Category Archives: Functional Neurosurgery

Update: Microvascular decompression for trigeminal neuralgia

Microvascular decompression (MVD) via lateral suboccipital approach is the standard surgical intervention for trigeminal neuralgia (TN).

Outcome

It has proven to be the most successful and durable surgical approach for trigeminal neuralgia (TN).

However, not all patients with TN manifest unequivocal neurovascular compression (NVC). Furthermore, over time patients with an initially successful MVD manifest a relentless rate of TN recurrence.

It does not achieve 100 % cure rate. Re-exploration of the posterior fossa may carry increased risk over first-time MVD and is not always successful, so other treatments are needed.

Case series

2017

Clinical characteristics, intraoperative findings, and postoperative curative effects were analyzed in 72 patients with trigeminal neuralgia who were treated by microvascular decompression. The patients were divided into arterial and venous compression groups based on intraoperative findings. Surgical curative effects included immediate relief, delayed relief, obvious reduction, and invalid result. Among the 40 patients in the arterial compression group, 32 had immediate pain relief of pain (80.0%), 5 cases had delayed relief (12.5%), and 3 cases had an obvious reduction (7.5%). In the venous compression group, 12 patients had immediate relief of pain (37.5%), 13 cases had delayed relief (40.6%), and 7 cases had an obvious reduction (21.9%). During 2-year follow-up period, 6 patients in the arterial compression group experienced recurrence of trigeminal neuralgia, but there were no recurrences in the venous compression group. Simple artery compression was followed by early relief of trigeminal neuralgia more often than simple venous compression. However, the trigeminal neuralgia recurrence rate was higher in the artery compression group than in the venous compression group 1).

2016

Indocyanine green videoangiography was performed in 17 TN patients undergoing microvascular decompression.

von Eckardstein et al., focused on whether ICG angiography is helpful in determining the site of conflict, particularly when not directly visible via the microscope, and whether fluorescence is strong enough to shine through the nerve obliterating the direct view of the compressing vessel.

In four patients, the site of conflict was immediately apparent after opening the cerebellopontine cistern, and ICG angiography did not provide the neurosurgeon with additional information. In another two patients, imaging quality and fluorescence were too poor. Of the remaining 11 patients with a hidden site of nerve-vessel conflict, ICG angiography was found to be helpful in anticipating the site of compression and the course of the artery in 7 patients, particularly in regard to the so-called shining-through effect through fiber bundles of the thinned nerve. Of all the patients, 88% reported at least improvement or cessation of their symptoms, including all of the patients with a shine-through effect.

ICG angiography could be a helpful adjunct in decompressing the trigeminal nerve and can guide the surgeon to the nerve-vessel conflict. Intensity of the fluorescence is powerful enough to shine through thinned and splayed trigeminal nerve fiber bundles 2).


A retrospective review of patient records from 1998 to 2015 identified a total of 942 patients with TN and 500 patients who underwent MVD. After excluding several cases, 306 patients underwent MVD as their first surgical intervention and 175 patients underwent subsequent MVD. Demographics and clinicopathological data and outcomes were obtained for analysis.

In patients who underwent subsequent MVD, surgical intervention was performed at an older age (55.22 vs 49.98 years old, p < 0.0001) and the duration of symptoms was greater (7.22 vs 4.45 years, p < 0.0001) than for patients in whom MVD was their first surgical intervention. Patients who underwent initial MVD had improved pain relief and no improvement in pain rates compared with those who had subsequent MVD (95.8% and 4.2% vs 90.3% and 9.7%, respectively, p = 0.0041). Patients who underwent initial MVD had significantly lower rates of facial numbness in the pre- and postoperative periods compared with patients who underwent subsequent MVD (p < 0.0001). The number of complications in both groups was similar (p = 0.4572).

The results demonstrate that patients who underwent other procedures prior to MVD had less pain relief and a higher incidence of facial numbness despite rates of complications similar to patients who underwent MVD as their first surgical intervention 3).

2015

A retrospective analysis of clinical data was performed in 99 patients who underwent MVD from May 2012 to June 2015. The outcome data from 27 MVD operations for 27 patients aged 70-80 years (mean 74.6 years) were compared with 72 MVD operations with 72 patients aged 25-69 years (mean 55.7 years). Preoperative comorbidities were recorded and postoperative worsening comorbidities and non-neurological complications were evaluated at discharge. Efficacy of the surgery and neurological complications were evaluated in July 2015.

No decrease in activity of daily living was found in any patient. Complete pain relief without medication was achieved in 77.8% and partial pain relief in 14.8% in the elderly group, and 83.3% and 9.7%, respectively, in the non-elderly group (p=0.750). Permanent neurological complication was not observed in the elderly group, whereas Vth nerve and VIIIth nerve complications were observed in the non-elderly group. Rates of preoperative multiple comorbidities and of cardiovascular comorbidity were significantly higher in the elderly group (p<0.01). Worsening comorbidity and new pathology at discharge were mainly hypertension in both groups, but glaucoma attack and asthma attack were observed in the elderly group. All pathologies were successfully managed.

MVD for elderly patients with TN can be achieved safely with careful perioperative management. Information of comorbidity should be shared with all staff involved in the treatment, who should work as a team to avoid worsening comorbidity. The possibility of unpredictable events in the elderly patients should always be considered 4).


Since 2004, there were a total of 51 patients with TIC and 12 with HS with available MRI scans. All patients underwent preoperative MRI to rule out non-surgical etiologies for facial pain and facial spasm, and confirm vascular compression. Follow-up after surgery was 13±22 months for the patients with TIC and 33±27 months for the patients with HS.

There were 45 responders to MVD in the TIC cohort (88%), with a Visual analog scale (VAS) of 1±3. All patients with HS responded to MVD between 25 and 100%, with a mean of 75±22%. Wound complications occurred in 10% of patients with MVD for TIC, and 1 patient reported hearing loss after MVD for HS, documented by audiogram. The congruence rate between the preoperative MRI and operative findings of vascular compression was 84% in TIC and 75% in HS.

MVD is an effective and safe modality of treatment for TIC and HS. In addition to ruling out structural lesions, MRI can offer additional information by highlighting vascular loops associated with compressions. On conventional scans as obtained here, the resolution of MRI was congruent with operative findings in 84% in TIC and 75% in HS. This review emphasizes that the decision to undertake MVD in TIC or HS should be based on clinical diagnosis and not visualization of a compressing vessel by MRI. Conversely, the presence of a compressing vessel by MRI demands perseverance by the surgeon until the nerve is decompressed 5).


The trigeminal nerve was sectioned into 5 zones. Zone 1, 2, 3, 4 was located at the rostral, caudal, ventral, and dorsal part of the nerve root entry zone (REZ) respectively, and zone 5 was located at the distal of the nerve root. This study contained 86 patients with trigeminal neuralgia underwent microvascular decompression. Every zone was exposed through preoperative imaging. During the operation, offending vessels were explored from zone 1 to zone 5, and different decompression techniques were used for different types of vessels.

Through zone exploration, the sensitivity of preoperative imaging was 96.5% and specificity was 100%. Location of the neurovascular conflict was in the zone 1 in 53.5% of the patients, zone 2 in 32.6%, zone 3 in 45.3%, zone 4 in 29.1%, and zone 5 in 34.9%. In total, 2 zones were both involved in 59.3%, and 3 zones were involved in 18.6%. All offending arteries were moved away and interposed with Teflon sponge. Offending veins of 11 patients were too small to interpose, and coagulated and cut was adopted. The other offending veins were interposed with wet gelatin and Teflon sponge, respectively 6).

2014

Lee et al. performed a retrospective review of cases of TN Type 1 (TN1) or Type 2 (TN2) involving patients 18 years or older who underwent evaluation (and surgery when indicated) at Oregon Health & Science University between July 2006 and February 2013. Surgical and imaging findings were correlated.

The review identified a total of 257 patients with TN (219 with TN1 and 38 with TN2) who underwent high-resolution MRI and MR angiography with 3D reconstruction of combined images using OsiriX. Imaging data revealed that the occurrence of TN1 and TN2 without NVC was 28.8% and 18.4%, respectively. A subgroup of 184 patients underwent surgical exploration. Imaging findings were highly correlated with surgical findings, with a sensitivity of 96% for TN1 and TN2 and a specificity of 90% for TN1 and 66% for TN2. Conclusions Magnetic resonance imaging detects NVC with a high degree of sensitivity. However, despite a diagnosis of TN1 or TN2, a significant number of patients have no NVC. Trigeminal neuralgia clearly occurs and recurs in the absence of NVC 7).

2002

A study comprises 42 cases of trigeminal neuralgia that underwent operation with endoscopic-assisted microvascular decompression between October 1992 and October 1998. This study was performed in the Ear, Nose, and Throat Department, Nord Hospital, in Marseille, France. The decompression was performed by means of a minimally invasive retrosigmoid approach without a cerebellar retractor. The cerebellopontine angle was then explored by a 30-degree endoscope that gives a panoramic view of this space, with clear visualization of the trigeminal nerve from the pons to Meckel’s cave, allowing for the identification of the precise location of the site of the conflict. Microvascular decompression was performed under the microscope by separating the offending vessel from the trigeminal nerve; separation was maintained by the insertion of a piece of Teflon.

The site of conflict was detected at the root entry zone of the nerve in 35 patients (83.3%) and at Meckel’s cave in 7 patients (16.7%). In 32 cases (76.2%), the type of contact between the vessel and the nerve was of the simple type (1 vessel coming in contact with the nerve in a single point); in 6 cases (14.3%), it was a multiple type (2 vessels touching the nerve in the same point); and in 4 cases (9.5%), it was a nutcracker type (2 vessels compressing the nerve between them). After at least 1-year follow-up and a single operation (cases that required a second operation for revision were considered failures), a successful result was obtained in 31 cases (73.8%), and an improvement was obtained in 4 cases (9.5%). The operation was a failure or early recurrence occurred in 7 cases (16.7%). Postoperative complications were rare. A cerebrospinal fluid leak occurred in only 1 case (2.4%) and was subsequently treated with lumbar puncture and a compressive bandage.

The minimally invasive retrosigmoid endoscopic-assisted microvascular decompression is an acceptable treatment of primary trigeminal neuralgia. Endoscopy provides a unique way to explore the cerebellopontine angle and to identify the exact location of the neurovascular conflict 8).


1) Shi L, Gu X, Sun G, Guo J, Lin X, Zhang S, Qian C. After microvascular decompression to treat trigeminal neuralgia, both immediate pain relief and recurrence rates are higher in patients with arterial compression than with venous compression. Oncotarget. 2017 Jan 20. doi: 10.18632/oncotarget.14765. [Epub ahead of print] PubMed PMID: 28122347.
2) von Eckardstein KL, Mielke D, Akhavan-Sigari R, Rohde V. Enlightening the Cerebellopontine Angle: Intraoperative Indocyanine Green Angiography in Microvascular Decompression for Trigeminal Neuralgia. J Neurol Surg A Cent Eur Neurosurg. 2016 Sep 23. PubMed PMID: 27704490.
3) Theodros D, Rory Goodwin C, Bender MT, Zhou X, Garzon-Muvdi T, De la Garza-Ramos R, Abu-Bonsrah N, Mathios D, Blitz AM, Olivi A, Carson B, Bettegowda C, Lim M. Efficacy of primary microvascular decompression versus subsequent microvascular decompression for trigeminal neuralgia. J Neurosurg. 2016 Jul 15:1-7. [Epub ahead of print] PubMed PMID: 27419826.
4) Amagasaki K, Watanabe S, Naemura K, Shono N, Nakaguchi H. Safety of microvascular decompression for elderly patients with trigeminal neuralgia. Clin Neurol Neurosurg. 2015 Dec 31;141:77-81. doi: 10.1016/j.clineuro.2015.12.019. [Epub ahead of print] PubMed PMID: 26765772.
5) Hitchon PW, Zanaty M, Moritani T, Uc E, Pieper CL, He W, Noeller J. Microvascular decompression and MRI findings in trigeminal neuralgia and hemifacial spasm. A single center experience. Clin Neurol Neurosurg. 2015 Oct 22;139:216-220. doi: 10.1016/j.clineuro.2015.10.012. [Epub ahead of print] PubMed PMID: 26519891.
6) Feng BH, Zheng XS, Liu M, Wang XQ, Wang XH, Ying TT, Li ST. Microvascular Decompression for Trigeminal Neuralgia: Zone Exploration and Decompression Techniques. J Craniofac Surg. 2015 Oct 21. [Epub ahead of print] PubMed PMID: 26501973.
7) Lee A, McCartney S, Burbidge C, Raslan AM, Burchiel KJ. Trigeminal neuralgia occurs and recurs in the absence of neurovascular compression. J Neurosurg. 2014 May;120(5):1048-54. doi: 10.3171/2014.1.JNS131410. Epub 2014 Feb 7. PubMed PMID: 24506241.
8) El-Garem HF, Badr-El-Dine M, Talaat AM, Magnan J. Endoscopy as a tool in minimally invasive trigeminal neuralgia surgery. Otol Neurotol. 2002 Mar;23(2):132-5. PubMed PMID: 11875338.

Update: Stereoelectroencephalography complications

In a systematic review of stereoelectroencephalography complications, thirty-five major complications (including 4 fatalities) were reported among 4,000 patients (0.8%) implanted with 33,000 electrodes 1).

SEEG has low associated complications, particularly regarding hemorrhage and infection 2).


Serletis et al., published wound infection (0.08%), hemorrhagic complications (0.08%), and a transient neurological deficit (0.04%) in a total of 5 patients (2.5%). One patient (0.5%) ultimately died due to intracerebral hematoma directly ensuing from SEEG electrode placement 3).


In the Cardinale et al., published series the major complication rate was 12 of 500 (2.4%), including 1 death for indirect morbidity. Median entry point localization error was 1.43 mm (interquartile range, 0.91-2.21 mm) with the traditional workflow and 0.78 mm (interquartile range, 0.49-1.08 mm) with the new one (P < 2.2 × 10). Median target point localization errors were 2.69 mm (interquartile range, 1.89-3.67 mm) and 1.77 mm (interquartile range, 1.25-2.51 mm; P < 2.2 × 10), respectively. 4).


Guénot et al had no general or neurologic complication occurred during the procedures. Two transient postprocedure side effects, consisting of paresthetic sensations in the mouth and mild apraxia of the hand, were observed 5).


In 10 patients that underwent this procedure, there were no derived complications 6).


The total complication rate was 4% in One hundred patients that underwent 101 robot-assisted SEEG procedures 7).


In the series of De Almeida et al., bilateral exploration of the temporal lobes has a morbidity rate of approximately 1%. A higher risk of hematomas occurs with the implantation of four or more electrodes in the frontal lobes 8).


1) Cardinale F, Casaceli G, Raneri F, Miller J, Lo Russo G. Implantation of Stereoelectroencephalography Electrodes: A Systematic Review. J Clin Neurophysiol. 2016 Dec;33(6):490-502. PubMed PMID: 27918344.
2) Yang M, Ma Y, Li W, Shi X, Hou Z, An N, Zhang C, Liu L, Yang H, Zhang D, Liu S. A Retrospective Analysis of Stereoelectroencephalography and Subdural Electroencephalography for Preoperative Evaluation of Intractable Epilepsy. Stereotact Funct Neurosurg. 2017 Jan 14;95(1):13-20. doi: 10.1159/000453275. [Epub ahead of print] PubMed PMID: 28088805.
3) Serletis D, Bulacio J, Bingaman W, Najm I, González-Martínez J. The stereotactic approach for mapping epileptic networks: a prospective study of 200 patients. J Neurosurg. 2014 Nov;121(5):1239-46. doi: 10.3171/2014.7.JNS132306. PubMed PMID: 25148007.
4) Cardinale F, Cossu M, Castana L, Casaceli G, Schiariti MP, Miserocchi A, Fuschillo D, Moscato A, Caborni C, Arnulfo G, Lo Russo G. Stereoelectroencephalography: surgical methodology, safety, and stereotactic application accuracy in 500 procedures. Neurosurgery. 2013 Mar;72(3):353-66; discussion 366. doi: 10.1227/NEU.0b013e31827d1161. PubMed PMID: 23168681.
5) Guénot M, Isnard J, Ryvlin P, Fischer C, Mauguière F, Sindou M. SEEG-guided RF thermocoagulation of epileptic foci: feasibility, safety, and preliminary results. Epilepsia. 2004 Nov;45(11):1368-74. PubMed PMID: 15509237.
6) Narváez-Martínez Y, García S, Roldán P, Torales J, Rumià J. [Stereoelectroencephalography by using O-Arm(®) and Vertek(®) passive articulated arm: Technical note and experience of an epilepsy referral centre]. Neurocirugia (Astur). 2016 Nov – Dec;27(6):277-284. doi: 10.1016/j.neucir.2016.05.002. Spanish. PubMed PMID: 27345416.
7) González-Martínez J, Bulacio J, Thompson S, Gale J, Smithason S, Najm I, Bingaman W. Technique, Results, and Complications Related to Robot-Assisted Stereoelectroencephalography. Neurosurgery. 2016 Feb;78(2):169-80. doi: 10.1227/NEU.0000000000001034. PubMed PMID: 26418870.
8) De Almeida AN, Olivier A, Quesney F, Dubeau F, Savard G, Andermann F. Efficacy of and morbidity associated with stereoelectroencephalography using computerized tomography–or magnetic resonance imaging-guided electrode implantation. J Neurosurg. 2006 Apr;104(4):483-7. PubMed PMID: 16619650.

Levetiracetam for hemifacial spasm

Levetiracetam proved its effectiveness and safety in the treatment of a case of HFS.Nevertheless, there is a need for further controlled studies with larger samples 1).


Kuroda et al., experienced two elderly hemifacial spasm (HFS) patients who exhibited a marked response to levetiracetam (LEV) without side effects. Although the exact underlying pharmacological mechanism remains unknown, we assume anti-kindling effect as one of the important pharmacological mechanism underlying the effect of LEV against HFS. Moreover, LEV is considered to be suitable for use in elderly patients because of its good tolerability. In addition, the lack of hepatic induction or inhibition makes it an easy and safe drug when used in addition to other anticonvulsants. Although the long-term benefit remains unknown, LEV may represent an alternative treatment for elderly HFS patients who are unable to undergo or decline surgical intervention and/or botulinum toxin injections or are intolerant to other anticonvulsants 2).


1) Biagio Carrieri P, Petracca M, Montella S. Efficacy of levetiracetam in hemifacial spasm: a case report. Clin Neuropharmacol. 2008 May-Jun;31(3):187-8. doi: 10.1097/WNF.0b013e3180ed44c8. PubMed PMID: 18520988.
2) Kuroda T, Saito Y, Fujita K, Yano S, Ishigaki S, Kato H, Murakami H, Ono K. Efficacy of levetiracetam in primary hemifacial spasm. J Clin Neurosci. 2016 Dec;34:213-215. doi: 10.1016/j.jocn.2016.05.025. PubMed PMID: 27460515.

Update: Foramen ovale

Oval opening in the greater wing of sphenoid bone transmitting the mandibular nerve as its major content. It serves as an important landmark for neurosurgeons in certain procedures as to gain access to trigeminal nerve. Therefore, its topographic position in relation to adjacent bony landmarks provides useful tool during these procedures.

Morphometric analysis was carried out on 104 foramina ovalia of 52 dry human skulls from South India. Following dimensions of foramen ovale were measured: antero-posterior length, transverse width, distance (d(1)) from tubercle of root of zygoma to the centre of the foramen (CF) and distance (d(2)) from the midline of the base of the skull to CF. Results: The mean antero-posterior length was 7.0±2.17mm on right side and 6.8±1.40mm on left side, mean transverse width was 5.0±0.42mm and 4.70±0.91mm on right and left side respectively. Mean d(1) was 32.58±1.72mm on right side and 32.75±1.76mm on left side. Mean d(2) was 25.83±1.26mm on right side and 25.08±1.31mm on left side. Conclusion: Regional variations in the morphometric measures may be useful in neurosurgical procedures like administration of anaesthesia involving the mandibular nerve 1).


Cannulation procedures, including those utilizing neuronavigational technology, are occasionally complicated by anatomical variation of the FO, sometimes resulting in miscannulation and subsequent adverse events. The FO, while commonly thought of as oval-shaped, has also been described as “almond,” “banana,” “D shape,” “pear,” and “triangular.” Because of the importance of the FO in neurosurgical procedures and the misunderstanding of FO shape, the aim of a study is to objectively describe the shape of the FO and its most likely shape variation. A total of 211 FO were evaluated by geometric morphometric analysis. A consensus shape is presented for the FO. No significant difference was found between the shapes of left- and right-sided FO. The most likely shape variation of the FO occurs as an inverse relationship between the anteromedial-posterolateral and anterolateral-posteromedial aspects of the foramen. The capacity to visualize the average FO shape and understand the most likely shape variance, as illustrated by Zdilla et al., will aid neurosurgeons in their approach to procedures requiring cannulation of the FO 2).


1) Patil J, Kumar N, K G MR, Ravindra S S, S N S, Nayak B S, Marpalli S, L S A. The foramen ovale morphometry of sphenoid bone in South Indian population. J Clin Diagn Res. 2013 Dec;7(12):2668-70. doi: 10.7860/JCDR/2013/7548.3727. Epub 2013 Dec 15. PubMed PMID: 24551606.
2) Zdilla MJ, Fijalkowski KM. The Shape of the Foramen Ovale: A Visualization Aid for Cannulation Procedures. J Craniofac Surg. 2016 Dec 23. doi: 10.1097/SCS.0000000000003325. [Epub ahead of print] PubMed PMID: 28027173.

Deep Brain Stimulation: Indications and Applications

Deep Brain Stimulation: Indications and Applications

From Pan Stanford

Deep Brain Stimulation: Indications and Applications

List Price: $179.95

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Drawing on the extensive clinical and research expertise of the Mayo Clinic Neural Engineering Laboratory, USA, led by Kendall H. Lee, MD, PhD, this book addresses the history of therapeutic electrical stimulation of the brain, its current application and outcomes, as well as theories about its underlying mechanisms. It reviews cutting-edge research on measures of local stimulation–evoked neurochemical release, latest imaging research on stimulation-induced neural circuitry activation, and the state of the art on closed-loop feedback devices for stimulation delivery.


Product Details

  • Published on: 2016-11-30
  • Original language: English
  • Binding: Hardcover
  • 600 pages

Book: Deep Brain Stimulation Programming: Mechanisms, Principles and Practice

Deep Brain Stimulation Programming: Mechanisms, Principles and Practice
By Erwin B Montgomery Jr

Deep Brain Stimulation Programming: Mechanisms, Principles and Practice

List Price:$79.95

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Deep brain stimulation programming (DBS) continues to grow as an effective therapy for a wide range of neurological and psychiatric disorders, helping patients reach optimal control of their disorder. With the technique finding so much success, the next question is how to make the complexities of post-operative programming cost-effective, especially when traditional medications and treatments can no longer do the job.

The second edition of Deep Brain Stimulation Programming is fully revised and up-to-date with the latest technologies and focuses on post-operative programing, which no other text does. This book provides programmers with a foundation of the brain as an electrical device, focusing on the mechanisms by which neurons respond to electrical stimulation, how to control the stimulation and the regional anatomy, and the many variations that influence a patient’s response to DBS. Dr. Montgomery explores new techniques of programming; including those based on stimulation frequency, closed-loop DBS, and the roles of oscillators in DBS; and new technological advances that make pre-existing theories of pathophysiology obsolete.

Key Features of the Second Edition Include
· Highlights post-operative deep brain stimulation;
· Includes the most recent discoveries in deep brain stimulation programming;
· Highly illustrated with figures for absorption of key programming and techniques;
· Provides an appendix of additional resources available through the Greenville Neuromodulation Center.


Product Details

  • Published on: 2016-11-04
  • Original language: English
  • Dimensions: 7.10″ h x .60″ w x 10.10″ l, .0 pounds
  • Binding: Hardcover
  • 248 pages

Editorial Reviews

Review

“This work is a comprehensive treatise of many of the theoretical and practical aspects of the application of Deep Brain Stimulation (DBS). It spans the fundamental principles of electrical stimulation, electrophysiology and neuroanatomical considerations and outlines an approach to programming DBS at the most commonly utilized targets for Parkinson’s disease. The book will be of value to practitioners who treat patients with DBS providing important key background knowledge and a practical path towards tackling the challenges of choosing optimal stimulation parameters for these patients.”
Andres M. Lozano, MD, PhD, FRCSC, FRSC, FCAHS, Dan Family Professor and Chairman in Neurosurgery, University of Toronto, Toronto, Ontario, Canada
“As we become a bionic generation there is a large knowledge gap in programming deep brain stimulation devices. Dr. Montgomery’s book addresses the principles of electrophysiology and the details of the pertinent brain regional anatomy. Dr. Montgomery helps the reader to identify and to utilize critical information to guide effective and efficient DBS programming. This is a must read, especially for new generation of health care professionals involved in the care of DBS patients.” —Michael S. Okun, MD, Adelaide Lackner Professor and Chairman of Neurology, University of Florida, Gainesville, FL

About the Author

Dr. Montgomery is a Movement Disorders Neurologist with a special interest in Parkinson’s disease. He has conducted research in motor neurophysiology, particularly the role of the basal ganglia-thalamic-cortical system and the pathophysiology of Parkinson’s disease for over 40 years. For the last 20 years, he has focused on deep brain stimulation in its clinical use and its underlying physiological mechanisms.

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