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Biomedical subjects

P L Gildenberg

Publications and source records attributed to P L Gildenberg.

At least 19 recordsLinked to original sources
PubMed2001

Spiegel and Wycis - the early years.

The field of human stereotactic surgery was introduced by Ernest A. Spiegel and Henry T. Wycis by a historical paper in Science in 1947. Spiegel was a conservative Vienna trained experimental neurologist who fled the Nazis to Temple Medical School in Philadelphia. Wycis was a huge flamboyant but brilliant neurosurgeon who started as Spiegel's student and then became his collaborator. They described a Horsley-Clarke apparatus that could be used in human stereotactic surgery. It relied on internal cerebral landmarks, which made it accurate enough to be used in humans. The fields of human neurophysiology, pneumoencephalography, radiology, and electrophysiology had advanced enough to provide for the first time the required technology. At the time of their initial publication, they had probably already performed surgery for psychiatric illness, pain, movement disorders, and aspiration of tumor cysts. The first decade after their publication was a remarkably productive time for them and the other pioneers who entered the field.

Animals↗
PubMed2001

Myelotomy through the years.

Although myelotomy was first designed to treat somatic pain by interruption of the decussating fibers of the spinothalamic tract, it was soon recognized that pain relief may be obtained in a wider distribution than the dermatomes represented by the interrupted nerves. In 1970, Hitchcock described relief of pain throughout the body by stereotactic production of a single lesion in the middle of the spinal cord at the cervico-medullary junction, a procedure named extra-lemniscal myelotomy by Schvarcz several years later. This led me to the observation reported in 1984 that pelvic pain might be controlled by a non-stereotactic lesion at the thoraco-lumbar area, which appeared to be particularly effective against visceral pain of cancer, in a procedure termed limited myelotomy. In 2000, Kim recognized that thoracic pain might be treated by a similar lesion in the high thoracic area, and termed his procedure thoracic dorsal column midline myelotomy. Up to that time, all authors had considered that pain relief was the result of interruption of a multi-synaptic pathway just dorsal to or within the central canal, which had not yet been defined. However, Willis identified a new pathway in the ventromedial dorsal columns in the post mortem spinal cord provided to him by my coauthor, which he further documented by animal physiologic studies. Nauta, at that same institution, reintroduced limited myelotomy based on those anatomical findings, naming the procedure punctate myelotomy. It must be recognized that all of these procedures have involved interruption of the same pathway, even before it was defined anatomically, and all authors provided similar observations about relief of particularly visceral pain.

Cordotomy↗
PubMed2000

Stereotactic biopsy of cerebral lesions in AIDS.

Stereotactic brain biopsy was used to establish diagnoses of conditions in patients with AIDS. Two hundred fifty stereotactic biopsies and one open resection were performed for 243 patients. Pathologically abnormal tissue was obtained in 246 (98%) of the procedures, and 16 patients (6%) had >1 diagnosis. Diagnoses included lymphoma in 82 (33%), progressive multifocal leukoencephalopathy in 73 (30%), and tumors not ordinarily associated with AIDS in 7 (3%). In one-third of the cases, the tissue diagnosis differed from the predicted diagnosis. Four of the first 32 patients (12%) developed intracranial bleeding hours after surgery, which was fatal in 3 (9%). Subsequently, all patients were treated with a coagulopathy protocol that included preoperative and postoperative administration of coagulation factors, and there were no further instances of delayed bleeding in the 218 subsequent patients. Among those later patients, there were 7 complications (3%), leading to 4 deaths (2%), a complication rate that compares favorably with that among patients without AIDS.

AIDS Dementia Complex↗
PubMed2000

Multimodality program involving stereotactic surgery in brain tumor management.

Stereotactic and image guided surgery is becoming increasingly important in the management of brain tumors. Although there are several stereotactic modalities that have been reported to be of value, it is the combination of techniques in a multimodality approach that seems to show the most promise. Both frame-based and frameless guidance may facilitate glioma resection, allowing the optimal amount of resection while permitting avoidance of surrounding eloquent areas. Not only does this optimize resection, but leaving a minimal amount of gross tumor may provide a better bed for intracavitary chemotherapy. Deep tumors may be localized and approached through a small channel. Surgical exposure may be minimized to protect uninvolved areas of the brain. There is increasing evidence that patients operated with imaging guidance have a more benign course and more rapid discharge, perhaps with a lower incidence of adverse neurological sequelae. Stereotactic conformal radiotherapy allows a higher tumor dose while sparing uninvolved brain from radiation more efficiently than conventional radiation. Residual tumor may be treated with a boost of stereotactic radiotherapy. Stereotactic instillation of radioisotope may be used to treat cystic tumors. Stereotactic insertion of cannulae or radioisotope seeds permits efficient brachytherapy. Stereotactic surgery has moved beyond a subspeciality, so that every neurosurgeon might benefit from using stereotactic techniques in brain tumor management.

Adult↗
PubMed2000

Multimodality program involving stereotactic surgery in brain tumor management.

Stereotactic and image-guided surgery is becoming increasingly important in the management of brain tumors. Although there are several stereotactic modalities that have been reported to be of value, it is the combination of techniques in a multimodality approach that seems to show the most promise. Both frame-based and frameless guidance may facilitate glioma resection, allowing the optimal amount of resection while permitting avoidance of surrounding eloquent areas. Not only does this optimize resection, but leaving a minimal amount of gross tumor may provide a better bed for intracavitary chemotherapy. Deep tumors may be localized and approached through a small channel, and surgical exposure may be minimized to protect uninvolved areas of the brain. There is increasing evidence that patients operated with imaging guidance have a more benign course and more rapid discharge, perhaps with a lower incidence of adverse neurological sequelae. Stereotactic conformal radiotherapy allows a higher tumor dose while sparing uninvolved brain from radiation more efficiently than conventional techniques, and residual tumor may be treated with a boost of stereotactic radiotherapy. Stereotactic instillation of radioisotopes may be used to treat cystic tumors. Stereotactic insertion of cannulae or radioisotope seeds permit efficient brachytherapy. Stereotactic surgery has moved beyond a subspeciality, so that every neurosurgeon might benefit from using stereotactic techniques in brain tumor management.

Adult↗
PubMed1999

History of the American Society for Stereotactic and Functional Neurosurgery.

The field of human stereotactic neurosurgery has just passed the half-century mark. Soon after its inception, the pioneers in the field began to meet to exchange information and ideas, which led to an international forum for stereotactic surgery. In 1973, the organization was expanded to form both the World Society for Stereotactic and Functional Neurosurgery, as well as the European and American Societies for Stereotactic and Functional Neurosurgery. Reviewing the programs of the meetings of those Societies permits one to review the nature of the information that was exchanged through the years, and, in doing so, to monitor the pulse of the field as it has developed. The first independent meeting of the American Society for Stereotactic and Functional Neurosurgery took place in Houston in 1980, at which there were 27 papers, 40% of which were on the newly emerging field of image-guided neurosurgery and the rest on classical functional neurosurgery. The five meetings since, occurring at approximately 4-year intervals, have documented the progress in epilepsy surgery, the reemergence of stereotactic surgery for movement disorders, the growth of stereotactic radiosurgery, and the genesis of frameless stereotactic techniques which have now become widespread.

Congresses as Topic↗
PubMed1998

The history of surgery for movement disorders.

Treatment of movement disorders by interruption of pathways within the nervous system has been a goal of neurosurgeons for the past century. When human stereotactic surgery was introduced 50 years ago, a major advance was made in surgical treatment of Parkinson's disease and other disorders of the motor system. Since then, the field has experienced a period of progressive growth, then abrupt decline, and now is more active than ever before and continuing to grow rapidly. Recent progress in computer science, imaging techniques, neurophysiology, and stereotactic targeting has provided the fuel for future progress.

History, 20th Century↗
PubMed1997

Where have we been? Where are we going?

The field of human stereotactic and functional neurosurgery is 50 years old. It began with the pioneering work of Spiegel and Wycis, who developed an apparatus to be used in human neurosurgery designed like the Horsley-Clarke apparatus invented for animal experimentation 40 years earlier, but based on targeting by intracerebral landmarks. During the past half century, the field of stereotactic surgery has evolved from a small field involving a handful of scientists to a field dominated by a technology that is permeating all of neurosurgery. A review of the scientific programs and activities of the World Society for Stereotactic and Functional Neurosurgery reflects the changing level of activity in these fields, the waxing and waning of functional neurosurgery that is now vital and active, and the evolution of stereotactic guidance into the field of computer-assisted neurosurgery. Functional neurosurgery involves the application of human neurophysiology to the treatment of various diseases that produce malfunction of the nervous system, and remains the domain of those few neurosurgeons well versed in neurological pathophysiology. Image-based or computerized stereotactic surgery, on the other hand, is used in those procedures common to neurosurgery, and should be available to any operating neurosurgeon.

Epilepsy↗
PubMed1997

Stereotactic craniotomy with the exoscope.

A three-dimensional computer graphic program has been developed to guide the surgeon through the resection of a brain tumor. It consists of a video camera mounted on a stereotactic frame which visualizes the operative field in real time. Superimposed on the video monitor is a computer generated model of the tumor or other resection target mass. The mass can be displayed in several modes. The computer image of the mass is adjusted to correspond to the surgeon's eye view, with appropriate settings for the stereotactic apparatus indicated. Prior to incision, the image of the mass is superimposed on the scalp to guide placement and size of the scalp and bone flaps. As the resection proceeds, a cross-section of the mass is illustrated on the video picture of the operative field. The distance from the camera to the surface is measured, and the cross-section at that depth is displayed. A small window indicates the surgeon's eye view and the tangential view of the mass with an indication of the cross-section currently being displayed. As resection proceeds, the distance to the bottom of the resection cavity is measured repeatedly. The image is updated to indicate only that level of the tumor under resection. As the far side of the tumor is encountered, the mass disappears from the monitor, signaling completion of the resection.

Brain Mapping↗
PubMed1996

Pallidotomy: a survey of current practice in North America.

Twenty-eight centers completed a survey about their current practice of pallidotomy. This sample represents a non-exhaustive survey of the current practice of pallidotomy in North America and is not a study of outcomes. 1015 patients underwent 1219 pallidotomies: 811 (80%) unilateral, 72 (7%) staged bilateral, and 132 (13%) simultaneous bilateral. Pallidotomy has long been an accepted procedure and the indications for this surgery, in the opinion of the responding centers, were rated on a scale of 1 (poor) to 4 (excellent) and demonstrated dyskinesia as the best indication (median = 4); on-off fluctuations, dystonia, rigidity, and bradykinesia as good indications (median = 3); and freezing, tremor and gait disturbance as fair indications (median = 2). Most centers used MRI alone (50%) or in combination with CT scan (n = 6) or ventriculopathy (n = 5) to localize the target. The median values of pallidal coordinates were: 2 mm anterior to the midcommissural point 21 mm lateral to the midsagittal plane and 5 mm below the intercommissural line. Microrecording was performed by half of the centers (n = 14) and half of the remaining centers were considering starting it (n = 7). Main criteria used to define the target included the firing pattern of spontaneous neuronal discharges (n = 13) and the response to joint movement (n = 10). Most centers performed motor (n = 26) and visual (n = 23) macrostimulation. Twenty four centers performed test lesions using median values of 55 degrees C temperatures for 30 s. Final lesions consisted of 3 permanent lesions placed 2 mm apart, each lesion created with median values of 75 degrees C temperatures for 1 minute. Median hospital stay was 2 days.

Brain Mapping↗
PubMed1995

Management of movement disorders. An overview.

Functional neurosurgery has been involved with management of movement disorders since the first days of stereotactic surgery. Those movement disorders that can be managed surgically are reviewed, along with general criteria for patient selection. A flow sheet of surgically managed movement disorders is supplemented by descriptions of how patients are assigned to various treatment categories and the various treatments available.

Humans↗
PubMed1994

The exoscope--a frame-based video/graphics system for intraoperative guidance of surgical resection.

A system has been devised to focus a video camera mounted on a CRW stereotactic frame onto the surgical field and to integrate the video picture with a computer-generated three-dimensional view of structures or targets deep within the brain. The surgical resection can then be done with the surgeon looking either at the composite picture on the video/computer monitor (as in almost all endoscopic surgery) or at the surgical field, to perform the resection using the conventional techniques most comfortable to the surgeon and most effective for the resection. The graphics platform on which the Exoscope program is built is the same as used for the RSA X-Knife stereotactic radiosurgery system. The X-Knife graphics program allows the reconstruction of a target mass (such as intracranial tumor) and desired objects (such as surrounding vessels) with accurate registration to stereotactic coordinates derived from the CRW localizing system. By mounting a video system through an externally mounted endoscope on the CRW arc, it is possible to orient the video image with great accuracy to this same stereotactic space. The two images are superimposed on a computer/video console in the operating room. The surgeon visualizes a real-time video image of the operating field upon which is a graphical representation of the computer-generated image of the target mass beneath the surface. In the corners are triplane orthogonal views through the center of target and a view parallel to the trajectory, so the surgeon may gauge his or her progress toward the target.(ABSTRACT TRUNCATED AT 250 WORDS)

Computer Graphics↗
PubMed1994

An informal survey of stereotactic and functional neurosurgery.

The authors present information on the frequency of stereotactic surgical procedures for numerous clinical indications, based on the results of an international survey. Also presented is information on the interest levels of neurosurgeons in various new technologies and applications for stereotactic techniques.

Computer Graphics↗
PubMed1994

Fractionated brachytherapy: catheter insertion and dosimetry.

The incorporation of the Omnitron device, a robotic isotope handling system, into a program of brachytherapy for glial tumors has made it possible to hyperfractionate treatment in 15-20 sessions over a 2- to 3-week period, which offers considerable theoretical advantage over conventional single dose regimens. Stereotactic catheter placement is by contrast-enhanced MR guidance, and takes advantage of the three-dimensional planning offered by voxel orientation. Initial placement is based on orientation to the three customary planes, with oblique planes added to define intercatheter placement more accurately. Catheters may be placed asymmetrically through the tumor or even at different angles of insertion to get the optimal conformation. Dosimetry is based on three-dimensional reconstruction in the Omnitron planning console, and takes advantage of the optimized localization of each catheter position. High-dose isotope insertion is performed robotically, with isotope position and dwell times controlled by computer. The phase I study demonstrates a wide safety margin and suggests better survival than would be expected with conventional management.

Brachytherapy↗
PubMed1993

Stereotactic biopsy in cerebral lesions of AIDS.

The experiences with stereotactic biopsies in 121 patients with AIDS compared to 142 non-AIDS patients are presented. In the AIDS group most of the tumors (38) were lymphomas (34). Other frequent diagnoses have been progressive multifocal leukoencephalopathy (20) and toxoplasmosis (16)--although most AIDS patients already had been treated for toxoplasmosis, and those who responded to it did not undergo biopsy. Initially among the AIDS patients there was a tendency of delayed intracranial bleeding (4 cases, 3 of them fatal). After initiation of a prophylactic coagulopathy protocol no other such complications have occurred in the following 70 biopsies.

Acquired Immunodeficiency Syndrome↗