millions awarded to man for surgery on wrong side of brain

So for your emergency surgery to repair the hemorrhage you better be coherent enough to ask the doctors if they know what they are doing.
http://www.cbsnews.com/news/arkansas-man-surgery-wrong-side-brain-millions/

Robotic worm for head surgery can cut around corners

Whom is looking into this for repair of aneuyrsms and hemorrhages and AVMs?
http://www.alphagalileo.org/ViewItem.aspx?ItemId=158183&CultureCode=en
Removing tumors from within the inner ear is a very delicate matter that typically requires surgeons to remove the entire mastoid bone. However, in the future, all doctors will need to do is cut a tunnel of 5 mm in diameter through the bone using a miniature robot named NiLiBoRo. The system is capable of adjusting its path while drilling through bone to steer around sensitive tissue such as blood vessels and nerves. Researchers will be displaying the new technology at the Compamed exhibition from November 16-19 in Düsseldorf (Hall 08a, Booth K38).
Surgery is unavoidable for treating inner ear tumors, but the inner ear is difficult to access. This is because it is covered by a cranial bone known as the mastoid, or petrosal bone. What’s more, the surrounding tissue contains lots of nerves and blood vessels. For this reason the surgeons will cut out as much of the mastoid bone as needed until they have located each one of these sensitive structures. Only then can they be sure not to damage them. What this entails most of the time is the removal of the entire bone. The hole thus created is filled in with fatty tissue taken from the abdomen after the completion of the procedure.
Performing surgery through a 5 mm wide tunnel
In the future this operation will be performed in a less invasive fashion, requiring just a small hole measuring 5 mm in diameter through which the tumor can be resected from the inner ear. The technology that makes this possible goes by the name of NiLiBoRo, a German acronym which stands for “Non-linear Drilling Robot”. The system is being developed by researchers in the Mannheim Project Group for Automation in Medicine and Biotechnology, part of the Fraunhofer Institute for Production Technology and Automation IPA, in cooperation with the Technical University of Darmstadt, the University of Aachen, and the Düsseldorf University Clinic. Drilling machines capable of boring a tunnel through bone already exist, but they can do so only in a straight line. “NiLiBoRo is the first one that can drill around corners as well,” says project group scientist Lennart Karstensen. It is this particular characteristic that makes it possible to perform minimally invasive surgery on inner ear tumors. If the tunnel were to run in a straight line, it would at times come troublingly close to hitting nerves. To avoid injuring nerve tissue, the tunnel would have to be no more than 1 to 2 mm in diameter. However, it is impossible to perform surgery through such a small opening. The NiLiBoRo on the other hand is capable of steering around sensitive areas. This makes it possible to achieve a tunnel diameter of 5 m, which is wide enough to perform the operation.
Hydraulic lines allow the robot worm to crawl forward
So how does this “worm” manage to drill around curves and corners through the mastoid bone? “The worm consists of a ‘head’ and a ‘tail’ section,” explains Karstensen. “Both of these parts are connected with one another by means of a flexible bellows mechanism.” The design is reminiscent of an articulated public transit bus in which the front and rear sections are coupled by means of a hose-like center section that looks like an accordion.
As it travels through the bone, the robot is connected to the “outside world” – in other words the control units and pumps in the operation room – by means of 8 to 12 hydraulic lines. It is these lines that allow the robot to crawl forward in the right direction. This is done by first pumping hydraulic fluid into three bladders found in the rear section of the robot. The bladders fill in the empty space between the worm and the bone and thereby fix the rear section of the robot in place. The hydraulic fluid then travels into the bellows. This causes the “accordion” to expand, which pushes the head forward. The worm stretches, so to speak, and presses its front section further into the bone. The drill attached to the head bores deeper inward. Now the rear section retracts towards the head in a motion similar to that of a real worm. To do so, the bladders in the front section are pumped full of fluid to hold the front in place while the fluid in the rear bladders is evacuated. At this point the fluid is also being sucked out of the bellows through the hydraulic lines. The robot contracts, which pulls the rear section up behind the front. In this way the NiLiBoRo makes its way forward bit by bit. “We can alter the robot’s direction of travel by adjusting the bladders in the front section. For instance, if we wanted to move left then we fill the left bladder with less fluid than the right, which will cause the robot to veer to the left,” says Karstensen.
In the laboratory, and later in the operation room, the path the NiLiBoRo takes as it drills its way forward is precisely monitored by an electromagnetic tracking system, or EMT for short. Designed by partners at the Technical University of Darmstadt, this system works by sporadically capturing images of the robot using computer tomography in order to monitor its position.
Researchers have already constructed an initial prototype of the NiLiBoRo, which is currently five times larger than the planned final version. Right now it is composed of only the forward section together with the heart of the machine, the bellows. The developers plan to continue optimizing and expanding the prototype piece by piece. Once all the technology has been developed, the NiLiBoRo will be shrunk down to its final size. Researchers hope to have the miniature robot ready for testing by physicians in two years.
http://www.fraunhofer.de/en/press/research-news/2015/november/robotic-worm-for-head-surgery-can-cut-around-corners.html

A U of S researcher makes a world breakthrough in brain science

Cool stuff. Why couldn't we have stroke researchers come up with advances like this? A great stroke association would challenge researchers to do BHAG research (Big Hairy Audacious Goals).  3d printing of damaged stroke areas should easily be possible. With a fast enough turnaround this should immensely help surgery to fix bleeds.
http://www.thestarphoenix.com/touch/story.html?id=11491825
Sometimes even a brain surgeon has a problem he can’t solve.
Earlier this year, Dr. Ivar Mendez, head of surgery at the University of Saskatchewan, was trying to plan a complex surgery.
The patient was to undergo deep brain stimulation, a procedure in which Mendez would insert electrodes into the brain to soothe overcharged neurons.
Mendez normally plans and programs this in advance using a computer — but this time, technology failed him.
He wanted to weave one electrode so that it could affect two targets, but the computer couldn’t tell him how. The human brain is too complex and too irregular a structure, and computers can’t predict how the tissue would interact with his tools.
“I wanted a way to really, before I did a surgery, to know exactly how this was going to reach the brain and the targets I wanted,” Mendez said.
He considered the option of 3D printing, but didn’t know if an accurate, transparent brain could actually be made.
So Mendez contacted the U of S school of engineering, which had a 3D printer, and assembled a team of engineers, a radiologist, MRI technicians and neuropsychology specialists. The trick was translating the MRI data into a language the printer could understand.
It took seven months before the team was able to print a prototype, complete with the smaller nuclear structures. It was the first time a brain has been 3D-printed specifically for this purpose.
The only catch was, the rubber wasn’t clear enough to see those smaller features. The new version, printed just a week and a half ago, is everything Mendez needs.
“You can actually do the surgery. You can actually put the needle in the brain,” he said. Once he’s done the practice run, he can program that exact route to be used during the actual surgery.
He noted that when surgeons enter a brain, they only do so through a small hole in the skull.
“You can get really lost, because you really don’t know. But when you have the model it lets you see exactly where you want to go.”
The model brain is made of a synthetic rubber that matches the consistency of the real thing. It feels less jiggly than you might think a brain should feel. You can press your fingers in slightly, but it remains firm, almost like a volleyball.
To Mendez, an artist as well as a neurosurgeon, the brain is an object of beauty. He feels humbled to hold that organic complexity in his hands, he said.
This is just the beginning of what the technology has to offer, Mendez said. A patient with a tumour or lesion could have their brain printed before a surgery as well, to help understand how it’s displacing other structures in the brain.
“And you really would not understand it, even if you rotate a 3D image, unless you actually see that,” Mendez said.

Eventually, we’ll see the dawn of 3D-printed biological materials such as organs and cells. Even now, we can print the cartilage of an ear, he said.
So, how long until we see a human-made biological brain?
“Who knows? But I think biological 3D printing will probably come within the next 25 years or so, or maybe more. Last year, I wouldn’t have thought we could print this complexity of the brain, and the structures within the brain.”

Long-term Results of Radiosurgery for Cerebral Arteriovenous Malformations

Your doctor will know about this if you have an AVM. You hope so.
http://cjns.metapress.com/content/b4033p6374152516/?id=B4033P6374152516

Abstract

Background: Stereotactic radiosurgery (SRS) is known to safely result in a high obliteration rate for small and medium sized arteriovenous malformations (AVM). Objective: To evaluate the long-term outcome of patients treated with SRS, with special emphasis given to obliteration and toxicity rates. Methods: We performed a review of 43 cerebral AVM patients, treated from 1998 to 2008 with a single SRS dose ranging from 21-25 Gy. Of these, 37 had a minimal follow-up of one year. Medical files were reviewed to assess patient and AVM characteristics, the SRS treatment, therapy prior to SRS, the obliteration rate and toxicities. Whenever necessary, outcome data was supplemented by telephone interviews with the patient or treating physician. Results: AVM size was ≥3cm in diameter in 21% of patients. Five patients (11.6%) underwent surgery prior to SRS and 31 patients (72.1%) received one or more embolizations prior to SRS. Of the patients followed with angiography ≥1 year post-SRS, 89% (33/37) had a complete obliteration of the nidus, after a median time of 24.7 months post-treatment. Embolization prior to SRS was not predictive of outcome. One patient suffered a non-fatal haemorrhage between treatment and obliteration. The rate of symptomatic radiation-induced radiological changes was 8.1%. Conclusion: Our study shows both obliteration and complication rates in the upper limit of those reported in the literature. SRS seems an attractive treatment option for small AVMs. Unlike other reports, the prior use of embolization did not impact negatively on obliteration rates.

Carotid bypass surgery doesn’t help cognitive performance after stroke

Why would anyone even think this surgery would help cognitive performance? There are too many stupid people in the stroke world. My cognitive performance has not gone down one bit since my right carotid artery completely closed up. Damn, does no one understand the Circle of Willis?
http://www.webwire.com/ViewPressRel.asp?aId=169866
Study Highlights:

• Surgery to improve blood flow to the brain does not reverse cognitive problems associated with low blood flow in patients who have experienced a stroke or mini-stroke.
• Although cognitive problems were worse in those with poorer blood flow, patients who received medical treatment plus cranial bypass surgery did no better than those who received medical treatment for diabetes, high cholesterol and high blood pressure alone.
• New approaches are needed to treat this potentially reversible condition.

HONOLULU, Feb. 8, 2013 – Surgery to bypass a blocked carotid artery in order to restore adequate blood flow to the brain does not improve cognitive performance in patients who’ve had a stroke or mini-stroke (TIA), according to research presented at the American Stroke Association’s International Stroke Conference 2013.

“When patients receive the best medical therapy – including statins for cholesterol and medications to control diabetes and high blood pressure – cognitive improvement is no different when bypass surgery is added to medical therapy,” said Randolph S. Marshall, M.D., M.S., lead author of the study and Elizabeth K. Harris Professor of Neurology and chief of the stroke division at the Neurological Institute of New York at Columbia University Medical Center.

In extracranial-intracranial (EC-IC) bypass, the surgeon connects a scalp artery outside the skull to a brain artery inside the skull through a small hole, bypassing the blocked carotid artery so more blood can flow to the brain. An earlier part of the study, the Carotid Occlusion Surgery Study (COSS), evaluated EC-IC in patients with a completely blocked carotid artery but measured a different outcome. COSS was stopped in 2010 after an interim analysis revealed that patients who underwent bypass had no fewer strokes than those on medical therapy alone.

The current study, Randomized Evaluation of Carotid Occlusion and Neurocognition (RECON), was an ancillary trial of COSS designed to determine whether the bypass could preserve or improve cognition over two years. Patients’ average age was 57.1 (range 41 - 75), and included 25 men and 10 women. The National Institutes of Health encouraged RECON to continue after the main trial was terminated.

Twenty-eight patients survived without a subsequent stroke to undertake the two-year cognitive evaluation, 15 on optimal medical treatment and 13 who had optimal medical treatment as well as EC-IC bypass.

All participants had experienced a clot-caused stroke or mini-stroke and had cognition problems. Patients with cognition problems reported mild short-term memory loss, poor concentration or not feeling mentally sharp. The most common abnormalities on cognitive testing were taking longer on timed tasks or on tasks that required switching back and forth between types of information.

Tests at baseline indicated that patients with the worst blood flow had the worst cognitive difficulties. However, surgery was no better than medical therapy at preserving or improving mental functioning in the two years after treatment began.

“One problem that could partly explain the negative results was that only three out of 13 patients in the surgical group actually achieved normal blood flow after the operation,” Marshall said.

The most cognitive improvement was found in patients who had better blood flow to the brain at baseline and those who had experienced a transient ischemic attack (mini-stroke) rather than a full stroke.

“It’s still quite likely that cognitive impairment due to a low blood flow state represents one of the only reversible types of dementia,” Marshall said. “Besides this bypass operation, there are other ways of achieving better blood flow – both mechanical and pharmacological – so the next direction for this work is to find a treatment that has a better chance of improving blood flow with fewer complications.”

CMS says? More data needed on best management of blocked carotid arteries

For those who need more information on the possibilities for their carotid arteries.
http://www.cardiovascularbusiness.com/index.php?option=com_articles&view=article&id=31546:cms-says-more-data-needed-on-best-management-of-blocked-carotid-arteries
The Centers for Medicare & Medicaid Services (CMS) held a meeting Jan. 25 with the hope of strengthening carotid atherosclerosis management. During said meeting, the Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) voted on evidence, procedures and the most beneficial strategies for the management of atherosclerosis to prevent stroke with most members agreeing that more data are necessary.

Currently, CMS covers coronary artery stenting for patients at a high risk of adverse events from carotid endarterectomy (CEA) for:

• Symptomatic patients with ? 70 percent stenosis;
• Symptomatic patients with a 50 to 70 percent stenosis when procedures are performed in FDA approved category B IDE trials or FDA approved post approval studies; and
• In asymptomatic patients with ? 80 percent stenosis when procedures are performed in FDA approved trials.

Members looked at both symptomatic and asymptomatic patients population to discuss whether carotid artery stenting (CAS), CEA and optimal medical therapy (OMT) improved outcomes in atherosclerotic patients. Additionally, CMS looked to understand whether previously published data on the topic is generalizable to the Medicare population.

Members voted on six questions and used the following responses: low confidence, intermediate confidence or high confidence. Questions dealt with whether CAS or CEA is the favored treatment strategy in various patient populations, previous data outlining the benefits/risks of CAS or CEA as opposed to OMT and what should be done in the future, among others.

During the meeting, William A. Gray, MD, an associate professor of Medicine at the Columbia University Medical Center in New York City, said the “concept of a ‘low-risk’ patient has not clearly been defined, nor identified.” Additionally, Gray said that to date, there are no trials that assess patients who are at a high surgical risk, and that post-trial CEA outcomes cannot be generalize to those who were not enrolled in the trial.

Gray went on to say that in symptomatic patients, CEA and CAS “appears equivalent” in terms of outcomes and stroke in the CREST trial, but noted women did better with CAS compared with CEA in the EVA-3S and ICSS trials.

Lastly, Gray said that the “correct cocktail of medical class” is missing in asymptomatic patients to determine the most optimal medical therapy to treat those with carotid artery disease. “The role of medical therapy remains a tantalizing but unproven alternative to revascularization in patients with established severe carotid stenosis,” Gray said in a statement.

Meanwhile, Robert M. Zwolak, MD, PhD, of the Dartmouth-Hitchcock Medical Center in Lebanon, N.H., looked at the real-world results of CAS and CEA during a presentation at the meeting, concluding that real-world results are not always comparable to what is found in randomized controlled trials.

Zwolak used 30-day stroke and death rates post-CAS and CEA from the SVS Registry as an example. Of 1,450 CAS patients and 1,368 CEA patients, the combined rates of stroke, death and MI was nearly 6 percent for CAS patients compared with nearly 3 percent in CEA patients. The 30-day stroke rates for CAS and CEA for asymptomatic patients was 2.11 percent vs. 1.28 percent, and 5.27 percent vs. 2.37 percent in symptomatic patients. Based on a Nationwide Inpatient Sample analysis, Zwolak reported that stroke and death rates in high surgical risk patients to be nearly two times higher after CAS vs. CEA.

“Even after risk-factor adjustment, stroke risk likely greater after CAS in population based studies,” Zwolak said.

When asked to vote on whether there is accurate evidence to determine whether or not CEA or CAS is the favored treatment as compared to optimal medical therapy in the Medicare population, the majority of the voting body said they had low- to intermediate- confidence about the data. This question was asked about asymptomatic patients not considered high risk for adverse events with CEA.

All voting members said that they had a low confidence that CAS would be the favored treatment strategy in asymptomatic carotid atherosclerosis patients who were not at high risk for stroke. However, many said they had a high confidence that optimal medical therapy alone should be the favored treatment strategy in this patient population.

All in all, the majority of the panelists agreed that more data are necessary to better define the best treatment strategy—CEA, CAS or OMT—for atherosclerotic Medicare patients.

Proximal balloon superior to distal protection in carotid artery stenting

For those needing their arteries cleaned out, read for stroke prevention strategies so you can ask your doctor.
http://www.theheart.org/article/1344705.do?utm_campaign=newsletter&utm_medium=email&utm_source=20120130_EN_Heartwire
Proximal balloon occlusion provides significantly greater embolic protection during carotid artery stenting (CAS) for internal artery stenosis when compared with a filter protection device, research shows [1]. Proximal balloon-occlusion devices do not cross the lesion before it is stented, which helps to significantly reduce embolic load in the brain during the carotid procedure, according to researchers.

To heartwire, senior investigator Dr Joachim Schofer (University Cardiovascular Center, Hamburg, Germany) said that while the question can't be answered clinically from these data, he believes there is connection between the asymptomatic "spots" observed on diffusion-weighted magnetic resonance imaging (DW-MRI) in their study and the risk of stroke. "I'm pretty convinced that proximal balloon occlusion is more effective than distal protection and would result in a lower rate of stroke," he said.

The results of the study, known as the Prevention of Cerebral Embolization by Proximal Balloon Occlusion Compared to Filter Protection During Carotid Artery Stenting (PROFI), are published online January 25, 2012 in the Journal of the American College of Cardiology.

Spots on the brain

The study included 62 consecutive symptomatic and asymptomatic patients undergoing CAS with embolic protection who were randomly assigned proximal balloon occlusion (MO.MA, Invatec) or filter protection (Emboshield Protection System, Abbott Vascular). Compared with the filter, which crosses the lesion before the stent is implanted and is deployed to catch debris during the procedure, the balloon-occlusion device is placed proximal to the lesion and inflated to occlude the external and common carotid arteries. Flow is reversed in the target vessel before the lesion is crossed and treated.

Using DW-MRI, the researchers found that the incidence of new cerebral ischemic lesions per patient was significantly greater among patients who underwent distal protection (87.1% in the filter group vs 45.2% in the balloon-occlusion group; p=0.001). The incidence of new ischemic lesions was significantly higher with filter protection in symptomatic and asymptomatic patients, and there was a trend toward more lesions in patients >80 years of age. Regarding the secondary end points, the researchers report that the number of lesions per patient and the volume of lesions per patient were significantly higher among those who received the filter device compared with balloon occlusion.

One patient had a minor stroke in the filter-protection group, while no major adverse cardiovascular or cerebrovascular events (MACCE) were observed in the balloon-occlusion patients. Schofer noted, however, the study is underpowered for clinical events.

Schofer told heartwire that filter-protection devices are relatively easy to use, and the risk they pose is related to the crossing of the lesion, which results in some dislodging of emboli. In addition, some particles might be too small to be captured by the filter or might pass by the filter if it is not placed properly against the vessel wall. The filters can also become overloaded, which can cause some debris to spill during retrieval. The proximal balloon-occlusion device does not have similar downsides, although it is slightly harder to use and does require more training, said Schofer.

Not all patients are good candidates for proximal balloon occlusion, either. Patients with contralateral occlusion were not included in this study, but balloon intolerance was still noted in 13% of patients. Contralateral new ischemic lesions that develop are likely caused by emboli dislodged when the catheters navigate through the aortic arch, said Schofer.