RESUMO
BACKGROUND: Several subcortical structures have been targeted for surgical treatment of dystonia, including motor thalamus, internal segment of globus pallidus (GPi), and more recently, the subthalamic nucleus (STN). Deep brain stimulation of GPi is currently the preferred surgical treatment, but it is unclear if targeting other structures would yield better results. Patients who have already had a pallidotomy yet continue to experience dystonic symptoms may be limited in further treatment options. METHODS: A patient with medically intractable, segmental, early-onset, primary torsion dystonia presented for surgical consultation after exhausting nearly all treatment options. Medications, botulinum toxin injections, cervical denervation surgery, and left-sided pallidotomy failed to give adequate relief. The patient was implanted with STN stimulating leads bilaterally according to standard procedures. RESULTS: The patient received a 36% improvement in dystonic symptoms as measured by several dystonia rating scales. These benefits persisted for 2 years after surgery despite several hardware-related complications, and the patient reported being very satisfied with the outcome. CONCLUSION: This result supports the efficacy of STN deep brain stimulation in dystonia patients, even those with prior pallidotomy.
Assuntos
Estimulação Encefálica Profunda/métodos , Distonia/fisiopatologia , Distonia/terapia , Palidotomia/métodos , Núcleo Subtalâmico/fisiopatologia , Adulto , Globo Pálido/cirurgia , Humanos , Masculino , Técnicas Estereotáxicas , Núcleo Subtalâmico/cirurgiaRESUMO
Deep brain stimulation is generally a safe and effective method of alleviating motor impairment in advanced-stage Parkinson's disease patients. However, adverse events of surgery have been noted, such as hemorrhage, infection, seizures, and device failure. In this report, we describe 2 cases of the unusual adverse event of ischemia associated with subthalamic nucleus stimulator implantation. We present the intraoperative neurological symptoms, microelectrode recording data, imaging findings, and other correlated events. In the first case, the clinical effects of ischemia were evident intraoperatively and coincided with silence during microelectrode recording from the ischemic region. In the second case, the timing of the ischemic event could not be determined precisely but also was associated with a difficult mapping. Subcortical ischemia may be an underrecognized event that confounds neurophysiological mapping of deep brain structures and affects clinical outcomes.
Assuntos
Infarto Cerebral/etiologia , Estimulação Encefálica Profunda/efeitos adversos , Eletrodos Implantados/efeitos adversos , Doença de Parkinson/reabilitação , Núcleo Subtalâmico/fisiopatologia , Doenças Talâmicas/etiologia , Idoso , Núcleo Caudado/irrigação sanguínea , Infarto Cerebral/diagnóstico , Infarto Cerebral/fisiopatologia , Imagem de Difusão por Ressonância Magnética , Dominância Cerebral/fisiologia , Feminino , Humanos , Processamento de Imagem Assistida por Computador , Masculino , Microeletrodos , Neurônios/fisiologia , Doença de Parkinson/fisiopatologia , Fatores de Risco , Técnicas Estereotáxicas , Cirurgia Assistida por Computador , Doenças Talâmicas/diagnóstico , Doenças Talâmicas/fisiopatologia , Tomografia Computadorizada por Raios XRESUMO
Carotid endarterectomy requires some sort of cerebral protection in some patients. Available strategies include routine shunting, pharmacologic cerebral protection, or selective shunting. Selective shunting may be based on preoperative criteria or, more commonly, some intraoperative determinant of adequacy of cerebral perfusion. There are several commonly used methods, but electroencephalography is a sensitive marker for adequacy of cerebral perfusion and we have found it an excellent tool in our strategy of selective shunting. This article reviews the various approaches to cerebral protection during carotid endarterectomy with emphasis on our experience with electroencephalography.