The advances of Deep Brain Stimulation (DBS) for treatment of Parkinson's disease (PD)

Advanced Parkinson's disease (PD) is characterized by the presence of motor fluctuations, various degrees of dyskinesia, and disability with functional impact on daily living and independence. Therapeutic management aims to extend levodopa (L-DOPA) benefit while minimizing motor complications and includes, in selected cases, the implementation of drug infusion and surgical techniques. The concept of deep brain stimulation (DBS) for PD was introduced over 20 years ago, but our understanding of the nuances of this procedure continues to improve. This review aims to demonstrate the advances of DBS in the treatment of PD patients. (AU)

Tratamiento quirúrgico de la distonía

A pesar de los recientes avances en la comprensión de los circuitos cerebrales involucrados en la distonía, las técnicas quirúrgicas invasivas y no invasivas han fallado en proporcionar un beneficio substancial a los pacientes que sufren de distonía, en comparación con los resultados observados en la enfermedad de Parkinson, no obstante, la lesionectomía, la estimulación cerebral profunda y el ultrasonido enfocado pueden proporcionar mejoría en los casos refractarios al manejo médico.

SUMMARY Despite recent advances in understanding brain circuits involved in dystonia, surgical techniques both invasive and not invasive have fail to provide substantial benefit to patients suffering from dystonia compared to the results seeing in Parkinson's disease, nonetheless, lesionectomy, deep brain stimulation and focused ultrasound can provide relief in medical refractory cases.

Tratamiento quirúrgico de la distonía / Surgical management for dystonia

RESUMEN A pesar de los recientes avances en la comprensión de los circuitos cerebrales involucrados en la distonía, las técnicas quirúrgicas invasivas y no invasivas han fallado en proporcionar un beneficio substancial a los pacientes que sufren de distonía, en comparación con los resultados observados en la enfermedad de Parkinson, no obstante, la lesionectomía, la estimulación cerebral profunda y el ultrasonido enfocado pueden proporcionar mejoría en los casos refractarios al manejo médico.

SUMMARY Despite recent advances in understanding brain circuits involved in dystonia, surgical techniques both invasive and not invasive have fail to provide substantial benefit to patients suffering from dystonia compared to the results seeing in Parkinson's disease, nonetheless, lesionectomy, deep brain stimulation and focused ultrasound can provide relief in medical refractory cases.

Inter-Racial, Gender and Aging Influences in the Length of Anterior Commissure-Posterior Commissure Line

OBJECTIVE: The length of anterior-posterior commissure (AC-PC) in racial groups, age, gender of patients with deep brain stimulation (DBS) and pallidotomy were investigated. METHODS: From January 1996 to December 2003, 211 patients were treated with DBS and pallidotomy. There were 160 (76%) Caucasians, 35 (17%) Hispanics, 12 (5%) Asians and 4 Blacks (2%). There were 88 males and 52 females in DBS-surgery group and 44 males, 27 females in pallidotomy group. Mean age was 58 year-old. There were 19 males and 19 females and mean age was 54.7 years in the control group. Measurements were made on MRI and @Target software. RESULTS: The average AC-PC distance was 24.89 mm (range 32 to 19), which increased with aging until 75 years old in Caucasian and also increased with aging in Hispanic, but the AC-PC distance peaked at 45 years old in Hispanic. The order of AC-PC distance were 25.2+/-2 mm in Caucasian, 24.6+/-2.24 mm in Asian, 24.53 mm in Black, 23.6+/-1.98 mm in Hispanic. The average AC-PC distance in all groups was 24.22 mm in female who was mean age of 56.35, 25.28 mm in male who was mean age of 60.19 and 24.5+/-2 mm in control group that was excluded because of the difference of thickness of slice. According to multiple regression analysis, the AC-PC distance was significantly correlated with age, race, and gender. CONCLUSION: The AC-PC distance is significantly correlated with age, gender, and race. The atlas of functional stereotaxis would be depended on the variation of indivisual brain that can influenced by aging, gender, and race.

Bilateral Pallidotomy for Dystonia with Glutaric Aciduria Type 1

Glutaric aciduria type 1 is an inborn error of lysine, hydroxylysine, and tryptophan metabolism caused by deficiency of glutaryl-coenzyme A dehydrogenase. The disease often appears in infancy with encephalopathy episode that results in acute basal ganglia and white matter degeneration. The majority of patients develop a dystonic-dyskinetic syndrome. This reports 6year-old boy who had been done previous gastrostomy due to swallowing difficulty underwent bilateral pallidotomy with intraoperative electromyography(EMG) monitoring for disabling dystonia. Intraoperative EMG was used to assess stimulation thresholds required for capsular responses and muscle tone. Surface EMG electrodes were placed on the face and cricopharyngeal muscles. Exact target were directly modified according to MRI-visualized anatomy. EMG response was consistently seen prior to visual observation of muscle activity. The surgery improved dystonic symptoms without swallowing difficulty.

Clinical Outcomes of Simultaneous Bilateral Pallidotomy in Advanced Parkinson's Disease

OBJECTIVE: Pallidotomy is known to improve the symptoms of idiopathic Parkinson, s disease (PD), motor fluctuations and dyskinesia related to levodopa therapy. Previous studies reported significantly higher complication rates associated with bilateral pallidotomy than unilateral pallidotomy. The authors assess the safety and clinical outcomes of bilateral pallidotomy for advanced PD. METHODS: Simultaneous bilateral pallidotomy was performed in eight patients with advanced PD between January 1, 2001 and December 31, 2001. All patients underwent lesion making in posteroventral site of internal globus pallidus. The target was localized using macroelectrode stimulation and MRI guided stereotactic technique. The lesions were made by radiofrequency currents. RESULTS: Among eight cases, seven had severe disabling dyskinesias. Compared with baseline scores, the values of dyskinesia after surgery was significantly decreased (P<0.05) for up to 1 year. The mean score changed from 4.4+/-2.1 to 0.3+/-0.5. According to Unified Parkinson's Disease Rating Scale (UPDRS), the mean motor score in off period, which was 38.3+/-13.8 was significantly decreased for 6 months (P<0.05). The ADL (on/off) scores and motor "on" scores of UPDRS were unchanged or deteriorated to 12 months after surgery. There was no apparent adverse effect after surgery in all patients. Only transient mild dysphagia happened in one patient. CONCLUSION: Simultaneous bilateral pallidotomy in advanced PD appears to be effective and safe, particularly in reducing the dyskinesia; in our experience, the side effects are not as high as reported by other groups.

Application of Leksell Stereotactic Frame Using External Landmarks in Stereotactic Surgery

OBJECTIVE: This study is designed to evaluate the usefulness of the cutaneous external landmarks in the application of a Leksell stereotactic frame for functional stereotactic surgery. METHODS: Surgical procedures included thalamotomy in 12 and pallidotomy in 4. Thalamotomy and later pallidotomy were performed in one. In application of the Leksell stereotactic frame, the authors used the cutaneous external landmarks including: (1) the pupil and the external acoustic meatus in group I, (2) the pupil and the crus of the helix in group II, (3) the lateral canthus, the crus of the helix, and inferior crura of antihelix in group III. This procedure was done for obtaining magnetic resonance(MR) images showing anterior and posterior commissure in the same axial scan. The targets were Vim for thalamotomy and GPi for pallidotomy. RESULTS: All MR images in group I, II, and III showed anterior and posterior commissures in the same axial scans except for two patients (17.7%) in group I. The MRI coordinate was accurate to localize the target within 1mm of the difference from electrophysiologic target in 76% of the patients. After surgery, a significant improvement was noticed in tremor scale and global outcome scale (p0.05). Transient postoperative complications including motor aphasia and hemihypesthesia were noticed in one each, which returned normal in 3 months. CONCLUSION: The cutaneous external landmarks are of value in applying Leksell stereotactic frame for obtaining magnetic resonance images, essentially showing anterior and posterior commissure. This method is also useful in saving total operation time, making patients comfortable, as well as cost effectiveness.

Magnetic Resonance Image Guided Unilateral Pallidotomy for Parkinson's Disease; Surgical Technique and Clinical Efficacy

OBJECTIVE: The authors present a clinical analysis to determine the clinical efficacy of unilateral palliotomy for Parkinson's disease without microelectrode recording procedure and to review the surgical technique, based on the anatomical landmark using magnetic resonance(MR) image. METHODS: Twenty-seven patients were retrospectively studied with extensive neurological examinations including Unified Parkinson's Disease Rating Scale(UPDRS) in 'levodopa-on and -off' tate before and at 6 and 12 months following MRI-guided pallidotomy. Lesion location was characterized using thin sliced MR image and measured on axial slice of TOF image. Lesion was performed with radiofrequency lesion generator. RESULTS: Final surgical target was 2.7+/-0.3mm in front of the intercommissural point, 4.0+/-1mm below the imtercommissural line, and 20.2+/-1.4mm lateral to the midline of the third ventricle. Significant improvements were observed in the total UPDRS scores and motor scores. And there was no significant postoperative complication and sequale except transient paresis(2 cases) and dysarthria(1 case). CONCLUSION: Steretotactic MR image guided pallidotomy with macrostimulation for the patients with Parkinson's disease is safe with minimal morbidity and significantly reduces the disabilities of Parkinson's disease.

Microelectrode guided stereotactic surgery for Parkinson's disease / 中国微创外科杂志

ObjectiveTo evaluate the clinical effects of microelectrode guided stereotactic pallidotomy and/or thalamotomy and deep brain stimulation (DBS) in the management of Parkinson's disease.MethodsA total of 510 patients with P arkinson's disease underwent stereotactic operations and 30 patients underwent D BS from April 1999 to March 2003. The 510 cases consisted of 385 cases of poster oventral pallidotomy (PVP), 91 cases of ventral intermedius (Vim) thalamotomy, 1 2 cases of PVP together with Vim thalamotomy on the same side, 8 cases of PVP on both sides at the same time, 10 cases of PVP on both sides at different times, and 4 cases of PVP on one side while Vim thalamotomy on the other at different t imes. Of the 30 cases of DBS (unilateral, 18 cases; bilateral, 12 cases), target s were located in subthalamic nucleus(STN) in 29 cases and ventralis intermedius nucl eus in 1 case.ResultsUnified Parkinson's disease rating scal e (UPDRS) scores were recorded postoperatively. Of the 510 cases, during the “off” and “on” stat es, symptoms improved by 47 3% and 38 7%, respectively. “On-off” phenomena a nd m otor symptoms disappeared. Follow-up information with a mean of 11 6 months in 2 20 cases revealed excellent outcomes in 130 cases (59 1%), improved in 75 (34 1%), a nd no change in 15 (6 8%). Of the 30 cases of DBS, during the “off” and “on ” state s, symptoms improved by 45 2% and 25 7%, respectively. All the 30 patients wer e followed for a mean of 10.3 months. No parameter adjustment was needed after 1 p ostoperative month in 18 cases, while the adjustment after operation was require d in the remaining 12 cases.ConclusionsPallidotomy is much m ore effective th an thalamotoy in Parkinson's patients with tremor. DBS can effectively control t he patient's motor symptoms.

Efficacy of Unilateral Pallidotomy for Parkinson's Diesease

OBJECTIVES: For Parkinsonian patients who had not reacted favorably on drug therapy are good candidate for ventroposterolateral pallidotomy, although not curative. We studied these patients after unilateral pallidotomy, to confirm the effectiveness and safety of this procedure. METHODS: We evaluated the 17 patients with idiopathic Parkinson's diesease who had undergone unilateral posteroventral pallidotomy. All patients responded to levodopa initially. Mean age was 55 years(38-75years), and mean duration of disease was 9.8 years(3-20years). Pre-and postoperative evaluation at 3 month intervals included Unified Parkinson's Disease Rating scale(UPDRS) scoring, Hoehn and Yahr(H and Y) staging, and neuropsychological examinations. RESULTS: Pallidotomy significantly improved parkinsonian symptom(tremor, rigidity, bradykinesia, dyskinesia, sensory symptom). Nine of 10 patients who showed dyskinesia preoperatively significant improvement. The mean dose of levodopa in 9 patients was lowered. The mean H and Y score and UPDRS score were improved in on and/or off time in 15 patients. Among patients who were not improved, one patient worsened, and the others showed no change. The mean overall UPDRS off score changed from 76 preoperatively to 44(33%) at 6 months and from 70 to 52(25%) at 1 year. Transient surgical morbidity was showen in four patients and included dysarthria, hypotonia and confusion. CONCLUSION: We conclude that pallidotomy is safe and effective in patients who have levodopa-reponsive parkinsonism with severe symptom fluctuation. Unilateral pallidotomy also considered helpful to ipsilateral symptom. Unilateral pallidotomy can improve all of parkinsonian's symptom and allow to reduce the levodopa medication. Most of patients show satisfactory results.

Pallidotomy Guided by MRI and Microrecording for Parkinson's Disease

OBJECTIVE: The exact position of the lesion during the pallidotomy is critical to obtain the clinical improvement of parkinson's disease without damage to surrounding structure. Ventriculogrphy, CT(computed tomograpy) or MRI(magnetic resonance imaging) have been used to determine the initial coordinates of stereotactic target for pallidotomy. The goal of this study was to determine whether microelectrode recording significantly improves the neurophysiologic localization of the target obtained from MRI. METHODS: Twenty patients were studied. They underwent a unilateral pallidotomy. Leksell frame was applied and T1 axial images parallel to the AC-PC(anterior commissure-posterior commissure) plane using a 1.5 Tesla MRI with 3mm slice thickness were obtained. Anteroposterior coordinate of target was chosen at 2mm in front of the midcommissural point and lateral coordinate between 19 and 22mm from the midline. The vertical coordinate was calculated on coronal slice using a fast spin echo inversion recovery sequence(FSEIR) related to the position of the choroidal fissure and ranged over 4-5mm below the AC-PC plane. Confirmation of the anatomical target was done on axial slices using the same FSEIR sequence. Microrecording was done at the pallidum contralateral to the symptomatic side using an electrode with a tip diameter of 1nm diameter tip and 1.1-1.4 mOhm impedance at 1000Hz. Electrophysiologic localization of the target was also confirmed intraoperatively by macrostimulation. RESULTS: Microrecording techniques were reliable to define the transition from the base of the pallidum which was characterized by the disappearance of spike activity and by the change of the audible background activity. Signals from high amplitude neurons firing at 200-400Hz were recorded in the pallidal base. X, Y and Z coordinates of target obtained from the MRI were within 1mm from the X, Y, Z coordinates obtained with microrecording in 16 patients (80%), 15 patients(75%), 10 patients(50%) respectively. The difference of Y coordinate between on MRI and on microrecording was 4mm in only one patient. CONCLUSION: The MRI was accurate to localize the target within 1mm of the error from microrecording target in 70% of the patients. 4mm discrepancy was observed only once. We conclude that MRI alone can be used to determine the target for pallidotomy in most patients. However, microrecording technique can still be extremely valuable in patents with aberrant anatomy or unusual MRI coordinates. We also consider physiologic confirmation of the target using macrostimulation to be mandatory in all cases.

Simultaneous Ipsilateral Posteroventral Pallidotomy and Ventrolateral Thalamotomy for Advanced Parkinson's Disease

Stereotactic thalamotomy has traditionally provided good relief of tremor for patients with intractable tremor dominant in Parkinson's disease. However bradykinesia, dyskinesia and rigidity are less reliably treated with this technique. Although posteroventral pallidotomy(PVP) can alleviate dyskinesias appendicular bradykinesia and rigidity, tremor may not be completely ameliorated. Between January 1993 and May 1997, the authors performed posteroventral pallidotomy(PVP) on 69 patients with Parkinson's disease who had bradikinesia, rigidity, drug induced dyskinesia and tremor. Of these patients who had only PVPs 17(25%) patients had severe tremor, 20(29%) patients moderate tremor and 32(46 %) patients mild or no tremor after the surgery. We have combined ventrolateral thalamotomy(VLT ) and PVP in 37 patients with moderate to severe tremor. Of the 37 patients, who had both PVP and VLT, 27(73%) patients showed good improvement, and fair improve-ment in 10(27%). Except for 6 cases with transient dysarthria we did not encounter any other operative complications from the ipsilateral combined PVP and VLT. The combination of the two procedures appear to provide excellent relief for the majority of symptoms in patients suffering from advanced Parkinsons disease with rigidity bradykinesia, dyskinesia and tremor.

Treatment of Parkinson's Disease by Streotactic Thalamotomy and Pallidotomy

The authors report the surgical results of thalamotomy and pallidotomy, performed at our hospital between 1983 and 1993 for the treatment of Parkinson's disease. The series included a retrospective analysis of 156 patients with this condition by stereotactic ventrolateral(VL) thalamotomy(126 patients, 138 thalamotomies) and posterolateral pallidotomy(30 patients, 30 pallidotomies). Each patient was followed up postoperatively, for one year. Among those who underwent the stereotactic VL thalamotomy, 136/138 procedures(99%) led to improvement of tremor, and 83/138(60%) resulted in reduced rigidity. Stereotactic posterolateral pallidotomy, led to improvement of bradykinesia after 27/30 procedures(90%), of rigidity after 22/30(73%) and of tremor after 13/30(43%). Drug-induced dyskinesia showed a 42% improvement in the thalamotomy series and a 93% improvement in the pallidotomy series; the difference between the two series was significant(p0.557). In addition, for groups with greater preoperative disability(Hoehn & Yahr staging, groups III and IV), improvement was more likely after pallidotomy than after thalamotomy. In the pallidotomy series, dysphasia was the only serious complication and this was seen after 20% of procedures. In the thalamotomy series, however, complications included hypotonia(24%), transient confusion(19%), transient dysphasia(11%), permanent dysarthria(7%), subjective numbness(4%) and epileptic seizure(3%). The authors believe that posterolateral pallidotomy is much more effective than VL thalamotomy for the control of Parkinsonian bradykinesia and rigidity, but that thalamotomy is still a useful surgical option for the control of Parkinsonian tremor.

Analysis of the related factors on staged bilateral multi-targets pallidotomy and thalamotomy for treatment of Parkinson's disease / 临床神经病学杂志

Objective To explore the related factors for improving the effect of the staged bilateral multi-targets pallidotomy and thalamotomy on Parkinson's disease.Methods 387 patients were divided into different groups according to various factors,including the age of patient,operation method,interval of radiofrequency and the diameter of electrode. The relationship between the above mentioned factors and the effect or complication was analyzed.Results All the symptoms of PD were significantly improved after second operation in the near future. Staged bilateral pallidotomy was the most popular operation way in clinical practicing. The incidence of complication of staged bilateral thalamotomy was high (100%). The rate of complication in the patients over 55 years old (29.70%) was higher than that in the patients not more than 55 years old (12.66%)( P