RICARDO GALHARDONI
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- Evaluation of Changes in Preoperative Cortical Excitability by Navigated Transcranial Magnetic Stimulation in Patients With Brain Tumor(2021) NEVILLE, Iuri Santana; SANTOS, Alexandra Gomes dos; ALMEIDA, Cesar Cimonari; HAYASHI, Cintya Yukie; SOLLA, Davi Jorge Fontoura; GALHARDONI, Ricardo; ANDRADE, Daniel Ciampi de; BRUNONI, Andre Russowsky; TEIXEIRA, Manoel Jacobsen; PAIVA, Wellingson SilvaBackground: This prospective study aimed to evaluate the cortical excitability (CE) of patients with brain tumors surrounding or directly involving the corticospinal tract (CST) using navigated transcranial magnetic stimulation (nTMS). Methods: We recruited 40 patients with a single brain tumor surrounding or directly involving the CST as well as 82 age- and sex-matched healthy controls. The patients underwent standard nTMS and CE evaluations. Single and paired pulses were applied to the primary motor area (M1) of both affected and unaffected cerebral hemispheres 1 week before surgery. The CE parameters included resting motor threshold (RMT), motor evoked potential (MEP) ratio for 140 and 120% stimulus (MEP 140/120 ratio), short-interval intracortical inhibition (SICI), and intracortical facilitation (ICF). Motor outcome was evaluated on hospital discharge and on 30-day and 90-day postoperative follow-up. Results: In the affected hemispheres of patients, SICI and ICF were significantly higher than in the unaffected hemispheres (p=0.002 and p=0.009, respectively). The 140/120 MEP ratio of patients' unaffected hemispheres was lower than that in controls (p=0.001). Patients with glioblastomas (GBM) had a higher interhemispheric RMT ratio than patients with grade II and III gliomas (p = 0.018). A weak correlation was observed among the RMT ratio and the preoperative motor score (R-2 = 0.118, p = 0.017) and the 90-day follow-up (R-2 = 0.227, p = 0.016). Conclusion: Using preoperative nTMS, we found that brain hemispheres affected by tumors had abnormal CE and that patients with GBM had a distinct pattern of CE. These findings suggest that tumor biological behavior might play a role in CE changes.
- Balloon compression vs radiofrequency for primary trigeminal neuralgia: a randomized, controlled trial(2021) STERMAN-NETO, Hugo; FUKUDA, Cristiane Yoko; DUARTE, Kleber Paiva; SILVA, Valquiria Aparecida da; RODRIGUES, Antonia Lilian de Lima; GALHARDONI, Ricardo; SIQUEIRA, Silvia R. D. T. de; SIQUEIRA, Jose Tadeu Tesseroli de; TEIXEIRA, Manoel Jacobsen; ANDRADE, Daniel Ciampi deSurgical procedures are necessary in up to 50% of trigeminal neuralgia patients. Although radiofrequency (RF) is more widely used, it is associated with high intraprocedural costs and long technical learning time. Other simpler procedures such as balloon compression (BC) require a lower training period and have significant lower costs. We evaluated the effects of BC and RF in pain control in primary trigeminal neuralgia in a randomized, double-blinded, head-to-head trial. Individuals were randomly allocated in 1 of 2 groups: BC and RF. Throughout pain, psychological and quality of life measurements were performed at baseline and after surgery. The main outcome was the worst pain in the last 24 hours (0-10) at 6 months postoperatively. After the inclusion of half of the estimated sample, a preplanned interim analysis was performed when 33 patients (62.1 = 9.4 y.) completed the study. Pain intensity (confidence interval [Cl] 95% 0.6 to 3.8, and -0.6 to 2.2, for BC and RF) did not significantly differ. Complications, interference of pain in daily life (01 95% -0.1 to 2.3 and -0.4 to 2.3, for BC and RF), neuropathic pain symptoms (01 95% 1.7 to 3.6 and 3.0 to 5.7, for BC and RF), mood (0195% 4.8 to 11.5 and 5.5 to 15.1, BC and RF, respectively), medication use, and quality of life (0195% 80.4 to 93.1 and 83.9 to 94.2, for BC and RF) were also not different. Radiofrequency presented more paresthetic symptoms than BC at 30 days after intervention. Based on these results, the study was halted due to futility because BC was not superior to RF.
- Posterior-superior insular deep transcranial magnetic stimulation alleviates peripheral neuropathic pain - A pilot double-blind, randomized cross-over study(2021) DONGYANG, Liu; FERNANDES, Ana Mercia; CUNHA, Pedro Henrique Martins da; TIBES, Raissa; SATO, Joao; LISTIK, Clarice; DALE, Camila; KUBOTA, Gabriel Taricani; GALHARDONI, Ricardo; TEIXEIRA, Manoel Jacobsen; SILVA, Valquiria Aparecida da; ROSI, Jefferson; ANDRADE, Daniel Ciampi deObjectives. - Peripheral neuropathic pain (pNeP) is prevalent, and current treatments, including drugs and motor cortex repetitive transcranial magnetic stimulation (rTMS) leave a substantial proportion of patients with suboptimal pain relief. Methods. - We explored the intensity and short-term duration of the analgesic effects produced in pNeP patients by 5 days of neuronavigated deep rTMS targeting the posterior superior insula (PSI) with a double-cone coil in a sham-controlled randomized cross-over trial. Results. - Thirty-one pNeP patients received induction series of five active or sham consecutive sessions of daily deep-rTMS to the PSI in a randomized sequence, with a washout period of at least 21 days between series. The primary outcome [number of responders (>50% pain intensity reduction from baseline in a numerical rating scale ranging from 0 to 10)] was significantly higher after real (58.1%) compared to sham (19.4%) stimulation (p = 0.002). The number needed to treat was 2.6, and the effect size was 0.97 [95% CI (0.6; 1.3)]. One week after the 5th stimulation day, pain scores were no longer different between groups, and no difference in neuropathic pain characteristics and interference with daily living were present. No major side effects occurred, and milder adverse events (i.e., short-lived headaches after stimulation) were reported in both groups. Blinding was effective, and analgesic effects were not affected by sequence of the stimulation series (active-first or sham-first), age, sex or pain duration of participants. Discussion. - PSI deep-rTMS was safe in refractory pNeP and was able to provide significant pain intensity reduction after a five-day induction series of treatments. Post-hoc assessment of neuronavigation targeting confirmed deep-rTMS was delivered within the boundaries of the PSI in all participants. Conclusion. - PSI deep-rTMS provided significant pain relief during 5-day induction sessions compared to sham stimulation.
- Letter: Altered Motor Excitability in Patients With Diffuse Gliomas Involving Motor Eloquent Areas: The Impact of Tumor Grading(2021) SANTOS, Alexandra Gomes dos; HAYASHI, Cintya Yukie; ALMEIDA, Cesar Cimonari de; PAIVA, Wellingson Silva; ANDRADE, Daniel Ciampi de; GALHARDONI, Ricardo; BRUNONI, Andre Russowsky; TEIXEIRA, Manoel Jacobsen; NEVILLE, Iuri Santana
- Combined effects of theta-burst stimulation with transcranial direct current stimulation of the prefrontal cortex: study protocol of a randomized, double-blinded, sham-controlled trial using Tc-99m-ECD SPECT(2021) RAZZA, Lais B.; BUCHPIGUEL, Carlos A.; SMET, Stefanie De; KLEIN, Izio; BAEKEN, Chris; GALHARDONI, Ricardo; VANDERHASSELT, Marie-Anne; BRUNONI, Andre R.Introduction: Non-invasive brain stimulation (NIBS) as monotherapy has been increasingly used to enhance the activity of brain networks. However, it is unclear whether a combination of distinct NIBS approaches could enhance prefrontal cortical (PFC) activity. Objective: We propose to investigate the combined and standalone effects of two NIBS modalities on the PFC through a working memory task, single photon emission computed tomography (SPECT), and salivary cortisol. We hypothesize that the combined protocol will provoke greater changes in the collected measures compared to the remining protocols. Methods: A randomized, double-blind, sham-controlled, full-factorial design will be conducted. The effects of transcranial direct current stimulation (tDCS) and intermittent theta-burst stimulation (iTBS) will be investigated over four different sessions (sham tDCS + sham iTBS, anodal tDCS + sham iTBS, anodal tDCS + active iTBS and sham tDCS + active iTBS) in 30 healthy adult volunteers. A 99mTc-ethylene cysteine dimer (99mTC-ECD) will be administered during the NIBS session and neuroimaging will be acquired within one hour. Salivary cortisol will be collected before and after each session and an n-back working memory task will be applied after the end of each NIBS session. The outcomes will be cerebral perfusion alterations (99mTC-ECD SPECT), accuracy and reaction time in the n-back task, and changes in salivary cortisol level. Conclusion: The results from this trial can guide future therapeutic protocols for NIBS treatments stimulating the PFC by demonstrating that the combination of NIBS techniques is feasible, tolerable, and can lead to greater enhancement of PFC activity.
- Dry needling has lasting analgesic effect in shoulder pain: a double-blind, sham-controlled trial(2021) PAI, Marcus Yu Bin; TOMA, Juliana Takiguti; KAZIYAMA, Helena Hideko Seguchi; LISTIK, Clarice; GALHARDONI, Ricardo; YENG, Lin Tchia; TEIXEIRA, Manoel Jacobsen; ANDRADE, Daniel Ciampi deIntroduction: Myofascial pain syndrome (MPS) affects most patients with chronic shoulder pain. Dry needling (DN) is a common treatment for MPS, but its temporal pattern and sensory effects remain unknown. Objectives: We evaluated in a randomized, sham-controlled study the pattern of analgesic efficacy and local sensory changes of a single session of DN for MPS in patients with chronic shoulder pain. Methods: Patients with chronic shoulder pain were randomized into active (n = 20) or sham (n = 21) groups. A single DN was performed by a researcher blinded to group assignment and pain outcomes. Pain intensity was assessed by the numeric rating score, and sensory thresholds were evaluated with a quantitative sensory testing protocol, including the area of tactile sensory abnormalities 7 days before needling, right before, and 7 days after the intervention. Results: Dry needling led to significant larger pain intensity reduction (from 6.30 +/- 2.05 to 2.40 +/- 2.45 in the active group; P = 0.02, effect size = -1.3 (95% CI [-2.0 to -0.68]); (number necessary to treat = 2.1). Pain reduction scores were significantly different on the second day after needling and persisted so until the seventh day and were accompanied by improvement in other dimensions of pain and a decrease in the area of mechanical hyperalgesia in the active DN group alone (P < 0.05). Conclusion: Active trigger points DN provided analgesic effects compared with sham and decreased the area of local mechanical hyperalgesia. These findings have practical clinical implications and may provide mechanistic insights behind MPS.
- Looking beyond the obvious: the importance of outcomes and outcomes measures in trigeminal neuralgia Reply(2021) ANDRADE, Daniel Ciampi de; STERMAN-NETO, Hugo; FUKUDA, Cristiane Yoko; DUARTE, Kleber Paiva; SILVA, Valquiria Aparecida da; RODRIGUES, Antonia Lilian de Lima; GALHARDONI, Ricardo; SIQUEIRA, Silvia R. D. T. de; SIQUEIRA, Jose Tadeu Tesseroli de; TEIXEIRA, Manoel Jacobsen
bookPart Neuromodulação não invasiva na neurologia e neurocirurgia(2021) ANDRADE, Daniel Ciampi A. de; KUBOTA, Gabriel Taricani; VALIENGO, Leandro da Costa Lane; GALHARDONI, Ricardo; RICHINHO, Valéria de Paula; PAIVA, Wellingson- Motor cortex stimulation for chronic neuropathic pain: results of a double-blind randomized study(2021) HAMANI, Clement; FONOFF, Erich T.; PARRAVANO, Daniella C.; SILVA, Valquiria A.; GALHARDONI, Ricardo; MONACO, Bernardo A.; NAVARRO, Jessie; YENG, Lin T.; TEIXEIRA, Manoel J.; ANDRADE, Daniel Ciampi deMotor cortex stimulation via surgically implanted electrodes has been used as an off-label treatment for chronic neuropathic pain, but its efficacy has not been fully established. We aimed to objectively study the efficacy of motor cortex stimulation and characterize potential predictors of response. In this randomized, double-blind, sham-controlled, single centre trial, we recruited 18 patients with chronic neuropathic pain who did not adequately respond to conventional treatment and had a numerical pain rating scale (NRS) score >= 6. Patients were initially assigned to receive 3 months of active ('on') or sham ('oif') stimulation in a double-blind cross-over phase. This was followed by a 3-month single-blind phase, and 6 months of open-label follow-up. A meaningful response in our trial was defined as a >= 30% or 2-point reduction in NRS scores during active stimulation. Using Bayesian statistics, we found a 41.4% probability of response towards on versus off motor cortex stimulation. The probability of improvement during active stimulation (double-blind, single-blind and open-label phases) compared to baseline was 47.2-68.5%. Thirty nine per cent of the patients were considered long-term responders, 71.4% of whom had facial pain, phantom limb pain or complex regional pain syndrome. In contrast, 72.7% of non-responders had either post-stroke pain or pain associated with brachial plexus avulsion. Thirty-nine per cent of patients had a substantial postoperative analgesic effect after electrode insertion in the absence of stimulation. Individuals with diagnoses associated with a good postoperative outcome or those who developed an insertional effect had a near 100% probability of response to motor cortex stimulation. In summary, we found that similar to 40% of patients responded to motor cortex stimulation, particularly those who developed an insertional effect or had specific clinical conditions that seemed to predict an appropriate postoperative response.
- Abnormal sensory thresholds of dystonic patients are not affected by deep brain stimulation(2021) LISTIK, Clarice; CURY, Rubens Gisbert; SILVA, Valquiria Aparecida da; CASAGRANDE, Sara Carvalho Barbosa; LISTIK, Eduardo; LINK, Naira; GALHARDONI, Ricardo; BARBOSA, Egberto Reis; TEIXEIRA, Manoel Jacobsen; ANDRADE, Daniel Ciampi deBackground Unlike motor symptoms, the effects of deep brain stimulation (DBS) on non-motor symptoms associated with dystonia remain unknown. Methods The objective of this study was to assess the effects of DBS on evoked experimental pain and cutaneous sensory thresholds in a crossover, double-blind on/off study and compare these results with those of healthy volunteers (HV). Results Sixteen patients with idiopathic dystonia (39.9 +/- 13 years old, n = 14 generalized) with DBS of the globus pallidus internus underwent a battery of quantitative sensory testing and assessment using a pain top-down modulation system (conditioned pain modulation, CPM). Results for the more and less dystonic body regions were compared in on and off stimulation. The patients' results were compared to age- and sex-matched HV. Descending pain modulation CPM responses in dystonic patients (on-DBS, 11.8 +/- 40.7; off-DBS, 1.8 +/- 22.1) was abnormally low (defective) compared to HV (-15.6 +/- 23.5, respectively p = .006 and p = .042). Cold pain threshold and cold hyperalgesia were 54.8% and 95.7% higher in dystonic patients compared to HV. On-DBS CPM correlated with higher Burke-Fahn-Marsden disability score (r = 0.598; p = .014). While sensory and pain thresholds were not affected by DBS on/off condition, pain modulation was abnormal in dystonic patients and tended to be aggravated by DBS. Conclusion The analgesic effects after DBS do not seem to depend on short-duration changes in cutaneous sensory thresholds in dystonic patients and may be related to changes in the central processing of nociceptive inputs.