Sirs, Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is currently the most common therapeutic surgical procedure for patients with advanced ParkinsonÕs disease (PD) and motor complications, not controlled by the pharmacological treatment. The success of the post-operative clinical outcome depends on careful patient selection and an optimal targeting of the STN. To improve the location accuracy of this nucleus, intraoperative microrecordings are performed in most centres. The standard procedure of electrodes implantation is usually carried out under local anaesthesia [1]. Experience in intraoperative microrecording of STN under general anaesthesia is scarce [2], and neuronal firing patterns are not well typified.We describe the intraoperative microrecording results obtained from a patient with advanced PD who underwent implantation of DBS electrodes in the STN under general anaesthesia using Bispectral Analysis of the Electroencephalogram (BIS). This technique allows hypnotic titration over the complete range of cortical activity. A BIS value of 65-85 is recommended for sedation and 40-65 for general anaesthesia [3]. BIS values correspond linearly to the hypnotic dose of intravenous or volatile agents [4] and, therefore, it allows changing the level of sedation and analgesia rapidly to accommodate specific requirements such as intraoperative microrecording.A 59-year-old man with a 7-year history of PD complicated with motor fluctuations and dyskinesias was scheduled for DBS of STN. General anaesthesia was used during the surgical procedure because the patient experienced a severe painful cervical dystonia which prevented positioning the stereotactic frame.Propofol 200 mg, fentanyl 150 lg and cisatracurium 10 mg were administered, then target propofol and remifentanyl concentrations were adjusted to achieve a BIS value of 60-65 during microrecordings, the lightest level of a general anaesthesia.
Direct aneurysm surgery started more than 70 years ago. Introduction of cerebral angiography by Moniz in 20s and operating microscope by Yas°argil in 60s were the real cornerstones in vascular neurosurgery. Since then the development of neuroanestesiology and further development of non-invasive imaging (MRA and CTA) together with the latest development of operating microscopes with intraoperative ICG angio have shifted vascular microneurosurgery to a different level to still compete with the 'non-invasiness' of endovascular therapy. There is an increasing demand to perform the already forgotten bypasses mastered only by few and with the high-flow techniques (e.g. ELANA) we can treat lesions that some time ago were considered impossible. Endovascular embolization to reduce the flow in AVM before surgery is very helpful in those cases that can not be treated by embolization or radiosurgery alone.We still need to find a way to detect aneurysms before they rupture and especially those thin-walled that are in an increased risk of rupture. Recent data on the pathobiology of the aneurysm wall may help us to better understanding of the growth mechanisms and it might be possible to develop more potent local or systemic pharmaceutical therapy to induce myo-intimal hyperplasia occluding the aneurysm and strengthening the wall to prevent rupture.
Simultaneous presentation of carotid stenosis and cerebral aneurysms is rare and it is conventionally accepted that symptomatic lesions need to be treated first. Our purpose was to describe our experience in managing patients who simultaneously presented significant carotid stenosis and cerebral aneurysm.
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