Subthalamotomy for advanced Parkinson disease

2002 ◽  
Vol 97 (3) ◽  
pp. 598-606 ◽  
Author(s):  
Philip C. Su ◽  
Ham-Min Tseng ◽  
Hon-Man Liu ◽  
Ruoh-Fang Yen ◽  
Horng-Huei Liou
Keyword(s):  
Parkinson Disease ◽  
Postural Stability ◽  
Rating Scale ◽  
Motor Fluctuation ◽  
Treated Group ◽  
Content Type ◽  
Cardinal Symptoms ◽  
Fine Print

Object. The aim of this study was to determine if subthalamotomy is effective in treating advanced Parkinson disease (PD). Methods. The authors performed microelectrode mapping—guided stereotactic surgery on the subthalamic nucleus in eight patients with PD. Lesioning was performed using radiofrequency heat coagulation and confirmed with magnetic resonance imaging. Three patients who underwent unilateral and four with bilateral subthalamotomy were evaluated for up to 18 months according to the Unified PD Rating Scale (UPDRS). One patient who underwent unilateral subthalamotomy died 6 months postsurgery. At 3 months into the “off” period after surgery, there were significant improvements in contralateral bradykinesia (p < 0.0002), rigidity (p < 0.0001), tremor (p < 0.01), axial motor features (p < 0.02), gait (p < 0.03), postural stability (p < 0.03), total UPDRS scores (p < 0.03), and Schwab and England scores (p < 0.04). The benefits were sustained at 6, 12, and 18 months, except for the improvement in tremor. At 12 months into the “on” period, significant benefits were present for motor fluctuation (p < 0.04), on dyskinesia (p < 0.006), off duration (p < 0.05), total UPDRS score (p < 0.02), and contralateral tremor (p < 0.05). Benefits for motor fluctuation, off duration, and off-period tremor were lost after the 18-month follow-up period. The levodopa requirement was reduced by 66% for the unilateral and 38% for the bilaterally treated group. Bilateral subthalamotomy offered more benefits than did unilateral surgery for various parkinsonian features in both the on and off periods. Three patients suffered hemiballismus, two recovered spontaneously, and one died of aspiration pneumonia after discontinuation of levodopa. Conclusions. These findings indicate that subthalamotomy can ameliorate the cardinal symptoms of PD, reduce the dosage of levodopa, diminish complications of the drug therapy, and improve the quality of life.

Long-term benefits in quality of life provided by bilateral subthalamic stimulation in patients with Parkinson disease

2005 ◽  
Vol 103 (2) ◽  
pp. 252-255 ◽  
Author(s):  
Kelly E. Lyons ◽  
Rajesh Pahwa
Keyword(s):  
Quality Of Life ◽  
Parkinson Disease ◽  
Motor Function ◽  
Well Being ◽  
Strongly Correlated ◽  
Content Type ◽  
Fine Print

Object. The goals of this study were to evaluate long-term benefits in quality of life in patients with Parkinson disease (PD) after bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN) and to evaluate the relationship between improvements in motor function and quality of life. Methods. Seventy-one patients who received bilateral STN stimulation implants and participated in follow-up review for at least 12 months were included in the study. Fifty-nine patients participated in a 12-month follow-up review and 43 patients in a follow-up review lasting at least 24 months. Patients' symptoms were assessed preoperatively by using the Unified PD Rating Scale (UPDRS) in the “medication-on” and “medication-off” conditions and quality of life was examined using the 39-item PD Questionnaire (PDQ-39). Patient evaluations were repeated postoperatively during periods of stimulation. The UPDRS activities of daily living (ADL) and motor scores as well as the PDQ-39 total, mobility, ADL, emotional well-being, stigma, and bodily discomfort scores were significantly improved at 12 months compared with baseline scores; the UPDRS ADL and motor scores as well as the PDQ-39 total, mobility, ADL, stigma, and bodily discomfort scores were significantly improved at the longest follow-up examination compared with baseline scores. There was a strong correlation between UPDRS motor and ADL scores and the PDQ-39 total, mobility, and ADL scores. Further analyses indicated that improvements in tremor were only correlated with PDQ-39 ADL subscale scores and rigidity was not correlated with any aspect of quality of life. Nevertheless, bradykinesia was strongly correlated with improvements in the PDQ-39 total, mobility, and ADL scores. Conclusions. Improvements in quality of life following bilateral DBS of the STN are maintained in the long term. These improvements are strongly correlated with improvements in motor function, primarily with regard to bradykinesia.

Bilateral subthalamic stimulation in patients with Parkinson disease: long-term follow up

2003 ◽  
Vol 99 (1) ◽  
pp. 71-77 ◽  
Author(s):  
Rajesh Pahwa ◽  
Steven B. Wilkinson ◽  
John Overman ◽  
Kelly E. Lyons
Keyword(s):  
Parkinson Disease ◽  
Rating Scale ◽  
Pulse Generator ◽  
Visual Disturbance ◽  
Open Label ◽  
Content Type ◽  
Long Term Follow Up ◽  
Fine Print

Object. Bilateral subthalamic nucleus (STN) stimulation is increasingly used in patients with advanced Parkinson disease (PD). This study was performed to evaluate the long-term efficacy and safety of bilateral STN stimulation in cases of PD. Methods. The authors performed a prospective, open-label study in patients with PD who underwent bilateral STN stimulation. The authors compared motor scores and activities of daily living (ADL) scores based on the Unified PD Rating Scale (UPDRS) obtained before surgery while patients were in the medication-off state with scores obtained at follow-up evaluations of these patients while in the medication-off/stimulator-on state. Data contained in patient diaries were also compared. Thirty-three patients with PD were evaluated 12 months postoperatively and 19 were evaluated at a mean follow-up time of 28 months. A comparison between UPDRS scores obtained in patients in the medication-off/stimulator-on state and those obtained when patients were in the baseline medication-off state showed a 27% improvement in ADL scores and a 28% improvement in motor scores after surgery. There was a 57% reduction in the use of levodopa-equivalent medication doses. The percentage of the waking day that patients were in the medication-on state increased from 38 to 72%. Surgical complications included seizures (three patients), confusion (five patients), hemiballismus (one patient), and visual disturbance (one patient). Stimulation-related adverse effects were mild. Device-related events included nine lead replacements, seven lead revisions, six extension replacements, and 12 implantable pulse generator (IPG) replacements; one IPG was cleaned and one IPG was placed in a pocket because of the presence of a shunt. Conclusions. Bilateral STN simulation is associated with a significant improvement in the motor features of PD. Device-related events were common in the first 20 patients who underwent surgery, often requiring repeated surgeries.

Staged bilateral pallidotomy for treatment of Parkinson disease

2001 ◽  
Vol 94 (3) ◽  
pp. 437-444 ◽  
Author(s):  
Peter M. Intemann ◽  
Donna Masterman ◽  
Indu Subramanian ◽  
Antonio DeSalles ◽  
Eric Behnke ◽  
...  
Keyword(s):  
Parkinson Disease ◽  
Rating Scale ◽  
Internal Capsule ◽  
Complication Rates ◽  
Content Type ◽  
Increased Risk ◽  
Disease Rating ◽  
Unilateral Pallidotomy ◽  
Fine Print

Object. Several investigators have described the motor benefits derived from performing unilateral stereotactic pallidotomy for the treatment of Parkinson disease (PD), but little is known about the efficacy and complication rates of bilateral procedures. The goal of this study was to assess both these factors in 12 patients. Methods. Eleven patients with medically intractable PD underwent staged bilateral pallidotomy and one patient underwent a simultaneous bilateral procedure. Unilateral pallidotomy resulted in an improvement in the patients' Unified Parkinson Disease Rating Scale (UPDRS) total scores and motor subscores, Hoehn and Yahr stages, and Schwab and England Activities of Daily Living scores. There were no complications. The second procedures were performed 5 to 25 months after the first, and nearly complete 3-month follow-up data are available for eight of these patients. Staged bilateral pallidotomy did result in further improvements in some symptoms, but the patients proved to be less responsive to levodopa. In contrast to outcomes of the initial unilateral pallidotomy, there were significant complications. One patient suffered an acute stroke, two patients suffered delayed infarctions of the internal capsule, four patients had mild-to-moderate worsening of speech and increased drooling, and one patient complained of worsening memory. Conclusions. Bilateral pallidotomy results in modest benefits but is associated with an increased risk of complications.

The mechanism and effect of chronic electrical stimulation of the globus pallidus for treatment of Parkinson disease

2004 ◽  
Vol 100 (6) ◽  
pp. 997-1001 ◽  
Author(s):  
Mitsuhiro Ogura ◽  
Naoyuki Nakao ◽  
Ekini Nakai ◽  
Yuji Uematsu ◽  
Toru Itakura
Keyword(s):  
Electrical Stimulation ◽  
Parkinson Disease ◽  
Globus Pallidus ◽  
Rating Scale ◽  
Underlying Mechanism ◽  
Clinical Effects ◽  
Content Type ◽  
Chronic Electrical Stimulation ◽  
Fine Print ◽  
Stimulation Of

Object. Although chronic electrical stimulation of the globus pallidus (GP) has been shown to ameliorate motor disabilities in Parkinson disease (PD), the underlying mechanism remains to be clarified. In this study the authors explored the mechanism for the effects of deep brain stimulation of the GP by investigating the changes in neurotransmitter levels in the cerebrospinal fluid (CSF) during the stimulation. Methods. Thirty patients received chronic electrical stimulation of the GP internus (GPi). Clinical effects were assessed using the Unified PD Rating Scale (UPDRS) and the Hoehn and Yahr Staging Scale at 1 week before surgery and at 6 and 12 months after surgery. One day after surgery, CSF samples were collected through a ventricular tube before and 1 hour after GPi stimulation. The concentration of neurotransmitters such as γ-aminobutyric acid (GABA), noradrenaline, dopamine, and homovanillic acid (HVA) in the CSF was measured using high-performance liquid chromatography. The treatment was effective for tremors, rigidity, and drug-induced dyskinesia. The concentration of GABA in the CSF increased significantly during stimulation, although there were no significant changes in the level of noradrenaline, dopamine, and HVA. A comparison between an increased rate of GABA concentration and a lower UPDRS score 6 months postimplantation revealed that the increase in the GABA level correlated with the stimulation-induced clinical effects. Conclusions. Stimulation of the GPi substantially benefits patients with PD. The underlying mechanism of the treatment may involve activation of GABAergic afferents in the GP.

The role of σ-receptors in levodopa-induced dyskinesia in patients with advanced Parkinson disease: a positron emission tomography study

2004 ◽  
Vol 100 (4) ◽  
pp. 606-610 ◽  
Author(s):  
Taro Nimura ◽  
Tadashi Ando ◽  
Keiichiro Yamaguchi ◽  
Takeshi Nakajima ◽  
Reizo Shirane ◽  
...  
Keyword(s):  
Parkinson Disease ◽  
Severity Score ◽  
Rating Scale ◽  
Binding Potential ◽  
Strong Positive Correlation ◽  
Female Ratio ◽  
Content Type ◽  
Positron Emission ◽  
Before And After ◽  
Fine Print

Object. Levodopa-induced dyskinesia (LID) in patients with Parkinson disease (PD) mimics acute dystonic reactions induced by antipsychotic agents, possibly mediated by σ-receptors; however, there are few reports in which the relationship between σ-receptors and LID in advanced PD is investigated. The binding potential of cerebellar σ-receptors before and after a pallidal surgery for dyskinesia in patients with advanced PD is assessed. Methods. Six patients with advanced PD (male/female ratio 3:3, age 56.7 ± 9.8 years) underwent stereotactic pallidal surgery (two posteroventral pallidotomy procedures and four deep brain stimulation of the globus pallidus internus, including one bilateral case). Clinical features of patients with PD were assessed using Hoehn and Yahr (H & Y) stages, the Unified Parkinson's Disease Rating Scale (UPDRS), and the Schwab and England Activities of Daily Life Scale (S & E). The LID was evaluated by LID severity score. The binding potential of cerebellar σ-receptors was determined before and after the surgery by 11C-nemonapride positron emission tomoraphy, a specific radioligand for σ-receptors in the cerebellum. All clinical scores, especially the LID severity score, were dramatically improved after the surgery (p < 0.05). Preoperatively, contralateral cerebellar binding potential was significantly elevated (p < 0.01), and it was reduced after the surgery, but it was still higher than that of healthy volunteers (p < 0.05). The ipsilateral cerebellar binding potential remained unchanged after the surgery. The level of binding potential did not correlate with H & Y stage, UPDRS, or S & E score, but a strong positive correlation was seen between the binding potential and the preoperative LID severity score when the patients were receiving medication (r = 0.893, p < 0.05). Conclusions. Cerebellar σ-receptors may potentially involve the genesis of LID in advanced PD.

CyberKnife stereotactic radiosurgical treatment of spinal tumors for pain control and quality of life

2005 ◽  
Vol 2 (5) ◽  
pp. 540-549 ◽  
Author(s):  
Jeffrey W. Degen ◽  
Gregory J. Gagnon ◽  
Jean-Marc Voyadzis ◽  
Donald A. McRae ◽  
Michael Lunsden ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Well Being ◽  
Spinal Tumors ◽  
Content Type ◽  
Cyberknife Radiosurgery ◽  
The Mean ◽  
Initial Score ◽  
Fine Print

Object. The authors conducted a study to assess safety, pain, and quality of life (QOL) outcomes following CyberKnife radiosurgical treatment of spinal tumors. Methods. Data obtained in all patients with spinal tumors who underwent CyberKnife radiosurgery at Georgetown University Hospital between March 2002 and March 2003 were analyzed. Patients underwent examination, visual analog scale (VAS) pain assessment, and completed the 12-item Short Form Health Survey (SF-12) before treatment and at 1, 3, 6, 8, 12, 18, and 24 months following treatment. Fifty-one patients with 72 lesions (58 metastatic and 14 primary) were treated. The mean follow-up period was 1 year. Pain was improved, with the mean VAS score decreasing significantly from 51.5 to 21.3 at 4 weeks (p < 0.001). This effect on pain was durable, with a mean score of 17.5 at 1 year, which was still significantly decreased (p = 0.002). Quality of life was maintained throughout the study period. After 18 months, physical well-being was 33 (initial score 32; p = 0.96) and mental well-being was 43.8 (initial score 44.2; p = 0.97). (The mean SF-12 score is 50 ± 10 [standard deviation].) Adverse effects included self-limited dysphagia (three cases), diarrhea (two cases), lethargy (three cases), paresthesias (one case), and wound dehiscence (one case). Conclusions. CyberKnife radiosurgery improves pain control and maintains QOL in patients treated for spinal tumors. Early adverse events are infrequent and minor. The authors await long-term follow-up data to determine late complications and tumor control rates.

Arteriovenous malformations of the brain

1972 ◽  
Vol 37 (5) ◽  
pp. 562-570 ◽  
Author(s):  
David M. C. Forster ◽  
Ladislau Steiner ◽  
Sten Håkanson
Keyword(s):  
Arteriovenous Malformations ◽  
Indications For Surgery ◽  
Content Type ◽  
Long Run ◽  
The Mean ◽  
The Brain ◽  
Fine Print

✓ The quality of survival of 150 patients with arteriovenous malformations of the brain is presented. The mean period of follow-up was over 15 years. The surgically operated and conservatively managed groups are compared, a comparison that in the long run appears to favor the operated cases. The results are discussed and indications for surgery summarized.

The treatment of posttraumatic tremor by stereotactic surgery

1994 ◽  
Vol 80 (5) ◽  
pp. 810-819 ◽  
Author(s):  
Joachim K. Krauss ◽  
Mohsen Mohadjer ◽  
Fritz Nobbe ◽  
Fritz Mundinger
Keyword(s):  
Head Trauma ◽  
Functional Disability ◽  
Rating Scale ◽  
Stereotactic Surgery ◽  
Long Term Results ◽  
Severe Head Trauma ◽  
Content Type ◽  
Fine Print

✓ The authors report the long-term results of stereotactic surgery for severe posttraumatic appendicular tremor in 35 patients. The tremors developed after severe head trauma in 33 patients (94%) and after mild to moderate head trauma in two (6%). In all but one, the tremor was most evident during activity. The amplitude of the kinetic tremor was greater than 5 cm in 33 patients (94%) and greater than 12 cm in 19 patients (54%). All were severely incapacitated in their daily living activities due to the tremors. The 35 patients underwent 42 stereotactic operations; five patients were reoperated on the same side and two were treated with a bilateral staged procedure. The contralateral zona incerta was the stereotactic target in 12 patients and was targeted in combination with the base of the ventrolateral (oroventral) thalamus in 23 patients. Long-term postoperative follow-up review was obtained in 32 patients (mean follow-up period 10.5 years). Persistent improvement of tremor was noted in 88%. The tremor was absent or markedly reduced in 65%. Functional disability was assessed and quantified with a modified form of an established rating scale for patients with tremor; it was reduced from a mean value of 57% of maximum disability to 37% over the long term (p < 0.001). Follow-up lesion assessment was obtained in 18 patients by multiplanar magnetic resonance imaging and at autopsy in one patient whose death was unrelated to surgery. As in previous studies, the frequency of persistent side effects was relatively high (38%). These consisted mainly of aggravation of preoperative symptoms. The results are compared to those of a total of 55 patients reported from 1960 to 1992. The occurrence of dystonia and dystonic postures is discussed. Stereotactic surgery is a powerful tool to alleviate posttraumatic tremor and to improve functional disability. However, as there is considerable risk of persistent morbidity in patients after severe head trauma, the operation should be restricted to selected cases with disabling tremor.

Ventricular shunt removal: the ultimate treatment of the slit ventricle syndrome

1998 ◽  
Vol 88 (3) ◽  
pp. 478-484 ◽  
Author(s):  
Jonathan J. Baskin ◽  
Kim H. Manwaring ◽  
Harold L. Rekate
Keyword(s):  
Third Ventriculostomy ◽  
Slit Ventricle Syndrome ◽  
Content Type ◽  
Number Of Patients ◽  
Csf Diversion ◽  
Shunt Removal ◽  
Slit Ventricle ◽  
Fine Print

Object. The aim of this study was to assess the effectiveness of an algorithm used to evaluate and prescribe treatment for patients having slit ventricle syndrome (SVS). Methods. All patients included in this protocol underwent fiberoptic intracranial pressure monitoring after removal or externalization of their ventricular shunt systems. A significant number of patients did not need extracranial cerebrospinal fluid (CSF) diversion and tolerated removal of their shunt systems without requiring further intervention. Patients who demonstrated a need for CSF drainage underwent an endoscopic third ventriculostomy, regardless of the putative cause of their hydrocephalus. Sixteen (72.7%) of 22 patients experienced resolution of or significant improvement in their SVS complaints after their inclusion in the protocol. Concomitantly, 14 (64%) of 22 patients were no longer shunt dependent after a mean follow-up period of 21.4 months. Conclusions. A significant number of patients debilitated by SVS may experience improvement in their symptoms and undergo shunt removal according to this protocol, improving their quality of life and simplifying their medical follow up.

Long-term follow up of bilateral deep brain stimulation of the subthalamic nucleus in patients with advanced Parkinson disease

2003 ◽  
Vol 99 (3) ◽  
pp. 489-495 ◽  
Author(s):  
Galit Kleiner-Fisman ◽  
David N. Fisman ◽  
Elspeth Sime ◽  
Jean A. Saint-Cyr ◽  
Andres M. Lozano ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Content Type ◽  
Over Time ◽  
Fine Print ◽  
Deep Brain

Object. The use of deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been associated with a marked initial improvement in individuals with advanced Parkinson disease (PD). Few data are available on the long-term outcomes of this procedure, however, or whether the initial benefits are sustained over time. The authors present the long-term results of a cohort of 25 individuals who underwent bilateral DBS of the STN between 1996 and 2001 and were followed up for 1 year or longer after implantation of the stimulator. Methods. Patients were evaluated at baseline and repeatedly after surgery by using the Unified Parkinson's Disease Rating Scale (UPDRS); the scale was applied to patients during periods in which antiparkinsonian medications were effective and periods when their effects had worn off. Postoperative UPDRS total scores and subscores, dyskinesia scores, and drug dosages were compared with baseline values, and changes in the patients' postoperative scores were evaluated to assess the possibility that the effect of DBS diminished over time. In this cohort the median duration of follow-up review was 24 months (range 12–52 months). The combined (ADL and motor) total UPDRS score during the medication-off period improved after 1 year, decreasing by 42% relative to baseline (95% confidence interval [CI 35–50%], p < 0.001) and the motor score decreased by 48% (95% CI 42–55%, p < 0.001). These gains did diminish over time, although a sustained clinical benefit remained at the time of the last evaluation (41% improvement over baseline, 95% CI 31–50%; p < 0.001). Axial subscores at the time of the last evaluation showed only a trend toward improvement (p = 0.08), in contrast to scores for total tremor (p < 0.001), rigidity (p < 0.001), and bradykinesia (p = 0.003), for which highly significant differences from baseline were still present at the time of the last evaluation. Medication requirements diminished substantially, with total medication doses reduced by 38% (95% CI 27–48%, p < 0.001) at 1 year and 36% (95% CI 25–48%, p < 0.001) at the time of the last evaluation; this decrease may have accounted, at least in part, for the significant decrease of 46.4% (95% CI 20.2–72.5%, p = 0.007) in dyskinesia scores obtained by patients during the medication-on period. No preoperative demographic variable, such as the patient's age at the time of disease onset, age at surgery, sex, duration of disease before surgery, preoperative drug dosage, or preoperative severity of dyskinesia, was predictive of long-term outcome. The only predictor of a better outcome was the patient's preoperative response to levodopa. Conclusions. In this group of patients with advanced PD who underwent bilateral DBS of the STN, sustained improvement in motor function was present a mean of 2 years after the procedure, and sustained reductions in drug requirements were also achieved. Improvements in tremor, rigidity, and bradykinesia were more marked and better sustained over time than improvements in axial symptoms. A good preoperative response to levodopa predicted a good response to surgery.

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