Stereotactic ventrolateralis thalamotomy for medically refractory tremor in post-levodopa era Parkinson's disease patients

1991 ◽  
Vol 75 (5) ◽  
pp. 723-730 ◽  
Author(s):  
Mark W. Fox ◽  
J. Eric Ahlskog ◽  
Patrick J. Kelly
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Mayo Clinic ◽  
Microelectrode Recording ◽  
Stereotactic Techniques ◽  
Content Type ◽  
Resting Tremor ◽  
Fine Print

✓ Thirty-six patients with Parkinson's disease and medically refractory tremor underwent stereotactic ventrolateralis thalamotomy at the Mayo Clinic between 1984 and 1989. All patients had been or were being treated with carbidopa/levodopa but with unsatisfactory tremor control. Modern stereotactic techniques, including microelectrode recording, were used to treat 36 patients, of whom 31 (86%) had complete abolition of tremor and three patients (5%) had significant improvement. Tremor recurred in two patients within 3 months of surgery; however, the remaining patients suffered no recurrence of tremor during follow-up periods ranging from 14 to 68 months (mean 33 months). Persistent complications (arm dyspraxia, dysarthria, dysphasia, or abulia) were noted in five patients but were a source of disability in only two. It is concluded that thalamotomy in carefully selected patients is a beneficial operation for the control of medically refractory parkinsonian resting tremor.

Gamma knife radiosurgery as a lesioning technique in movement disorder surgery

1998 ◽  
Vol 89 (2) ◽  
pp. 183-193 ◽  
Author(s):  
Ronald F. Young ◽  
Anne Shumway-Cook ◽  
Sandra S. Vermeulen ◽  
Peter Grimm ◽  
John Blasko ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Movement Disorder ◽  
Gamma Knife ◽  
Movement Disorders ◽  
Gamma Knife Radiosurgery ◽  
Safety And Efficacy ◽  
Content Type ◽  
Fine Print

Object. To increase knowledge of the safety and efficacy of the use of gamma knife radiosurgery in patients with movement disorders, the authors describe their own experience in this field and include blinded independent assessments of their results. Methods. Fifty-five patients underwent radiosurgical placement of lesions either in the thalamus (27 patients) or globus pallidus (28 patients) for treatment of movement disorders. Patients were evaluated pre- and postoperatively by a team of observers skilled in the assessment of gait and movement disorders who were blinded to the procedure performed. The observers were not associated with the surgical team and concomitantly and blindly also assessed a group of 11 control patients with Parkinson's disease who did not undergo any surgical procedures. All stereotactic lesions were made with the Leksell gamma unit using the 4-mm secondary collimator helmet and a single isocenter with maximum doses from 120 to 160 Gy. Clinical follow-up evaluation indicated that 88% of patients who underwent thalamotomy became tremor free or nearly tremor free. Statistically significant improvements in performance were noted in the independent assessments of Unified Parkinson's Disease Rating Scale (UPDRS) scores in the patients undergoing thalamotomy. Of patients undergoing pallidotomy who had exhibited levodopainduced dyskinesias, 85.7% had total or near-total relief of that symptom. Clinical assessment indicated improvements in bradykinesia and rigidity in 64.3% of patients who underwent pallidotomy. Independent blinded assessments did not reveal statistically significant improvements in Hoehn and Yahr scores or UPDRS scores. On the other hand, 64.7% of patients showed improvements in subscores of the UPDRS, including activities of daily living (58%), total contralateral score (58%), and contralateral motor scores (47%). Total ipsilateral score and ipsilateral motor scores were both improved in 59% of patients. One (1.8%) of 55 patients experienced a homonymous hemianopsia 9 months after pallidotomy due to an unexpectedly large lesion. No other complications of any kind were seen. Neuropsychological test scores that were obtained for the combined pallidotomy and thalamotomy treatment groups preoperatively and at 6 months postoperatively demonstrated an absence of cognitive morbidity. Follow-up neuroimaging confirmed correct lesion location in all patients, with a mean maximum deviation from the planned target of 1 mm in the vertical axis. Measurements of lesions at regular intervals on postoperative magnetic resonance images demonstrated considerable variability in lesion volumes. The safety and efficacy of functional lesions made with the gamma knife appear to be similar to those made with the assistance of electrophysiological guidance with open functional stereotactic procedures. Conclusions. Functional lesions may be made safely and accurately using gamma knife radiosurgical techniques. The efficacy is equivalent to that reported for open techniques that use radiofrequency lesioning methods with electrophysiological guidance. Complications are very infrequent with the radiosurgical method. The use of functional radiosurgical lesioning to treat movement disorders is particularly attractive in older patients and in those with major systemic diseases or coagulopathies; its use in the general movement disorder population seems reasonable as well.

Long-term improvement in patients with severe Parkinson's disease after implantation of fetal ventral mesencephalic tissue in a cavity of the caudate nucleus: 5-year follow up in 10 patients

1997 ◽  
Vol 86 (6) ◽  
pp. 931-942 ◽  
Author(s):  
Juan J. López-Lozano ◽  
Gonzalo Bravo ◽  
Begoña Brera ◽  
Isabel Millán ◽  
Jose Dargallo ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Caudate Nucleus ◽  
Adrenal Medulla ◽  
Open Surgery ◽  
Clinical Symptoms ◽  
Content Type ◽  
Ventral Mesencephalic ◽  
Fine Print

✓ Different groups worldwide have observed in recent years that stereotactic implantation of fetal tissue can ameliorate the clinical symptoms of Parkinson's disease. The authors therefore investigated whether implantation of fetal ventral mesencephalic (FVM) tissue via open surgery is also capable of producing an improvement and whether this improvement is transient or long lasting. The authors report their findings in a 5-year follow-up study in 10 patients with Hoehn and Yahr Grade IV or V Parkinson's disease in whom a single FVM graft was implanted in a cavity created in the right caudate nucleus. The results indicate that the implants improved motor function and that clinical recovery persisted in seven of the 10 patients 5 years after implantation. Amelioration was observed in both the on and off phases and was accompanied by a 64% reduction in the levodopa dose and withdrawal of the dopamine agonist. The on phase was prolonged from 39% of the waking day to 72%, with reduced intensity and duration of dyskinesias. All symptoms that were analyzed showed improvement, although they differed in intensity and time of onset. The course of improvement seemed to be stepwise, with significant improvement between 5 and 7 months postimplantation followed by two waves of progress peaking in Months 15 and 36. Withdrawal of cyclosporine in three patients after more than 2 years of administration produced a decline in the patients' clinical conditions. In conclusion, the results indicate that open surgery implantation of FVM tissue in the caudate nucleus improves the clinical condition of parkinsonian patients and that this improvement can persist for at least 5 years. In comparison with two earlier series reported by the authors, which involved implants of perfused adrenal medulla and coimplantation of adrenal medulla and peripheral nerve, the course and pattern of improvement in these implant recipients suggests that their recovery can be attributed to more than one factor.

Gamma knife thalamotomy for treatment of tremor: long-term results

2000 ◽  
Vol 93 (supplement_3) ◽  
pp. 128-135 ◽  
Author(s):  
Ronald F. Young ◽  
Skip Jacques ◽  
Rufus Mark ◽  
Oleg Kopyov ◽  
Brian Copcutt ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Essential Tremor ◽  
Gamma Knife ◽  
Rating Scale ◽  
Long Term Results ◽  
Content Type ◽  
Fine Print

Object. The purpose of this study was to investigate the long-term effects of gamma knife thalamotomy for treatment of disabling tremor. Methods. One hundred fifty-eight patients underwent magnetic resonance imaging—guided radiosurgical nucleus ventralis intermedius (VIM) thalamotomy for the treatment of parkinsonian tremor (102 patients), essential tremor (52 patients), or tremor due to stroke, encephalitis, or cerebral trauma (four patients). Preoperative and postoperative blinded assessments were performed by a team of independent examiners skilled in the evolution of movement disorders. A single isocenter exposure with the 4-mm collimator helmet of the Leksell gamma knife unit was used to make the lesions. In patients with Parkinson's disease 88.3% became fully or nearly tremor free, with a mean follow up of 52.5 months. Statistically significant improvements were seen in Unified Parkinson's Disease Rating Scale tremor scores and rigidity scores, and these improvements were maintained in 74 patients followed 4 years or longer. In patients with essential tremor, 92.1% were fully or nearly tremor free postoperatively, but only 88.2% remained tremor free by 4 years or more post-GKS. Statistically significant improvements were seen in the Clinical Rating Scale for tremor in essential tremor patients and these improvements were well maintained in the 17 patients, followed 4 years or longer. Only 50% of patients with tremor of other origins improved significantly. One patient sustained a transient complication and two patients sustained mild permanent side effects from the treatments. Conclusions. Gamma knife VIM thalamotomy provides relief from tremor equivalent to that provided by radiofrequency thalamotomy or deep brain stimulation, but it is safer than either of these alternatives. Long-term follow up indicates that relief of tremor is well maintained. No long-term radiation-induced complications have been observed.

Pallidal stimulation for generalized dystonia

2000 ◽  
Vol 92 (3) ◽  
pp. 453-456 ◽  
Author(s):  
Volker M. Tronnier ◽  
Wolfgang Fogel
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Stereotactic Surgery ◽  
Treatment Alternative ◽  
Content Type ◽  
Pallidal Stimulation ◽  
Generalized Dystonia ◽  
Fine Print

✓ Pallidal stereotactic surgery is a well-accepted treatment alternative for Parkinson's disease. Another indication for this procedure is medically refractory dystonia, especially generalized dystonia with abnormal axial and extremity movements and postures. Improvement of dystonia after pallidotomy has been reported in several recent papers. In this report the authors describe three patients with generalized dystonia (two primary, one secondary) and their improvement after bilateral pallidal stimulation at follow-up times of between 6 and 18 months.

Reversal of experimental parkinsonism by using selective chemical ablation of the medial globus pallidus

1999 ◽  
Vol 90 (5) ◽  
pp. 928-934 ◽  
Author(s):  
Daniel M. Lieberman ◽  
Marc-Etienne Corthesy ◽  
Alex Cummins ◽  
Edward H. Oldfield
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Kainic Acid ◽  
Globus Pallidus ◽  
Optic Tract ◽  
High Flow ◽  
Content Type ◽  
Chemical Ablation ◽  
Selective Chemical ◽  
Fine Print

Object. Symptoms from Parkinson's disease improve after surgical ablation of the medial globus pallidus (GPm). Although, in theory, selective chemical ablation of neurons in the GPm could preserve vital structures jeopardized by surgery, the potential of this approach is limited when using traditional techniques of drug delivery. The authors examined the feasibility of convection-enhanced distribution of a neurotoxin by high-flow microinfusion to ablate the neurons of the GPm selectively and reverse experimental Parkinson's disease (akinesia, tremor, and rigidity).Methods. Initially, to test the feasibility of this approach, the GPms of two naive rhesus macaques were infused with kainic acid or ibotenic acid through two cannulas that had been placed using the magnetic resonance imaging—guided stereotactic technique. Two weeks later the animals were killed and their brains were examined histologically to determine the presence of neurons in the GPm and the integrity of the optic tract and the internal capsule. To examine the therapeutic potential of this paradigm, unilateral experimental Parkinson's disease was induced in six macaques by intracarotid infusion of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP) and their behavior was studied for 12 weeks after chemopallidotomy was performed using kainic acid (three animals) or control infusion (three animals).Conclusions. Chemopallidotomy using kainic acid permanently reversed the stigmata of MPTP-induced parkinsonism. By contrast, the control animals exhibited a transient recovery following intrapallidal infusion and then relapsed back to their baseline state. The use of high-flow microinfusion of selectively active toxins has the potential for treatment of Parkinson's disease and, by expanding the range of approachable targets to include large nuclei, for broad applications in clinical and experimental neuroscience.

Long-term follow-up results of selective VIM-thalamotomy

1986 ◽  
Vol 65 (3) ◽  
pp. 296-302 ◽  
Author(s):  
Yoshishige Nagaseki ◽  
Tohru Shibazaki ◽  
Tatsuo Hirai ◽  
Yasuhiro Kawashima ◽  
Masafumi Hirato ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Essential Tremor ◽  
The Other ◽  
Content Type ◽  
Early Results ◽  
Initial Surgery ◽  
Long Term Follow Up

✓ The authors report the results of a long-term follow-up study of the effects of the physiologically defined selective VIM (nucleus ventralis intermedius)-thalamotomy on tremor of Parkinson's disease in 27 patients and essential tremor in 16 patients. The follow-up period ranged from 3.25 to 10 years (mean 6.58 years). In 43 patients a total of 50 operations (including four bilateral operations and three reoperations) were carried out. The early (2 to 4 weeks after surgery) and late effects on the tremors were determined clinically and electromyographically. Fourteen parkinsonian cases were treated with minimal lesions (about 40 cu mm). Their late results were very similar to the early results: in 10, the tremors were completely abolished, three had a slight residual tremor, and one underwent reoperation 3 months after the first surgery. Eleven essential tremor cases were treated with minimal lesions. Six of these tremors were completely abolished, four patients had slight residual tremors, and one patient with a recurrence underwent reoperation 2 years after the initial surgery. In these 23 successful operations with minimal lesions (excluding two cases with reoperation), the tremor was abolished without discernible long-lasting side effects. The other 23 operations on 16 patients with Parkinson's disease (including one reoperation) and on seven with essential tremor (one of whom also had a minimal lesion on the other side) involved relatively large lesions. In this group, the surgery was successful in almost every case. It was concluded that radiographically and physiologically monitored selective VIM-thalamotomy for parkinsonian and essential tremor is effective even when lesioning is minimal. Moreover, the beneficial effect is maintained over a long period of time.

Long-term follow-up review of cases of Parkinson's disease after unilateral or bilateral thalamotomy

1984 ◽  
Vol 60 (5) ◽  
pp. 1033-1044 ◽  
Author(s):  
Keizo Matsumoto ◽  
Fumio Shichijo ◽  
Tsuneharu Fukami
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Medical Treatments ◽  
Content Type ◽  
Bilateral Surgery ◽  
Long Term Follow Up ◽  
Grade 3 ◽  
Control Study

✓ Follow-up reviews were carried out on 86 of 103 patients with Parkinson's disease who underwent unilateral or bilateral ventrolateral (VL) thalamotomy in the period from 1964 to 1969. Of these 86 patients, 64 received unilateral surgery, and 22 bilateral surgery. The follow-up periods were at least 10 years from the operation (from the second intervention in cases with bilateral procedures). In the group that received unilateral surgery, no progression after surgery was seen in three of six patients classified preoperatively in Grade I (Hoehn and Yahr's Grade 1), nine of 20 patients in Grade IIa (Hoehn and Yahr's Grade 2), 13 of 23 patients in Grade IIb (Hoehn and Yahr's Grade 3), and six of 15 patients in Grade III (Hoehn and Yahr's Grade 4). In the group that received bilateral surgery, one of three patients in Grade I and one of 11 patients in Grade IIa before the second intervention maintained continuous full social activities for over 10 years after the second surgery without any medication. In addition, eight of 11 patients classified preoperatively in Grade IIa and five of eight patients in Grade IIb seemed to show no progression after the second operation; four of 22 patients stopped taking their medication because of improvement in their symptoms. No patient who received bilateral surgery had progression of the disease to death. Observations suggested the efficacy of thalamic surgery, not only for improvement of motor symptoms but also for reducing progression of the disease, although no control study was made. Thalamotomy is still used to treat Parkinson's disease as an alternative to current medical treatments, such as L-dopa therapy.

Predictors of neuropsychological outcome in patients following microelectrode-guided pallidotomy for Parkinson's disease

2000 ◽  
Vol 93 (3) ◽  
pp. 410-420 ◽  
Author(s):  
Alois A. Obwegeser ◽  
Ryan J. Uitti ◽  
John A. Lucas ◽  
Robert J. Witte ◽  
Margaret F. Turk ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Neuropsychological Performance ◽  
Neuropsychological Outcome ◽  
Semantic Fluency ◽  
Patient Age ◽  
Content Type ◽  
Patient Âgé ◽  
Neuropsychological Changes ◽  
Fine Print

Object. The authors studied neuropsychological performance following microelectrode-guided posteroventral pallidotomy in patients with Parkinson's disease (PD) and evaluated correlations with presurgical and surgical factors.Methods. Neuropsychological changes 3 months (43 patients) and 12 months (27 patients) after microelectrode-guided pallidotomy for PD are reported in a series of 44 consecutive patients with the disease, who improved neurologically, as measured by the Unified Parkinson's Disease Rating Scale (UPDRS) in both the “off” (p < 0.001) and best “on” (p < 0.001) states.Findings of the vocabulary subtest of the Wechsler Adult Intelligence Scale—Revised (p < 0.01), Letter Fluency (p < 0.001), Verbal Fluency for semantic categories (p < 0.001), and the Wisconsin Card Sorting Test (p < 0.01) showed a significant decline in neuropsychological performance in patients 3 months after undergoing left-sided pallidotomy. Impairment in the language domain (semantic fluency) persisted at the 12-month follow-up examination (p < 0.01). Visual memory improved after right-sided pallidotomies (p < 0.01 after 3 months), with a nonsignificant trend toward persistent improvement 1 year postsurgery (p < 0.02 after 12 months). Preoperative semantic fluency was influenced by patient age (p < 0.001) and by the width of the third ventricle (p < 0.05), as measured by magnetic resonance imaging.A regression model revealed that semantic fluency 3 months postoperatively was significantly affected by the baseline score (p < 0.001), side of surgery (p < 0.001), handedness (p < 0.01), and patient age (p < 0.05). However, postoperative lesion volume, lesion location, number of tracks, number of lesions, distance from anatomical landmarks, or UPDRS score did not significantly contribute to neuropsychological outcome.Conclusions. Neuropsychological changes in a cohort of patients with PD who underwent pallidotomy and experienced excellent clinical benefits and minimum postoperative complications, emphasize the importance of neuropsychological examinations and further investigation of predictive factors.

Brain targets in surgery for Parkinson's disease

1985 ◽  
Vol 62 (3) ◽  
pp. 349-351 ◽  
Author(s):  
Lauri V. Laitinen
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
White Matter ◽  
Great Variability ◽  
Content Type ◽  
Fine Print

✓ Sixteen neurosurgeons were requested to define their preferred surgical target for treatment of parkinsonism. The scattergram thus obtained showed a great variability among surgeons. Although there was a concentration of targets in the ventrolateral (VL) nucleus of the thalamus, there was a separation by as much as 6 to 7 mm between targets. One surgeon placed the lesion in the subthalamic white matter below the VL nucleus, and two placed it outside the thalamus in the pallidothalamic pathways in Forel's field. It is assumed that successful surgery interrupts the pallidothalamocortical pathways that transmit tremor and rigidity impulses, regardless of which part of the pathways is severed.

Prefrontal dysfunction following unilateral posteroventral pallidotomy in Parkinson's disease

1999 ◽  
Vol 90 (6) ◽  
pp. 1005-1010 ◽  
Author(s):  
Tetsuo Yokoyama ◽  
Yoko Imamura ◽  
Kenji Sugiyama ◽  
Shigeru Nishizawa ◽  
Naoki Yokota ◽  
...  
Keyword(s):  
Parkinson’S Disease ◽  
Parkinson's Disease ◽  
Cognitive Function ◽  
Digit Span ◽  
Preoperative Evaluation ◽  
Word Fluency ◽  
Yahr Stage ◽  
Content Type ◽  
Posteroventral Pallidotomy ◽  
Fine Print

Object. Pre- and postoperative cognitive function was evaluated in patients with Parkinson's disease (PD) who underwent unilateral posteroventral pallidotomy (PVP) to clarify the effects of this operation on cognitive function.Methods. Cognitive function was assessed before surgery and 1 month and 3 months afterward by using a battery of neuropsychological tests consisting of orientation, digit span (forward and backward), digit learning, 5-minute memory of five words, similarities, serial sevens, animal name listing, and the kana pick-out test, as well as the Japanese version of the Mini-Mental State. Preoperative evaluation revealed that patients experienced difficulties in performing the neuropsychological tasks of reasoning and abstraction, working memory of numerals, word fluency, and concept formation compared with 36 healthy volunteers (p < 0.05). A simple regression analysis showed strong relationships in a negative fashion between preoperative (r = 0.81, p = 0.002) and 1-month (r = 0.79, p = 0.0059) and 3-month (r = 0.85, p = 0.0016) postoperative gross-total scores and Hoehn and Yahr staging. Preoperative and postoperative scores at 1 month and 3 months were analyzed by analysis of variance, but only the Fisher's post hoc test revealed the source of difference. All tasks except orientation (p = 0.0292) were unchanged in the 10 patients who underwent surgery on the right side. The scores for this task at 1 month postsurgery were significantly lower (p = 0.0203) but improved to preoperative values by 3 months. In the 15 patients who underwent surgery on the left side significant differences among tasks were revealed for serial sevens (p = 0.0471) and animal naming (p = 0.0425). The scores for these tasks were significantly lower at 1 month postoperatively (p = 0.0431 for serial sevens and p = 0.0408 for animal naming), but improved by 3 months after the operation.Conclusions. The present data revealed that cognitive dysfunction in patients with PD relates to advancement of Hoehn and Yahr stage, but PVP is not associated with significant long-lasting cognitive deficits.

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