Clinical case of Dr. Marta del Álamo
Intradural clinoidectomy is one of the most highly valued techniques in modern vascular neurosurgery, especially in the treatment of aneurysms of the carotid-ophthalmic segment and the superior hypophyseal artery. In this case, uploaded to the online surgery app SurgSchool, presented by the Dr. Javier Ibanez (Son Espases Hospital, Palma de Mallorca), the surgical strategy applied to a young patient with a small aneurysm diagnosed incidentally is explained step by step.
The treatment of essential tremor has experienced significant progress with the incorporation of magnetic resonance-guided high-intensity focused ultrasound (MRgFUS/HIFU)In this case, uploaded to the online surgery app SurgSchool, the Dr. Marta del Álamo present an thalamotomy in the ventral intermediate nucleus (VIM) of the thalamus performed using HIFU, a minimally invasive, incision-free technique, indicated for patients with disabling essential tremor.
Indications and patient selection
The procedure is performed in a 72-year-old patient with long-standing essential tremorrefractory to pharmacological treatment. Appropriate patient selection is key, including prior evaluation of the Skull Density Ratio (SDR) using cranial CT, which conditions the effective transmission of ultrasound.
Stereotactic preparation and fixation
The procedure begins with the placement of a stereotactic frame Under local anesthesia, ensuring complete immobilization of the head. Subsequently, a cooling membrane with water circulationThis is essential to prevent overheating of the scalp, since a significant portion of the ultrasonic energy is reflected by the cranial bone.
Magnetic resonance imaging planning
The planning is done entirely under magnetic resonance, using specific sequences (FIESTA, STIR, axial, sagittal and coronal planes) to:
- Identify the anterior and posterior commissures
- Define the midline
- View the internal capsule and avoid side effects
- Mark areas where ultrasound cannot pass (air sinuses, calcifications)
The target is set on the VIM coreadjusting laterality and depth according to individual anatomy and the size of the third ventricle.
HIFU treatment phase
The patient remains awake, without sedationallowing for continuous clinical assessment. initial sonicationsLow-energy injections are performed to confirm correct localization, producing a transient effect. After verifying clinical improvement and the absence of adverse effects, the energy is gradually increased until therapeutic temperatures (≈54–56 °C) are reached, achieving a definitive injury.
Between each sonication, the system performs automatic movement checks and cooling pauses. Tremor progression is assessed through intraoperative motor tests (spiral, directed movements, simulated drinking, facial and speech examination).
Results and safety
During the procedure, a progressive and significant clinical improvement of the tremorThis was confirmed both clinically and by intraoperative MRI visualization of the lesion. Dr. del Álamo points out that the side effects are usually mild and transientgait instability being the most frequent, with a low rate of long-term persistence.
HIFU in functional neurosurgery
In-the-megaly thalamotomy using HIFU represents an effective alternative to open surgery and deep brain stimulation (DBS) in selected patients, offering:
- Absence of incision
- Outpatient procedure
- Real-time clinical assessment
- High stereotactic accuracy
