Postural Instability and Gait Disorder After Subthalamic Nucleus Deep Brain Stimulation

2020 ◽  
pp. 119-124
Author(s):  
Mónica M. Kurtis ◽  
Javier R. Pérez-Sánchez
Keyword(s):  
Deep Brain Stimulation ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Synergistic Effects ◽  
Disease Onset ◽  
Postural Instability ◽  
Electrode Placement ◽  
Medication Side ◽  
Balance Problems ◽  
Deep Brain

Parkinson disease (PD) patients who have undergone surgery and develop festinating gait and postural instability are challenging to diagnose and treat. This chapter describes the case of an early-onset PD patient who underwent deep brain stimulation (DBS) 4 years after disease onset due to motor and nonmotor fluctuations and medication side effects (impulse control disorder). A year after surgery, the patient developed gait and balance problems in the on-medication/on-stimulation states that resolved after turning stimulation off or withdrawing medication for 12 hours. However, other symptoms, including as bradykinesia, rigidity, and tremor, reappeared. Troubleshooting involved magnetic resonance imaging to evaluate electrode placement and complete screening of all contacts with successful reprogramming and medication adjustments. The pathophysiology of balance problems is discussed, including the synergistic effects of subthalamic nucleus DBS and dopaminergic treatment, which may lead to increased postural sway and lower limb dystonia.

Spatial Topographies of Unilateral Subthalamic Nucleus Deep Brain Stimulation Efficacy for Ipsilateral, Contralateral, Midline, and Total Parkinson Disease Motor Symptoms

2015 ◽  
Vol 11 (1) ◽  
pp. 80-88
Author(s):  
Mahesh B Shenai ◽  
Andrew Romeo ◽  
Harrison C Walker ◽  
Stephanie Guthrie ◽  
Ray L Watts ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Rating Scale ◽  
Electrode Placement ◽  
Kriging Interpolation ◽  
Motor Symptoms ◽  
Disease Rating ◽  
Deep Brain

Abstract BACKGROUND Subthalamic nucleus (STN) deep brain stimulation is a successful intervention for medically refractory Parkinson disease, although its efficacy depends on optimal electrode placement. Even though the predominant effect is observed contralaterally, modest improvements in ipsilateral and midline symptoms are also observed. OBJECTIVE To elucidate the role of contact location of unilateral deep brain stimulation on contralateral, ipsilateral, and axial subscores of Parkinson disease motor symptoms. METHODS Eighty-six patients receiving first deep brain stimulation STN electrode placements were identified, yielding 73 patients with 3-month follow-up. Total preoperative and postoperative Unified Parkinson Disease Rating Scale Part III scores were obtained and divided into contralateral, ipsilateral, and midline subscores. Contact location was determined on immediate postoperative magnetic resonance imaging. A 3-dimensional ordinary “kriging” algorithm generated spatial interpolations for total, ipsilateral, contralateral, and midline symptom categories. Interpolative reconstructions were performed in the axial planes (z = −0.5, −1.0, −1.5, −3.5, −4.5, −6.0) and a sagittal plane (x = 12.0). Interpolation error and significance were quantified by use of a cross-validation technique and quantile-quantile analysis. RESULTS There was an overall reduction in Unified Parkinson Disease Rating Scale Part III symptoms: total = 37.0 ± 24.11% (P < .05), ipsilateral = 15.9 ± 51.8%, contralateral = 56.2 ± 26.8% (P < .05), and midline = 26.5 ± 34.7%. Kriging interpolation was performed and cross-validated with quantile-quantile analysis with high correlation (R2 > 0.92) and demonstrated regions of efficacy for each symptom category. Contralateral symptoms demonstrated broad regions of efficacy across the peri-STN area. The ipsilateral and midline regions of efficacy were constrained and located along the dorsal STN and caudal zona incerta. CONCLUSION We provide evidence for a unique functional topographic window in which contralateral, ipsilateral, and midline structures may achieve the best efficacy. Although there are overlapping regions, laterality demonstrates distinct topographies. Surgical optimization should target the intersection of optimal regions for these symptom categories.

Principles of deep brain stimulation

2019 ◽  
pp. 865-872
Author(s):  
Erlick A.C Pereira ◽  
Alexander L Green ◽  
Tipu Z Aziz
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Deep Brain Stimulation ◽  
Brain Stimulation ◽  
Diffusion Tensor ◽  
Electrode Placement ◽  
Obsessive Compulsive ◽  
Randomized Controlled Clinical Trials ◽  
Medication Side ◽  
Deep Brain

Deep brain stimulation (DBS) is a minimally invasive targeted neurosurgical intervention that enables structures deep in the brain to be stimulated electrically by an implanted pacemaker. It has become the treatment of choice in Parkinson’s disease patients with either disabling medication side effects, on-off fluctuations, or tremor. Its efficacy in Parkinson’s disease has been demonstrated robustly by randomized controlled clinical trials, with numerous brain areas having been targeted in the last two decades for indications including dystonia and tremor in movement disorders; depression, obsessive-compulsive disorder, and Tourette’s syndrome in psychiatry; epilepsy, cluster headache, and chronic pain. The principles of framed stereotactic surgery enabling DBS electrode placement are reviewed here, before describing the putative mechanisms underlying DBS and its action upon individual neurons. Recent and future developments in DBS technology such as segmented, directional leads, and smart, adaptive stimulation are then discussed alongside related technological advances such as diffusion tensor imaging, robotic surgery, and molecular and cellular therapies. The role of stereotactic lesions in the era of DBS and the different modalities of lesioning are then summarized.

Postural instability and gait disorders after subthalamic nucleus deep brain stimulation in Parkinson’s disease: a PET study

2019 ◽  
Vol 266 (11) ◽  
pp. 2764-2771 ◽  
Author(s):  
Kévin Ahrweiller ◽  
J. F. Houvenaghel ◽  
A. Riou ◽  
S. Drapier ◽  
P. Sauleau ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Deep Brain Stimulation ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Postural Instability ◽  
Gait Disorders ◽  
Deep Brain

scholarly journals Balance and Gait Improvements of Postoperative Rehabilitation in Patients with Parkinson’s Disease Treated with Subthalamic Nucleus Deep Brain Stimulation (STN-DBS)

2019 ◽  
Vol 2019 ◽  
pp. 1-5 ◽  
Author(s):  
Kazunori Sato ◽  
Noriaki Aita ◽  
Yoshihide Hokari ◽  
Eriko Kitahara ◽  
Mami Tani ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Deep Brain Stimulation ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Postural Instability ◽  
Postoperative Rehabilitation ◽  
Gait Performance ◽  
Post Hoc ◽  
Stn Dbs ◽  
Deep Brain

Background. Deep brain stimulation of the subthalamic nucleus (STN-DBS) is a surgical treatment to reduce the “off” state motor symptoms of Parkinson’s disease (PD). Postural instability is one of the major impairments, which induces disabilities of activities of daily living (ADLs). The effectiveness of STN-DBS for postural instability is unclear, and the effect of rehabilitation following STN-DBS has remained uncertain. Objective. The purpose of this study was to examine changes in balance ability, gait function, motor performance, and ADLs following 2 weeks of postoperative rehabilitation in PD patients treated with STN-DBS. Methods. Sixteen patients were reviewed retrospectively from February 2016 to March 2017. All patients were tested in their “on” medication state for balance and gait performance using the Mini-Balance Evaluation Systems Test (Mini-BESTest) and the Timed “Up and Go” (TUG) test before the operation, after the operation, and during the discharge period. The UPDRS motor score (UPDRS-III) and Barthel Index (BI) were assessed before the operation and during the discharge period. Rehabilitation focused on muscle strengthening with stretching and proactive balance training. Friedman’s test and the post hoc Wilcoxon’s signed-rank test were used to analyze the balance assessments, and ANOVA and the post hoc Tukey’s test were used to analyze gait performance. The significance level was p<0.05. Results. During the discharge period, the Mini-BESTest and TUG were significantly improved compared with the preoperative and postoperative periods (p<0.05). There were no differences between preoperative and postoperative periods in the Mini-BESTest (p=0.12) and TUG (p=0.91). The BI and motor sections of the UPDRS did not differ significantly between the preoperative and postoperative periods (p=0.45, p=0.22). Conclusion. The results of this study suggest that postoperative rehabilitation improves balance and gait ability in patients with PD treated with STN-DBS.

Subthalamic nucleus deep brain stimulation outcome in young onset Parkinson's disease: a role for age at disease onset?

2011 ◽  
Vol 83 (3) ◽  
pp. 251-257 ◽  
Author(s):  
Aristide Merola ◽  
Maurizio Zibetti ◽  
Carlo Alberto Artusi ◽  
Alice Marchisio ◽  
Valeria Ricchi ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Deep Brain Stimulation ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Disease Onset ◽  
Young Onset ◽  
Deep Brain

scholarly journals Toward defining deep brain stimulation targets in MNI space: A subcortical atlas based on multimodal MRI, histology and structural connectivity

2016 ◽  
Author(s):  
Siobhan Ewert ◽  
Philip Plettig ◽  
M. Mallar Chakravarty ◽  
Andrea Kühn ◽  
Andreas Horn
Keyword(s):  
Deep Brain Stimulation ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Spatial Information ◽  
Structural Connectivity ◽  
Electrode Placement ◽  
List Type ◽  
High Definition ◽  
Probability Maps ◽  
Deep Brain

AbstractThree-dimensional atlases of subcortical brain structures are valuable tools to reference anatomy in neuroscience and neurology. In the special case of deep brain stimulation (DBS), the three most common targets are the subthalamic nucleus (STN), the internal part of the pallidum (GPi) and the ventral intermediate nucleus of the thalamus (VIM). With the help of atlases that define the position and shape of these target regions within a well-defined stereotactic space, their spatial relationship to implanted deep brain stimulation (DBS) electrodes may be determined.Here we present a composite atlas based on manual segmentations of a multi-modal high-resolution MNI template series, histology and structural connectivity. To attain exact congruence to the template anatomy, key structures were defined using all four modalities of the template simultaneously. In a first step tissue probability maps were defined based on the multimodal intensity profile of each structure. These observer-independent probability maps provided an excellent basis for the subsequent manual segmentation particularly when defining the outline of the target regions.Second, the key structures were used as an anchor point to coregister a histology based atlas into standard space. Finally, a sub-segmentation of the subthalamic nucleus into three functional zones was estimated based on structural connectivity. The resulting composite atlas uses the spatial information of the MNI template for DBS key structures that are visible on the template itself. For remaining structures, it relies on histology or structural connectivity. In this way the final atlas combines the anatomical detail of a histology based atlas with the spatial accuracy of key structures in relationship to the template anatomy. Thus, the atlas provides an ideal tool for the analysis of DBS electrode placement.Highlights:Composite subcortical atlas based on a multimodal, high definition MNI template series, histology and tractographyHigh definition atlas of DBS targets exactly matching MNI 152 NLIN 2009b spaceMultimodal subcortical segmentation algorithm applied to MNI template

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