Subthalamic nucleus stimulation for Parkinson disease: benefits observed in levodopa-intolerant patients

2001 ◽  
Vol 95 (2) ◽  
pp. 213-221 ◽  
Author(s):  
Yoichi Katayama ◽  
Masahiko Kasai ◽  
Hideki Oshima ◽  
Chikashi Fukaya ◽  
Takamitsu Yamamoto ◽  
...  
Keyword(s):  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Large Dose ◽  
Daily Activity ◽  
Daily Activities ◽  
Content Type ◽  
Percentage Time ◽  
Group I ◽  
Group Ii ◽  
Fine Print

Object. A blinded evaluation of the effects of subthalamic nucleus (STN) stimulation was performed in levodopaintolerant patients with Parkinson disease (PD). These patients (Group I, seven patients) were moderately or severely disabled (Hoehn and Yahr Stages III–V during the off period), but were receiving only a small dose of medication (levodopa-equivalent dose [LED] 0–400 mg/day) because they suffered unbearable side effects. The results were analyzed in comparison with those obtained in patients with advanced PD (Group II, seven patients) who were severely disabled (Hoehn and Yahr Stages IV and V during the off period), but were treated with a large dose of medication (500–990 mg/day). Methods. The patients were evaluated twice at 6 to 8 months after surgery. To determine the actual benefits afforded by STN stimulation to their overall daily activities, the patients were maintained on their medication regimen with optimal doses and schedules. Stimulation was turned off overnight for at least 12 hours. It was turned on in the morning (or remained turned off), and each patient's best and worst scores on the Unified Parkinson's Disease Rating Scale during waking daytime activity were recorded as on- and off-period scores, respectively. The order of assessment with respect to whether stimulation was occurring was determined randomly. The STN stimulation markedly improved daily activity and total motor scores in Group I patients. The percentage time of immobility (Hoehn and Yahr Stages IV and V) became 0% in patients who were intermittently immobile while not receiving stimulation. Improvements were demonstrated in tremor, rigidity, akinesia, and gait subscores. The STN stimulation produced less marked but still noticeable improvements in the daily activity and total motor scores in Group II patients. The percentage time of immobility as well as the LED was reduced in patients who displayed intermittent immobility with pronounced motor fluctuations while not receiving stimulation. Improvements were demonstrated in tremor, rigidity, and dyskinesia subscores in these patients. In contrast, STN stimulation did not improve the overall daily activities at all in patients who had become unresponsive to a tolerable dose of levodopa and were continuously immobile, even though these patients' tremor and rigidity subscores were still improved by stimulation. Conclusions. Consistent with earlier findings, the great benefit of STN stimulation in levodopa-intolerant patients is that STN stimulation can reduce the level of required levodopa medication. This suggests that STN stimulation could be a therapeutic option for patients with less-advanced PD by allowing levodopa medication to be maintained at as low a dose as possible, and to prevent adverse reactions to the continued use of large-dose levodopa.

Bilateral stimulation of the subthalamic nucleus in patients with Parkinson disease: a study of efficacy and safety

2002 ◽  
Vol 96 (4) ◽  
pp. 666-672 ◽  
Author(s):  
Tanya Simuni ◽  
Jurg L. Jaggi ◽  
Heather Mulholland ◽  
Howard I. Hurtig ◽  
Amy Colcher ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Bilateral Stimulation ◽  
Content Type ◽  
Preoperative Status ◽  
Fine Print ◽  
Deep Brain ◽  
Stimulation Of

Object. Palliative neurosurgery has reemerged as a valid therapy for patients with advanced Parkinson disease (PD) that is complicated by severe motor fluctuations. Despite great enthusiasm for long-term deep brain stimulation (DBS) of the subthalamic nucleus (STN), existing reports on this treatment are limited. The present study was designed to investigate the safety and efficacy of bilateral stimulation of the STN for the treatment of PD. Methods. In 12 patients with severe PD, electrodes were stereotactically implanted into the STN with the assistance of electrophysiological conformation of the target location. All patients were evaluated preoperatively during both medication-off and -on conditions, as well as postoperatively at 3, 6, and 12 months during medication-on and -off states and stimulation-on and -off conditions. Tests included assessments based on the Unified Parkinson's Disease Rating Scale (UPDRS) and timed motor tests. The stimulation effect was significant in patients who were in the medication-off state, resulting in a 47% improvement in the UPDRS Part III (Motor Examination) score at 12 months, compared with preoperative status. The benefit was stable for the duration of the follow-up period. Stimulation produced no additional benefit during the medication-on state, however, when compared with patient preoperative status. Significant improvements were made in reducing dyskinesias, fluctuations, and duration of off periods. Conclusions. This study demonstrates that DBS of the STN is an effective treatment for patients with advanced, medication-refractory PD. Deep brain stimulation of the STN produced robust improvements in motor performance in these severely disabled patients while they were in the medication-off state. Serious adverse events were common in this cohort; however, only two patients suffered permanent sequelae.

Microsurgical C-2 ganglionectomy for chronic intractable occipital pain

1998 ◽  
Vol 89 (3) ◽  
pp. 359-365 ◽  
Author(s):  
Andres M. Lozano ◽  
Graham Vanderlinden ◽  
Robert Bachoo ◽  
Peter Rothbart
Keyword(s):  
Axonal Regeneration ◽  
Excellent Result ◽  
Spontaneous Pain ◽  
Content Type ◽  
Group I ◽  
Experienced Pain ◽  
Pain Outcome ◽  
Group Ii ◽  
Fine Print

Object. The authors evaluated the effectiveness of microsurgical C-2 ganglionectomy in 39 patients with medically refractory chronic occipital pain. In this procedure the neurons transmitting sensory inputs from the occiput are removed and, unlike peripheral nerve ablation, axonal regeneration is not possible. Methods. The patients in this series had symptoms for 1 to 43 years. In 22 patients the occipital pain was caused by trauma; in 17 patients the pain was spontaneous. Pain relief failed in 17 patients who had undergone a previous occipital neurectomy or C-2 rhizolysis. Twenty-three patients experienced pain that was described as shocklike, electric, shooting, jabbing, stabbing, sharp, or exploding (Group I). Eight patients described their pain as dull, pounding, aching, throbbing, or pressurelike (Group II). The patients underwent unilateral or bilateral C-2 open microsurgical ganglionectomies. The postoperative follow-up period ranged from 19 to 48 months. Nineteen patients experienced an excellent result (> 90% reduction in pain). Pain caused by trauma or that described using Group I terms responded best to ganglionectomy (80% good or excellent response). In contrast, the majority of the patients with nontraumatic pain or those described using Group II descriptors did not achieve favorable results. Conclusions. The authors conclude that: 1) patients who suffer from chronic occipital pain after having sustained injury obtain worthwhile benefit from microsurgical C-2 ganglionectomy; 2) patients suffering from migraine, tension, and vascular headaches involving the occipital area are most often not helped by this operation; and 3) terms such as “shock,” “electric,” “shooting,” “jabbing,” and “sharp” used to describe occipital pain predict a favorable pain outcome following a C-2 ganglionectomy.

Failure of third ventriculostomy in the treatment of aqueductal stenosis in children

1999 ◽  
Vol 90 (3) ◽  
pp. 448-454 ◽  
Author(s):  
Giuseppe Cinalli ◽  
Christian Sainte-Rose ◽  
Paul Chumas ◽  
Michel Zerah ◽  
Francis Brunelle ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Aqueductal Stenosis ◽  
Third Ventriculostomy ◽  
Content Type ◽  
Group I ◽  
Endoscopic Guidance ◽  
Group Ii ◽  
Fine Print

Object. The goal of this study was to analyze the types of failure and long-term efficacy of third ventriculostomy in children.Methods. The authors retrospectively analyzed clinical data obtained in 213 children affected by obstructive triventricular hydrocephalus who were treated by third ventriculostomy between 1973 and 1997. There were 120 boys and 93 girls. The causes of the hydrocephalus included: aqueductal stenosis in 126 cases; toxoplasmosis in 23 cases, pineal, mesencephalic, or tectal tumor in 42 cases; and other causes in 22 cases. In 94 cases, the procedure was performed using ventriculographic guidance (Group I) and in 119 cases by using endoscopic guidance (Group II). In 19 cases (12 in Group I and seven in Group II) failure was related to the surgical technique. Three deaths related to the technique were observed in Group I. For the remaining patients, Kaplan—Meier survival analysis showed a functioning third ventriculostomy rate of 72% at 6 years with a mean follow-up period of 45.5 months (range 4 days–17 years). No significant differences were found during long-term follow up between the two groups. In Group I, a significantly higher failure rate was seen in children younger than 6 months of age, but this difference was not observed in Group II. Thirty-eight patients required reoperation (21 in Group I and 17 in Group II) because of persistent or recurrent intracranial hypertension. In 29 patients shunt placement was necessary. In nine patients in whom there was radiologically confirmed obstruction of the stoma, the third ventriculostomy was repeated; this was successful in seven cases. Cine phase-contrast (PC) magnetic resonance (MR) imaging studies were performed in 15 patients in Group I at least 10 years after they had undergone third ventriculostomy (range 10–17 years, median 14.3 years); this confirmed long-term patency of the stoma in all cases.Conclusions. Third ventriculostomy effectively controls obstructive triventricular hydrocephalus in more than 70% of children and should be preferred to placement of extracranial cerebrospinal shunts in this group of patients. When performed using ventriculographic guidance, the technique has a higher mortality rate and a higher failure rate in children younger than 6 months of age and is, therefore, no longer preferred. When third ventriculostomy is performed using endoscopic guidance, the same long-term results are achieved in children younger than 6 months of age as in older children and, thus, patient age should no longer be considered as a contraindication to using the technique. Delayed failures are usually secondary to obstruction of the stoma and often can be managed by repeating the procedure. Midline sagittal T2-weighted MR imaging sequences combined with cine PC MR imaging flow measurements provide a reliable tool for diagnosis of aqueductal stenosis and for ascertaining the patency of the stoma during follow-up evaluation.

Cerebral protection by intermittent reperfusion during temporary focal ischemia in the rat

1996 ◽  
Vol 85 (5) ◽  
pp. 923-928 ◽  
Author(s):  
Carlos A. David ◽  
Ricardo Prado ◽  
W. Dalton Dietrich
Keyword(s):  
Arterial Occlusion ◽  
Focal Ischemia ◽  
Global Ischemia ◽  
Cerebral Injury ◽  
Histopathological Analysis ◽  
Content Type ◽  
Group I ◽  
Group Ii ◽  
Temporary Clipping ◽  
Fine Print

✓ Temporary arterial occlusion has been routinely used as an adjunct in intracranial aneurysm surgery. This has commonly been performed using a protocol of multiple short periods of occlusion alternating with periods of restoration of normal circulation. Recently, the logical basis of this method has come under scrutiny. There is extensive experimental evidence to suggest that repetitive, brief periods of global ischemia may cause more severe cerebral injury than an equivalent single period of global ischemia. Only recently has this issue begun to be addressed with regard to focal ischemia. Hence, despite the common use of temporary clipping, little experimental data are available regarding the ischemic consequences of temporary arterial occlusion with periods of reperfusion versus uninterrupted temporary occlusion. To investigate this issue, a protocol of occlusion/reperfusion that simulates the temporal profile that occurs during surgery was performed in a rat model of focal ischemia. Sixteen anesthetized Sprague—Dawley rats were divided into two groups. The animals in Group I underwent 60 minutes of uninterrupted middle cerebral artery occlusion and the animals in Group II were subjected to six separate 10-minute occlusion periods with 5 minutes of reperfusion between occlusions. Histopathological analysis was performed 72 hours postischemia. Group I had significantly increased mean infarction volumes (50.0 ± 12.1 mm3) compared to Group II (8.7 ± 3.1 mm3) (p = 0.008). Injuries in Group I occurred in both the cortex and striatum, whereas Group II showed only striatal injuries. Furthermore, the extent of the injuries in Group II was less severe, characterized by ischemic neuronal injury rather than frank infarction. The results indicate that intermittent reperfusion is neuroprotective during temporary focal ischemia and support the hypothesis that intermittent reperfusion is beneficial if temporary clipping is required during aneurysm repair.

Effect of subthalamic nucleus stimulation on obsessive—compulsive disorder in a patient with Parkinson disease

2004 ◽  
Vol 100 (6) ◽  
pp. 1084-1086 ◽  
Author(s):  
Denys Fontaine ◽  
Vianney Mattei ◽  
Michel Borg ◽  
Daniel von Langsdorff ◽  
Marie-Noelle Magnie ◽  
...  
Keyword(s):  
Parkinson Disease ◽  
Obsessive Compulsive Disorder ◽  
Subthalamic Nucleus ◽  
Obsessive Compulsive ◽  
Content Type ◽  
Motor Disability ◽  
Compulsive Disorder ◽  
Subthalamic Nucleus Stimulation ◽  
Scale Scores ◽  
Fine Print

✓ The authors report on a patient with Parkinson disease (PD) and severe obsessive—compulsive disorder (OCD), in whom bilateral stimulation of the subthalamic nucleus (STN) was used to treat both PD and OCD symptoms. This 49-year-old man had displayed symptoms of PD for 13 years. Progressively, his motor disability became severe despite optimal medical treatment. In parallel, he suffered severe OCD for 16 years, with obsessions of accumulation and compulsions of gathering and rubbing that lasted more than 8 hours per day. Bilateral high-frequency STN stimulation was performed to treat motor disability. After surgery (at 1-year follow up), motor and OCD symptoms were dramatically improved. The pre- and postoperative Yale—Brown Obsessive—Compulsive Scale scores were 32 and 1, respectively. No additional antiparkinsonian drugs were administered. This case and other recent reports indicate that OCD symptoms can be improved by deep brain stimulation, a finding that opens new perspectives in the surgical treatment of severe and medically intractable OCD.

Determining the position and size of the subthalamic nucleus based on magnetic resonance imaging results in patients with advanced Parkinson disease

2004 ◽  
Vol 100 (3) ◽  
pp. 541-546 ◽  
Author(s):  
Erich O. Richter ◽  
Tasnuva Hoque ◽  
William Halliday ◽  
Andres M. Lozano ◽  
Jean A. Saint-Cyr
Keyword(s):  
Magnetic Resonance ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Anterior Commissure ◽  
Mr Images ◽  
Posterior Commissure ◽  
Content Type ◽  
Imaging Results ◽  
Fine Print ◽  
Brain Atlases

Object. The subthalamic nucleus (STN) is a target in surgery for Parkinson disease, but its location according to brain atlases compared with its position on an individual patient's magnetic resonance (MR) images is incompletely understood. In this study both the size and location of the STN based on MR images were compared with those on the Talairach and Tournoux, and Schaltenbrand and Wahren atlases. Methods. The position of the STN relative to the midcommissural point was evaluated on 18 T2-weighted MR images (2-mm slices). Of 35 evaluable STNs, the most anterior, posterior, medial, and lateral borders were determined from axial images, dorsal and ventral borders from coronal images. These methods were validated using histological measurements in one case in which a postmortem examination was performed. The mean length of the anterior commissure—posterior commissure was 25.8 mm. Subthalamic nucleus borders derived from MR imaging were highly variable: anterior, 4.1 to −3.7 mm relative to the midcommissural point; posterior, 4.2 to 10 mm behind the midcommissural point; medial, 7.9 to 12.1 mm from the midline; lateral, 12.3 to 15.4 mm from the midline; dorsal, 0.2 to 4.2 mm below the intercommissural plane; and ventral, 5.7 to 9.9 mm below the intercommissural plane. The position of the anterior border on MR images was more posterior, and the medial border more lateral, than its position in the brain atlases. The STN was smaller on MR images compared with its size in atlases in the anteroposterior (mean 5.9 mm), mediolateral (3.7 mm), and dorsoventral (5 mm) dimensions. Conclusions. The size and position of the STN are highly variable, appearing to be smaller and situated more posterior and lateral on MR images than in atlases. Care must be taken in relying on coordinates relative to the commissures for targeting of the STN.

Changes in CSF pressure after mannitol in patients with and without elevated CSF pressure

1988 ◽  
Vol 69 (6) ◽  
pp. 869-876 ◽  
Author(s):  
Patrick Ravussin ◽  
Mounir Abou-Madi ◽  
David Archer ◽  
René Chiolero ◽  
James Freeman ◽  
...  
Keyword(s):  
Intracranial Hypertension ◽  
Venous Pressure ◽  
Tumor Resection ◽  
Fluid Pressure ◽  
Content Type ◽  
Csf Pressure ◽  
Arterial Blood ◽  
Group I ◽  
Group Ii ◽  
Fine Print

✓ In view of the current concern that rapid infusion of mannitol might initially aggravate intracranial hypertension, the effects of a mannitol infusion on lumbar cerebrospinal fluid pressure (CSFP) were investigated in 49 patients. The studies were performed when the patients were under general anesthesia prior to elective craniotomy for tumor resection or intracerebral aneurysm clipping. The patients were divided into two groups: 24 patients with normal CSFP (Group I, mean CSFP 10.5 mm Hg) and 25 with raised CSFP (Group II, mean CSFP 20.8 mm Hg). Measurements of CSFP, mean arterial blood pressure (MABP), and central venous pressure (CVP) were made serially during and after the infusion of 20% mannitol (1 gm ⋅ kg−1 infused over a 10-minute interval). In both groups, mannitol infusion provoked a fall in MABP and an increase in CVP. An immediate increase in CSFP was observed in Group II, whereas CSFP increased transiently but significantly in Group I. Analysis of the arterial and venous driving pressures which contribute to CSFP suggests that the transient increase in CSFP after mannitol in Group I was partly due to the increase in CVP. The presence of intracranial hypertension may thus alter the CSFP response to arterial and venous pressure changes. Cerebral blood volume (CBV) was measured in dogs in a separate study analogous to the human protocol. The CBV increased approximately 25% over control values after mannitol infusion both in the normal animals and in those with CSFP raised by an epidural balloon. The response of the CSFP to mannitol infusion differed between both groups in a fashion similar to that observed in the human subjects. Thus, differences in CBV changes after mannitol do not account for the difference in CSFP response between normal subjects and those with raised CSFP.

Gamma knife subthalamotomy for Parkinson disease: the subthalamic nucleus as a new radiosurgical target

2002 ◽  
Vol 97 ◽  
pp. 592-599 ◽  
Author(s):  
Marcus F. Keep ◽  
Lois Mastrofrancesco ◽  
Daniel Erdman ◽  
Brent Murphy ◽  
Lynn S. Ashby
Keyword(s):  
Mr Imaging ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Gamma Knife ◽  
Gamma Knife Radiosurgery ◽  
Single Shot ◽  
Content Type ◽  
The Right ◽  
End Stage ◽  
Fine Print

✓ The authors present the neuroimaging, treatment planning, and radiosurgical technique for the first reported case of unilateral radiosurgical subthalamotomy, which was performed to control motor symptoms associated with advanced Parkinson disease (PD) in a patient who had undergone previous contralateral radiofrequency (RF) pallidotomy. A 73-year-old woman with end-stage PD had undergone RF pallidotomy of the right globus pallidus with resolution of symptoms. Two years following this procedure, due to the natural progression of her disease, she suffered recurrent motor fluctuations, dyskinesia, and worsening bradykinesia of the right side. Her Parkinson's Disease Disability Rating (PDDR) score was 28. Computerized tomography and magnetic resonance (MR) imaging were used to localize the left subthalamic nucleus (STN). The patient underwent gamma knife radiosurgery—a single shot of 120 Gy was administered using the 4-mm collimator helmet. The patient was evaluated up to 42 months after the procedure. The dyskinesia became minimal. Right-sided motor control improved as did her balance. At 3 months after treatment MR imaging demonstrated the radiosurgical lesion in the left STN. At 3.5 years postradiosurgery, she experienced minimal focal (oral) dyskinesia, no bradykinesia or rigidity, and her PDDR score was 11. Radiosurgery of the STN in this case was safe and effective. The STN is a readily localized anatomical target with neuroimaging. Radiosurgery avoids the risks of open procedures.

Movement-related neurons of the subthalamic nucleus in patients with Parkinson disease

2002 ◽  
Vol 97 (5) ◽  
pp. 1167-1172 ◽  
Author(s):  
Aviva Abosch ◽  
William D. Hutchison ◽  
Jean A. Saint-Cyr ◽  
Jonathan O. Dostrovsky ◽  
Andres M. Lozano
Keyword(s):  
Receptive Field ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Receptive Fields ◽  
Median Number ◽  
Content Type ◽  
Pooled Data ◽  
Somatotopic Organization ◽  
Fine Print ◽  
Deep Brain

Object. The subthalamic nucleus (STN) is a target in the surgical treatment of Parkinson disease (PD). Little is known about the neurons within the human STN that modulate movement. The authors' goal was to examine the distribution of movement-related neurons within the STN of humans by using microelectrode recording to identify neuronal receptive fields. Methods. Data were retrospectively collected from microelectrode recordings that had been obtained in 38 patients with PD during surgery for placement of STN deep brain stimulation electrodes. The recordings had been obtained in awake, nonsedated patients. Antiparkinsonian medications were withheld the night before surgery. Neuronal discharges were amplified, filtered, and displayed on an oscilloscope and fed to an audio monitor. The receptive fields were identified by the presence of reproducible, audible changes in the firing rate that were time-locked to the movement of specific joint(s). The median number of electrode tracks per patient was six (range two–nine). The receptive fields were identified in 278 (55%) of 510 STN neurons studied. One hundred one tracks yielded receptive field data. Fourteen percent of 64 cells tested positive for face receptive fields, 32% of 687 cells tested positive for upper-extremity receptive fields, and 21% of 242 cells tested positive for lower-extremity receptive fields. Sixty-eight cells (24%) demonstrated multiple-joint receptive fields. Ninety-three cells (65%) with movement-related receptive fields were located in the dorsal half of the STN, and 96.8% of these were located in the rostral two thirds of the STN. Analysis of receptive field locations from pooled data and along individual electrode tracks failed to reveal a consistent somatotopic organization. Conclusions. Data from this study demonstrate a regional compartmentalization of neurons with movement-related receptive fields within the STN, supporting the existence of specific motor territories within the STN in patients suffering from PD.

Apnea testing for the determination of brain death: a modified protocol

1992 ◽  
Vol 76 (6) ◽  
pp. 1029-1031 ◽  
Author(s):  
Edward C. Benzel ◽  
Jay P. Mashburn ◽  
Steven Conrad ◽  
Denise Modling
Keyword(s):  
Brain Death ◽  
Apnea Test ◽  
Content Type ◽  
Group I ◽  
The Mean ◽  
Group Ii ◽  
Safe Approach ◽  
Apnea Testing ◽  
Fine Print

✓ The absence of spontaneous respirations at a PaCO2 of 60 mm Hg or above has traditionally been accepted as the respiratory criteria for the determination of brain death. The testing of patients for the presence or absence of apnea has been complicated because the rate of PaCO2 elevation may vary substantially from patient to patient, and a nonlinear relationship exists between the rate of PaCO2 increase and the duration of apnea. In an attempt to refine the apnea test and to further elucidate the physiology of hypercapnia in humans, 11 patients who met all but the respiratory criteria for brain death were evaluated using a modification of a previously utilized apnea testing protocol. All patients were brought to a PaCO2 of 40 mm Hg or above prior to the apnea test. Baseline PaCO2 ranged from 40 to 45 mm Hg in six patients (Group I) and from 46 to 51 mm Hg in five patients (Group II). The mean rate of PaCO2 increase was 5.1 ± 1.4 mm Hg/min in Group I and 6.7 ± 3.1 mm Hg/min in Group II. No problems with cardiovascular instability or hypoxia were encountered during testing in this series. This refinement of the apnea test allows for a streamlined and safe approach to brain death detection.

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