Surgical Management of Parkinson’s Disease: The Role of Lesioning Procedures in Developing Countries in the Modern Era

BACKGROUND: The known loss of dopaminergic cells in the pars-compacta of the substantia nigra that is the hallmark of PD. The cellular pathophysiology of the motor dysfunction is beginning to be better understood, thereby providing a stronger scientific rationale for surgical interventions. Yet, to date, there are no treatments that prevent, halt, or cure PD. Surgical strategies, offer symptomatic relief or control of motor complications associated with drug treatment. Both pallidotomy and thalamotomy were extensively used in the treatment of PD in the1950’s and 1960’s. With the introduction of levodopa (L-dopa) in the1960’s and the realization of its striking benefits, surgery was almost abandoned and used only for patients with severe tremor. Surgical therapy is now being used earlier and more often. There are currently three brain regions being considered as targets for functional neurosurgery for PD (other than transplantation). Either CNS lesions (thalamotomy, pallidotomy or subthalamic nucleus lesions) or deep brain stimulation [DBS]. These targets are: The ventral intermediate nucleus of the thalamus (Vim), the internal segment of the Globus Pallidus (GPi) and the subthalamic nucleus (STN). OBJECTIVE: To assess the outcome (3 months & 6 months) of lesioning procedures in parkinson’s disease (PD) patients meeting the inclusion criteria. METHODS: A prospective clinical study conducted on 10 IPD patients during the period from October 2018 to March 2021 at Cairo University Hospitals. This study was concerned to improve the motor symptoms of IPD patients by stereotactic radiofrequency ablative procedures. Cases were restricted to 10 patients due to the Covid-19 pandemic and restriction of elective cases for chronic patients at Cairo University hospitals. RESULTS: In our study we operated upon 10 IPD patients who were meeting our selection criteria by ablative procedures contralateral to parkinsonian symptoms. Age of the patients ranged 17 – 70y with mean of 50.5 ± 16.35 y with predominance in males representing 6 patients. Mean duration of Parkinson`s disease according to history ranged from 2 to 12 y with mean of 8 ± 3.1 years. Patients were divided into three groups according to their presentation and the operation done for them. Thalamotomy group: Pre-operatively, the UPDRS III off & on respectively was 24.4/15.2 and post-operatively was 13/7.4 with improvement 47% / 51%. The tremor subscore was 5.4/2.8 pre-operatively and 1.4/0.8 post-operatively with average of 72% improvement. The UPDRS II pre was 17.2/11.6 and post it became 10.6/7 with 39% improvement. Modified H&Y 2.4/1.7 pre & post-operatively (29% improvement). Pallidotomy group: Pre-operatively, the UPDRS III off & on respectively was 38.5/23.5 and post-operatively was 28/16 with improvement 27% / 32%. The rigidity subscore was 5/2.5 pre-operatively and 2/1 post-operatively with average of 60% improvement. The bradykinesia subscore was 9/5.5 pre-operatively and 5.5/2.5 post-operatively with average of 47% improvement. The dyskinesia subscore was 4.5 pre-operatively and 1.2 post-operatively with average of 71% improvement. The UPDRS II pre was 22/12.5 and post it became 16/10 with 25% improvement. Modified H&Y 2.75/2.25 pre & post-operatively (18% improvement). Combined group: Pre-operatively, the UPDRS III off & on respectively was 41.33/28.67 and post-operatively was 15.67/11.33 with improvement 62% /60%. The rigidity subscore was 5/3.33 pre-operatively and 1.67/1 post-operatively with average of 68% improvement. The bradykinesia subscore was 10/6 pre-operatively and 4/1.33 post-operatively with average of 72% improvement. The UPDRS II pre was 28.33/19.33 and post it became 16.33/10.67 with 43% improvement. Modified H&Y 2.83/2 pre & post-operatively (29% improvement). Postoperatively, there was a high significant statistical finding in all clinical score and subscore of parkinsonian symptoms. CONCLUSION: The study concludes that lesioning procedure should be revisited globally using the modern techniques of targeting and controlled thermal lesion protocols guided by capsular somatotopy and intraoperative macroelectrode stimulation, that will improve the outcome dramatically. Ablative procedures proved their efficacy in controlling motor symptoms of IPD and their cost-benefit in low & middle-income nations.

Numerical Study of Bubble Cloud and Thermal Lesion Evolution During Acoustic Droplet Vaporization Enhanced Hifu Treatment

Acoustic droplet vaporization (ADV) has proven to enhance high intensity focused ultrasound (HIFU) thermal ablation of tumor. It has also been demonstrated that triggering droplets before HIFU exposure could be a potential way to control both the size and the shape of the thermal lesion. In this paper, a numerical model is proposed to predict the thermal lesion created in ADV enhanced HIFU treatment. Bubble oscillation was coupled into a viscoelastic medium in the model to more closely represent real applications in tissues. Several physical processes caused by continuous wave ultrasound and elevated temperature during the HIFU exposure were considered, including rectified diffusion, gas solubility variation with temperature in the medium, boiling, etc. Four droplet concentrations spanning two orders of magnitude were calculated. The bubble cloud formed from triggering of the droplets by the pulse wave ultrasound, along with the evolution of the shape and location of the bubble cloud and thermal lesion during the following continuous wave exposure were obtained. The increase of bubble void fraction caused by continuous wave exposure were found to be consistent with the experimental observation. With the increase of droplet concentration, the predicted bubble cloud shapes vary from tadpole to triangular and double triangular, while the thermal lesions move toward the transducer. The results show that the assumptions used in this model increased the accuracy of the results. This model may be used for parametrical study of ADV enhanced HIFU treatment and be further used for treatment planning and optimization in the future.

Prospects for improving primary health care to children with thermal injuries

Introduction. Burn injury in children has been and remains one of the most significant cause of disability and death in the world. An important aspect in relation to the prognosis and course of the wound process is the quality of the first aid provided at the prehospital stage. Untimely diagnosed shock, inadequately prescribed anesthesia, attempts to perform surgical treatment of wounds at the site of the accident can fatally affect the prognosis of the disease.Material and methods. A retrospective analysis of medical documentation of 328 children who were treated at the burn center from 2016 to 2019 was made. Selection criteria were: arrival to the center by ambulance, shock, transfer to ICU. To analyze actions performed in the prehospital stage, a number of parameters were identified: diagnosis, length of transportation, specialists in the ambulance team, TBSA (total burn surface area), thermal inhalation lesion, and others.Results. The overwhelming majority of errors refer to diagnostics: shock (94.5%), incorrect TBSA assessment (63.7%), inadequate pain relief (61.9%), etc. A reliable correlation was revealed between ineffective analgesia and incorrect assessment of thermal lesion area. Life-threatening conditions develop in case of incorrect primary surgical treatment of wounds, incorrect vascular puncture, tracheal intubation, etc.Conclusions. The revealed difficulties in providing the primary medical aid to burnt patients at the site of accident require the development of a clearer and more understandable algorithm for medical personnel who provide the first aid to children with burns.

Numerical Analysis on the Effects of Saline Injection and Deformation for Radiofrequency Catheter Ablation

Radiofrequency catheter ablation is an interventional procedure used to treat arrhythmia. An electrode catheter that could inject saline has been developed to prevent steam pop on heart tissue during radiofrequency catheter ablation. Thus, we investigated to numerical model on the effect of saline injection and heart tissue’s deformation. In this study, the hyperelastic model was implemented to analyze heart tissue deformation due to the catheter’s contact force. Besides, the advection–diffusion equation was used to analyze the mixture between saline and blood. We developed the multiphysics model that predicts thermal lesions based on the deformation of the heart and mixing between saline and blood flow. The thermal lesion and the maximum temperature in the numerical model that considered mixing saline and blood were smaller than that of other numerical models that did not consider mixing. Therefore, we observed that the saline injection was affected by thermal lesion due to higher electrical conductivity than blood flow and injection at a lower temperature than the human body. The numerical model was researched that considering the deformation of the heart tissue and saline injection in radiofrequency catheter ablation affects the heart tissue’s thermal lesion and maximum temperature.

MODELLING OF TEMPERATURE FIELD DISTRIBUTION IN BIOLOGICAL TISSUE THERMAL LESION

Early determination of the thermal lesion degree in case of scald accelerates the treatment process and increases its effectiveness. The thermal lesion degree can be evaluated by determining the temperature difference between healthy and injured areas of biological tissue. For this purpose, a model of biological tissue in the form of a multilayer structure can be used. Heat exchange processes in such a structure are described by a generalized thermal model. Such structure contains conditionally flat heat sources located in each layer, which have the form of a developed network of blood vessels. The considered model of biological tissue quite accurately describes the heat exchange processes in body tissues. The article considers heat exchange processes that take place in biological tissue and a number of assumptions that should be used to mathematically describe these processes were identified. During the analysis of heat transfer process, the equations of temperature distribution in the tissue layers and the boundary conditions that describe the thermal interaction of the model with the environment are determined. As a result, the model of the stationary thermal regime of a biological tissue fragment in the form of a generalized thermal model and a mathematical model of the temperature field distribution in this fragment is obtained. This model is determined by many parameters, which are divided into 3 groups: thermophysical parameters; structural and topological parameters; parameters of the blood vascular system. Models of the particular fragment thermal regime are unequivocally determined by a combination of these parameters. For the analysis of temperature in any point of biological tissue modelled part mathematical model of temperature field distribution in stationary mode was developed. This model allows reasonable approach to the thermal lesion degree evaluation on the basis of the surface temperature difference between healthy and injured areas of tissue.

Thermal and electric Characteristics of High-power Short-duration Radiofrequency Ablation and Standard Radiofrequency Ablation: A Computer Simulation Study

Background: High power-short duration ablation is an emerging conception for cardiac RF treatment. But the biophysical ablation properties of this technique have not been fully explored. This study compared the electric field characteristics and thermal lesion dimension in High power-short duration (HP-SD) radio frequency (RF) ablation and standard RF ablation by using the finite element method. Results: The results demonstrated that the lesion size and temperature in HP–SD RF ablation increased faster than standard RF ablation. The thermal lesion volume in both ablation modes demonstrated a linear increase and the rate of increase of HP–SD RF ablation grew faster than that of standard RF ablation. For HP–SD application at 50 W for 5 s, the lesion depth was shallower (1.74 to 2.1 mm vs 2.40 to 3.15 mm) and the surface lesion diameter was broader (2.76 to 3.32 mm vs 2.42 to 2.66 mm) than that for standard RF ablation at 25 W for 30 s. Conclusion: Compared with standard RF ablation, HP–SD RF ablation creates a broader lesion width and surface lesion diameter but shallower lesion depth, with a faster increase in temperature. HP–SD ablation is more able to achieve uniform and contiguous lesion shape, which is a suitable for point-to-point RF ablation procedures.Higher temperature was formed in deeper space of cardiac tissue in HP–SD ablation. The duration of HP–SD ablation should be strictly controlled for preventing the steam occur in tissue.

A row-generation approach for simultaneous multiple needle trajectory planning in radiofrequency ablation

Radiofrequency ablation is a thermal therapy for moderately-sized cancerous tumors. A target is killed with high temperatures obtained due to the current passed through one or more electrodes (needles) inserted into it. The needles' trajectory must be meticulously planned to prevent interference with dense organs like bone or puncturing of critical structures like veins. By approximating the thermal lesion to an ellipse, we predefine several valid needle trajectories and then solve an integer programming model to identify pairwise valid needle positions, that meet clinical criteria, using a variation of the classic set cover model. To improve the models' tractability and scalability, we use row generation-based decomposition techniques that determines pairwise validity using two different types of cuts. Finally, we analyze target and OAR damage using several thermal damage models. Thus, for the first time we present a full treatment plan that incorporates novel trajectory planning with thermal dose computations. Our method is tested on 12 liver targets: three targets each with four different surgical margins. We show promising results that meet clinical guidelines while obtaining full target coverage.

High Intensity Focused Ultrasound and Microbubble Induced Tissue Ablation: Effect of Treatment Parameters on Thermal Lesion Volume and Temperature

Microbubble agents have been shown to increase therapeutic effect of HIFU (High intensity focused ultrasound). Here, the effects of treatment parameters on lesion volume and temperature are investigated.

High Intensity Focused Ultrasound and Microbubble Induced Tissue Ablation: Effect of Treatment Parameters on Thermal Lesion Volume and Temperature

Microbubble agents have been shown to increase therapeutic effect of HIFU (High intensity focused ultrasound). Here, the effects of treatment parameters on lesion volume and temperature are investigated.

Ultrasound shear wave elastography: numerical modeling and time-frequency analysis with an application in HIFU thermal lesion detection

In this work, a new numerical framework is proposed and implemented to simulate acoustic wave propagation in 3D viscoelastic heterogeneous media. The framework is based on the elastodynamic wave equation in which a 3D second-order time-domain perfectly matched layer (PML) formulation is developed to model unbounded media. The numerical framework is discretized by a finite difference formulation and its stability analysis is discussed. The proposed numerical method is capable of simulating 3D shear and longitudinal acoustic waves for arbitrary source geometries and excitations, together with arbitrary initial and boundary conditions. After validation of the framework, it was used to simulate the propagation of ultrasound shear wave in high intensity focused ultrasound (HIFU) induced thermal lesions located within soft tissue. The parameters in these simulations were obtained from standard double-indentation measurements of the viscoelastic parameters of normal and thermally coagulated chicken breast tissue samples. A HIFU system was used to induce thermal lesions in tissue. In this study, a new elastography procedure was also introduced to differentiate between the normal and HIFU induced thermal lesions. This method is based on time-frequency analysis of shear wave propagation within the tissue. In the proposed method, the Wigner-Ville distribution has been used as a time-frequency analytical technique to detect the location of shear wave propagating within the tissue, and to estimate the shear speed of the wave as well as its center frequency and attenuation coefficient. This method was applied to the acoustic wave propagation simulation results of the HIFU thermal lesion. It was finally used to estimate the local viscoelastic parameters of the medium. It was demonstrated that the proposed method is capable of differentiating the thermal lesions from the normal tissue based on their viscoelastic parameters.