Faculty Bibliography

Posteroventral pallidotomy (PVP) has received renewed interest as an ablative procedure for the symptomatic treatment of Parkinson's disease. In previous reports, the proximity of the optic tract to the lesion target in the globus pallidus internus has resulted in the occurrence of visual field deficits in as much as 14% of patients. The authors have used intraoperative visual evoked potentials (VEPs) during PVP to reduce this risk. All procedures were performed in awake patients. Flash stimuli were delivered to each eye via fiberoptic sources. Baseline flash VEPs were recorded at O1/Cz (left visual cortex to vertex), Oz/Cz (midline visual cortex to vertex), and O2/Cz (right visual cortex to vertex) for OS, OU, and OD stimulation. Epochs were acquired before and after localization, after macroelectrode stimulation, after temporary thermal lesioning, and after permanent thermal lesioning. Forty-seven patients underwent a total of 59 procedures. Visual evoked potentials were recorded reproducibly in all patients. In 11 procedures, VEP changes were reported, including six amplitude changes (10-80%), six latency shifts (3-10 msec), and one report of "variability." In four procedures, VEP changes prompted a change in target coordinates. One false-positive and one false-negative VEP change were encountered. The only confirmed visual deficit was a superior quadrantanopsia, present on formal fields, but clinically asymptomatic. The authors conclude that VEPs may be useful for procedures performed in the awake patient because of the lack of anesthetic-induced variability. The 1.7% visual morbidity reported here (one in 59 patients) compares favorably with other series using microelectrodes. Visual evoked potentials may be a useful monitoring technique to reduce the incidence of clinically significant visual morbidity during pallidotomy, especially during formal lesioning of the ventral pallidum adjacent to the optic tract.

Radiosurgery is one of the surgical treatments of trigeminal neuralgia. Through precise irradiation of the proximal trigeminal nerve identified on high-resolution imaging, pain relief can be achieved after a short latency interval. This image-guided approach has been useful for both patients with persistent pain after other surgeries, and as a primary surgical option. A minimum dose of 70 Gy delivered with the gamma knife has been associated with low risk for facial numbness, and no other morbidity. Management of trigeminal neuralgia without an incision, transfacial needle placement or nerve section may prove useful to increasing numbers of patients.

With improvements in imaging technology, the detection of both cavernous malformations and venous malformations has increased markedly in recent years. Although much has been learned about the association of cavernous and venous malformations, important questions regarding the true nature of such a relationship remain unanswered. It has been proposed that certain venous malformations produce local venous hypertension with resultant microhemorrhage, growth factor release, and creation of cavernous malformations. The authors report on two patients with cerebellopontine venous malformations associated with cavernous malformations. Both patients demonstrated persistent regional parenchymal enhancement associated with the vascular malformations. In addition, both patients had significant clinical symptoms referable to the region of affected brain. This previously undescribed finding may represent an imaging correlate to the complex interaction among venous malformations, venous hypertension, and cavernous malformations.