Safety and long-term efficacy of ventro-oral thalamotomy for focal hand dystonia: A retrospective study of 171 patients.

OBJECTIVE: To report the safety and long-term efficacy of ventro-oral thalamotomy for 171 consecutive patients with task-specific focal hand dystonia. METHODS: Between October 2003 and February 2017, 171 consecutive patients with task-specific focal hand dystonia underwent unilateral ventro-oral thalamotomy. Etiologies included writer's cramps (n = 92), musician's dystonias (n = 58), and other occupational task-related dystonias (n = 21). The task-specific focal hand dystonia scale was used to evaluate patients' neurologic conditions (range 1-5, high score indicated a better condition). The scores before surgery; at 1 week, 3 months, and 12 months postoperatively; and the last available follow-up period were determined. Postoperative complications and postoperative recurrence were also evaluated. RESULTS: The scores before surgery; at 1 week (1.72 ± 0.57, 4.33 ± 0.85 [p < 0.001]), 3 months (4.30 ± 1.06 [p < 0.001]), and 12 months (4.30 ± 1.13 [p < 0.001]); and the last available follow-up (4.39 ± 1.07 [p < 0.001]) postoperatively improved. The mean clinical follow-up period was 25.4 ± 32.1 months (range: 3-165). Permanent adverse events developed in 6 patients (3.5%). Eighteen patients developed recurrent dystonic symptoms postoperatively. Of these 18 patients, 9 underwent ventro-oral thalamotomy again, of which 7 achieved improvement. CONCLUSION: Ventro-oral thalamotomy is a feasible and reasonable treatment for patients with refractory task-specific focal hand dystonias. Prospective, randomized, and blinded studies are warranted to clarify more accurate assessment of the safety and efficacy of ventro-oral thalamotomy for task-specific focal hand dystonia. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that for patients with task-specific focal hand dystonia, ventro-oral thalamotomy improves dystonia.

Improved motor performance in patients with acute stroke using the optimal individual attentional strategy.

It is believed that motor performance improves when individuals direct attention to movement outcome (external focus, EF) rather than to body movement itself (internal focus, IF). However, our previous study found that an optimal individual attentional strategy depended on motor imagery ability. We explored whether the individual motor imagery ability in stroke patients also affected the optimal attentional strategy for motor control. Individual motor imagery ability was determined as either kinesthetic- or visual-dominant by a questionnaire in 28 patients and 28 healthy-controls. Participants then performed a visuomotor task that required tracing a trajectory under three attentional conditions: no instruction (NI), attention to hand movement (IF), or attention to cursor movement (EF). Movement error in the stroke group strongly depended on individual modality dominance of motor imagery. Patients with kinesthetic dominance showed higher motor accuracy under the IF condition but with concomitantly lower velocity. Alternatively, patients with visual dominance showed improvements in both speed and accuracy under the EF condition. These results suggest that the optimal attentional strategy for improving motor accuracy in stroke rehabilitation differs according to the individual dominance of motor imagery. Our findings may contribute to the development of tailor-made pre-assessment and rehabilitation programs optimized for individual cognitive abilities.

Stereotactic Thalamotomy for Hairdresser's Dystonia: A Case Series.

BACKGROUND: Hairdresser's dystonia is a rarely reported form of focal hand dystonia, and the clinical course and treatment remains poorly understood. OBJECTIVES: The aim of this report was to clarify the impact of thalamotomy on hairdresser's dystonia. METHODS: Four consecutive patients with hairdresser's task-specific dystonia evaluated at Tokyo Women's Medical University Hospital between 2008 and 2013 were treated with stereotactic thalamotomy, and were recruited for this case series. RESULTS: The mean age at the onset of symptoms was 37.25 ± 10.64 years, the median duration of symptoms was 4.25 ± 1.3 years, and the mean follow-up period was 17 ± 12.37 months. Two of the 4 patients returned to work with significant improvement following the stereotactic thalamotomy and the beneficial effects persisted for the duration of their clinical follow-up. The other 2 patients experienced transient improvements for up to 3 months. Surgical complications included only dysarthria in 2 patients, and did not interfere with their daily activities. No patients experienced a deterioration of dystonic symptoms after thalamotomy. CONCLUSION: Although the benefits of thalamotomy remain vulnerable to incorrect or insufficient coagulation, stereotactic thalamotomy may be a feasible and effective procedure for patients with hairdresser's dystonia.

Bilateral Stereotactic Thalamotomy for Bilateral Musician's Hand Dystonia.

BACKGROUND: Focal hand dystonia in musicians, also known as musician's dystonia, is a task-specific movement disorder characterized by unwanted involuntary muscle contractions occurring only when playing a musical instrument. CASE DESCRIPTION: Case 1 was a 50-year-old female professional pianist who underwent staged bilateral ventro-oral (Vo) thalamotomy, with an interval between the first and second surgery of 4 years. The first surgery (right Vo thalamotomy) led to significant improvements in dystonic symptoms without any complications. Pre- and postoperative Tubiana's musician's dystonia scale (TMDS) scores were 2 and 5, respectively. The second surgery (left Vo thalamotomy) also led to significant improvements in dystonic symptoms, with dysarthria and verbal recall disturbance resolving within 3 months. Pre- and postoperative TMDS scores were 2 and 5, respectively. The patient was subsequently able to return to live-stage performances. Case 2 was a 48-year-old male clarinet repair technician who underwent staged bilateral Vo thalamotomy, with an interval between the first and second surgery of 13 months. The first surgery (right Vo thalamotomy) led to dramatic improvements in symptoms without any complications. Pre- and postoperative TMDS scores were 2 and 5, respectively. The second surgery (left Vo thalamotomy) also led to significant improvements in symptoms with transient hypophonia. Pre- and postoperative TMDS scores were 2 and 5, respectively. The patient was subsequently able to return to work without difficulty. CONCLUSIONS: The findings in these 2 cases indicate the utility of bilateral stereotactic Vo thalamotomy in the treatment of medically intractable musician's dystonia affecting both hands.

Long-term improvement of musician's dystonia after stereotactic ventro-oral thalamotomy.

OBJECTIVE: Musician's dystonia is a task-specific movement disorder that causes twisting or repetitive abnormal finger postures and movements, which tend to occur only while playing musical instruments. Such a movement disorder will probably lead to termination of the careers of affected professional musicians. Most of the currently available treatments have yet to provide consistent and satisfactory results. We present the long-term follow-up results of ventro-oral thalamotomy for 15 patients with musician's dystonia. METHODS: Between October 2003 and September 2010, 15 patients with medically intractable task-specific focal hand dystonia that occurred only while playing musical instruments underwent ventro-oral thalamotomy. We used Tubiana's musician's dystonia scale to evaluate the patients' pre- and postoperative neurological conditions. RESULTS: All patients except 1 (93%) experienced dramatic improvement of dystonic symptoms immediately after ventro-oral thalamotomy. The mean follow-up period was 30.8 months (range=4-108 months). None of the patients experienced recurrence or deterioration of symptoms during the follow-up periods. INTERPRETATION: Ventro-oral thalamotomy remarkably improved musician's dystonia, and the effect persisted for a long duration.

Green light emitting diodes accelerate wound healing: characterization of the effect and its molecular basis in vitro and in vivo.

Because light-emitting diodes (LEDs) are low-coherent, quasimonochromatic, and nonthermal, they are an alternative for low level laser therapy, and have photobiostimulative effects on tissue repair. However, the molecular mechanism(s) are unclear, and potential effects of blue and/or green LEDs on wound healing are still unknown. Here, we investigated the effects of red (638 nm), blue (456 nm), and green (518 nm) LEDs on wound healing. In an in vivo study, wound sizes in the skin of ob/ob mice were significantly decreased on day 7 following exposure to green LEDs, and complete reepithelialization was accelerated by red and green LEDs compared with the control mice. To better understand the molecular mechanism(s) involved, we investigated the effects of LEDs on human fibroblasts in vitro by measuring mRNA and protein levels of cytokines secreted by fibroblasts during the process of wound healing and on the migration of HaCat keratinocytes. The results suggest that some cytokines are significantly increased by exposure to LEDs, especially leptin, IL-8, and VEGF, but only by green LEDs. The migration of HaCat keratinocytes was significantly promoted by red or green LEDs. In conclusion, we demonstrate that green LEDs promote wound healing by inducing migratory and proliferative mediators, which suggests that not only red LEDs but also green LEDs can be a new powerful therapeutic strategy for wound healing.

MRI-guided subthalamic nucleus deep brain stimulation without microelectrode recording: can we dispense with surgery under local anaesthesia?

AIMS: Subthalamic nucleus (STN) deep brain stimulation (DBS) for Parkinson's disease (PD) is traditionally performed under local anaesthetic (LA). STN visualization and routine validation of electrode location on stereotactic MRI may allow surgery under general anaesthesia (GA). This study compares the clinical outcome of MRI-guided STN DBS performed under LA or GA in a consecutive patient series. METHODS: Unified Parkinson's Disease Rating Scale motor scores (UPDRS-III) in 14 GA patients (mean age 56.1 years, disease duration 13.8 years) were compared with those of 68 LA patients (mean age 57.5 years, disease duration 15.2 years). RESULTS: Baseline UPDRS-III were worse in the GA group, both on medication (GA: 20.9 ± 10.8; LA: 13.2 ± 7.8, p < 0.01) and off medication (GA: 57.9 ± 16.6; LA: 48.2 ± 15.7, p < 0.05). On stimulation off medication motor scores significantly improved in both groups (GA: 27.3 ± 11.8, mean 12-month follow-up; LA: 23.7 ± 11.8, mean 14-month follow-up). The percentage improvement was similar in both groups (GA: 52.8%; LA: 50.8%, p = 0.96). Transient surgical complications occurred in 1 GA and 7 LA patients. CONCLUSIONS: MRI-guided STN DBS under GA with routine stereotactic verification of lead location did not have a negative effect on efficacy or safety. Surgery under GA is a viable option in patients who would find it hard to tolerate awake surgery due to disease severity, comorbidities or anxiety.

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

OBJECT: Levodopa-induced dyskinesia (LID) in patients with Parkinson disease (PD) mimics acute dystonic reactions induced by antipsychotic agents, possibly mediated by sigma-receptors; however, there are few reports in which the relationship between sigma-receptors and LID in advanced PD is investigated. The binding potential of cerebellar sigma-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 sigma-receptors was determined before and after the surgery by 11C-nemonapride positron emission tomoraphy, a specific radioligand for sigma-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 sigma-receptors may potentially involve the genesis of LID in advanced PD.

The impact of stereotactic pallidal surgery on the dopamine D2 receptor in Parkinson disease: a positron emission tomography study.

OBJECT: The aim of this study was to estimate the impact of stereotactic pallidal surgery on the binding potential of dopamine D2 receptors in patients with advanced Parkinson disease (PD). METHODS: Six patients with advanced PD (three men and three women; mean age 56.7 +/- 9.8 years, Hoehn and Yahr stage 3.3 +/- 1.1/3.9 +/- 1.2 [on/off scores], mean +/- standard deviation) underwent stereotactic pallidal surgery. One underwent right posteroventral pallidotomy (PVP), one received left PVP, three were treated with deep brain stimulation (DBS) of the left globus pallidus internus (GPi), and one with bilateral DBS of the GPi. The binding potential of the dopamine D2 receptors of these patients was determined before and after surgery by using positron emission tomography scanning with 11C-nemonapride and it was compared with the value in eight healthy volunteers. The authors also examined whether changes in the D2 receptor binding potential were correlated with the clinical outcome. The clinical symptoms, especially those in the off state, were significantly improved after surgery. Preoperatively, the D2 receptor binding potential in the putamen was elevated by 27% (p < 0.01) and that in the thalamus was 29% lower than that in controls (p < 0.01). The D2 receptor binding potential in the putamen and thalamus returned to control levels after surgery. The preoperative level of the D2 receptor binding potential in the anterior cingulate cortex was comparable to that of controls, but it declined significantly after surgery, whereas the D2 receptor binding potential in other regions of both hemispheres showed no significant changes after surgery. Although the D2 receptor binding potential did not correlate with the Hoehn and Yahr stage, the Schwab and England score, or the Unified PD Rating Scale (UPDRS) score, a positive correlation was seen between the percent improvement rate of the total UPDRS score in the off state and the percentage change of the D2 receptor binding potential in the putamen (r = 0.773, p = 0.0417 according to the Pearson linear correlation). CONCLUSIONS: The altered dopamine D2 receptor binding potential in the putamen might play a crucial role in clinical improvement after PVP or DBS of the GPi in advanced PD.