[Treatment of a case of essential tremor with subthalamic stimulation]. / Tratamiento de un caso de temblor esencial con estimulacion subtalamica.

INTRODUCTION: Chronic stimulation of the subthalamic nucleus (STN) has proved itself to be useful in treating Parkinson's disease and especially in dealing with the tremor suffered by patients. Yet there is very little experience to support the use of STN as an alternative therapy in non Parkinsonian tremors. CASE REPORT: Our study considered the case of a patient who had been diagnosed as suffering from drug resistant essential tremor which was predominant in the distal region of the upper right limb and was treated by unilateral stimulation of the STN. RESULTS: The patient's clinical state improved significantly from the first weeks onwards. After a year and a half of therapy, the patient had achieved a stable improvement of 82.4% on the tremor scale and medication was reduced by 41.7%. CONCLUSIONS: SNT stimulation appears as a suitable target for the treatment of drug resistant essential tremor.

[Treatment of a case of generalised dystonia using subthalamic stimulation]. / Tratamiento de un caso de distonía generalizada mediante estimulación subtalámica.

INTRODUCTION: Generalised dystonia is an entity that does not usually respond well to medical treatment. Different surgical targets have therefore been used in the treatment of dystonia, including several thalamic nuclei or the internal globus pallidus. The subthalamic nucleus plays a fundamental role in the physiology of the basal ganglia. It could therefore be considered to be a good potential target for stimulation. CASE REPORT: A patient who was confined to a wheelchair and who had not responded to a number of different medical treatment protocols or to a bilateral thalamotomy was treated with bilateral deep brain stimulation in the subthalamic nucleus. Tetrapolar electrodes were placed in both subthalamic nuclei in two stages. The patient showed a significant improvement from the very beginning of the post-operative period. After six months' progression, the patient was able to walk unaided and the dystonic seizures diminished significantly. Unfortunately, the patient died from choking. We used a bipolar stimulation protocol at 50 Hz with 210 micros pulses, which do not reach the levels of maximum charge density that are considered to be harmful. CONCLUSION: The subthalamic nucleus can be a good surgical target for deep brain stimulation in cases of generalised dystonia; it responds well to stimulation at intermediate frequencies with safe charge densities.

Tratamiento de un caso de distonía generalizada mediante estimulación subtalámica / Treatment of a case of generalised dystonia using subthalamic stimulation

Introducción. La distonía generalizada es una entidad que no suele responder bien al tratamiento médico. Por ello, se han empleado diferentes blancos quirúrgicos para su tratamiento, entre ellos diversos núcleos talámicos o el globo pálido interno. El núcleo subtalámico desempeña un papel fundamental en la fisiología de los ganglios basales. Por ello, podría considerarse como un buen blanco potencial para la estimulación. Caso clínico. Se trató con estimulación cerebral profunda bilateral en el núcleo subtalámico a un paciente postrado en silla de ruedas, que no había respondido a múltiples protocolos de tratamiento médico ni a una talamotomía bilateral. Se colocaron estimuladores en ambos núcleos subtalámicos, en dos tiempos. El paciente presentó una mejoría significativa, ya desde el período posoperatorio inmediato. Tras seis meses de evolución, el paciente era independiente para la marcha, y disminuyeron significativamente las crisis distónicas. Desgraciadamente, el paciente falleció a causa de un atragantamiento. Se empleó un protocolo de estimulación bipolar a 50 Hz, con pulsos de 210 micorseg, que no alcanzan los niveles de densidad máxima de carga que se consideran lesivos. Discusión. El núcleo subtalámico puede ser un buen blanco quirúrgico para la estimulación cerebral profunda en caso de distonía generalizada; responde bien a la estimulación a frecuencias intermedias con densidades de carga seguras (AU)

Introduction. Generalised dystonia is an entity that does not usually respond well to medical treatment. Different surgical targets have therefore been used in the treatment of dystonia, including several thalamic nuclei or the internal globus pallidus. The subthalamic nucleus plays a fundamental role in the physiology of the basal ganglia. It could therefore be considered to be a good potential target for stimulation. Case report. A patient who was confined to a wheelchair and who had not responded to a number of different medical treatment protocols or to a bilateral thalamotomy was treated with bilateral deep brain stimulation in the subthalamic nucleus. Tetrapolar electrodes were placed in both subthalamic nuclei in two stages. The patient showed a significant improvement from the very beginning of the post-operative period. After six months’ progression, the patient was able to walk unaided and the dystonic seizures diminished significantly. Unfortunately, the patient died from choking. We used a bipolar stimulation protocol at 50 Hz with 210 µs pulses, which do not reach the levels of maximum charge density that are considered to be harmful. Conclusion. The subthalamic nucleus can be a good surgical target for deep brain stimulation in cases of generalised dystonia; it responds well to stimulation at intermediate frequencies with safe charge densities (AU)

La moderna psicocirugía: un nuevo enfoque de la neurocirugía en la enfermedad psiquiátrica / Modern-day psychosurgery: a new approach to neurosurgery in psychiatric disease

Objetivo. Se pretende ofrecer una revisión actualizada de las diferentes posibilidades quirúrgicas en el manejo de ciertos trastornos psiquiátricos refractarios al tratamiento conservador (farmacoterapia, psicoterapia, terapia electroconvulsiva). Desarrollo. Para esta investigación, revisamos los trabajos publicados por los centros con mayor experiencia en esta cirugía, fundamentalmente en Norteamérica y Europa, desde sus inicios en los años 30, con la polémica leucotomía prefrontal, hasta la aparición de las modernas técnicas estereotáxicas. Se analizan las bases anatomofisiológicas, las principales indicaciones clínicas, las técnicas quirúrgicas utilizadas y los resultados, así como las perspectivas de futuro de este tratamiento neuroquirúrgico. Conclusiones. La evolución más destacable de la psicocirugía en los últimos años ha sido la combinación de una selección más rigurosa de los pacientes con la mayor especificidad del tratamiento efectuado sobre las estructuras cerebrales implicadas en la enfermedad psiquiátrica. Los procedimientos psicoquirúrgicos más empleados en la actualidad son la cingulotomía, la capsulotomía anterior, la tractotomía subcaudada, la leucotomía límbica y la hipotalamotomía posteromedial, con respuestas favorables en torno al 35-70 por ciento de los casos. Los diagnósticos psiquiátricos donde se pueden encontrar mejores resultados son el trastorno obsesivo-compulsivo, los estados de ansiedad crónica y la depresión mayor. Los avances actuales en las técnicas de neuroimagen, el mayor conocimiento neurofisiológico y las revolucionarias técnicas de neuromodulación, en especial la estimulación cerebral profunda, ofrecen expectativas todavía más prometedoras a la neurocirugía psiquiátrica (AU)

Aims. To obtain an up-to-date review of the different possible surgical approaches in the management of certain psychiatric disorders that are refractory to conservative treatment (pharmacotherapy, psychotherapy, electroconvulsive therapy). Method. In order to conduct this research we reviewed the work published by centres with the most experience in this type of surgery, mainly in North America and Europe, since its beginnings in the 1930s, with the controversy concerning prefrontal leucotomy, until the appearance of modern stereotactic techniques. We analyse the anatomophysiological bases, their main clinical indications, the surgical techniques used and their results, as well as perspectives for the future of this neurosurgical treatment. Conclusions. The most noteworthy progress in psychosurgery in recent years has been the combination of a more rigorous selection of patients and the higher degree of specificity with which treatment is performed on the brain structures involved in psychiatric disease. The most widely employed psychosurgical procedures at present are cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leucotomy and postero-medial hypothalamotomy, with favourable responses in about 35-70% of cases. The psychiatric diagnoses where the best results are to be found are obsessive-compulsive disorder, chronic anxiety states and major depression. Current progress in neuroimaging techniques, increased neurophysiological knowledge and the revolutionary neuromodulation techniques, especially deep brain stimulation, offer an even more promising future for psychiatric neurosurgery (AU)

[Modern day psychosurgery: a new approach to neurosurgery in psychiatric disease]. / La moderna psicocirugía: un nuevo enfoque de la neurocirugía en la enfermedad psiquiátrica.

AIMS: To obtain an up to date review of the different possible surgical approaches in the management of certain psychiatric disorders that are refractory to conservative treatment (pharmacotherapy, psychotherapy, electroconvulsive therapy). METHOD: In order to conduct this research we reviewed the work published by centres with the most experience in this type of surgery, mainly in North America and Europe, since its beginnings in the 1930s, with the controversy concerning prefrontal leucotomy, until the appearance of modern stereotactic techniques. We analyse the anatomophysiological bases, their main clinical indications, the surgical techniques used and their results, as well as perspectives for the future of this neurosurgical treatment. CONCLUSIONS: The most noteworthy progress in psychosurgery in recent years has been the combination of a more rigorous selection of patients and the higher degree of specificity with which treatment is performed on the brain structures involved in psychiatric disease. The most widely employed psychosurgical procedures at present are cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leucotomy and postero medial hypothalamotomy, with favourable responses in about 35 70% of cases. The psychiatric diagnoses where the best results are to be found are obsessive compulsive disorder, chronic anxiety states and major depression. Current progress in neuroimaging techniques, increased neurophysiological knowledge and the revolutionary neuromodulation techniques, especially deep brain stimulation, offer an even more promising future for psychiatric neurosurgery.