Therapeutic efficacy of unilateral subthalamotomy in Parkinson's disease: results in 89 patients followed for up to 36 months.

BACKGROUND: Stereotactic thermocoagulative lesions of the subthalamic nucleus (STN) have been shown to induce significant motor improvement in patients with Parkinson's disease (PD). PATIENTS AND METHODS: 89 patients with PD were treated with unilateral subthalamotomy. 68 patients were available for evaluations after 12 months, 36 at 24 months and 25 at 36 months. RESULTS: The Unified Parkinson's Disease Rating Scale (UPDRS) motor scores improved significantly contralaterally to the lesion in the "off" and "on" states throughout the follow-up, except for the "on" state at the last evaluation. Axial features and signs ipsilateral to the lesion progressed steadily throughout the study. Levodopa daily doses were significantly reduced by 45%, 36% and 28% at 12, 24 and 36 months post-surgery. 14 patients (15%) developed postoperative hemichorea-ballism which required pallidotomy in eight. These 14 patients had significantly higher dyskinesia scores (levodopa induced) preoperatively than the entire cohort. CONCLUSION: Unilateral subthalamotomy was associated with significant and sustained motor benefit contralateral to the lesion. Further work is needed to ascertain what factors led to severe, persistent chorea-ballism in a subset of patients. Subthalamotomy may be considered an option in circumstances when deep brain stimulation is not viable.

Bilateral subthalamotomy in Parkinson's disease: initial and long-term response

We conducted an open label pilot study of the effect of bilateral subthalamotomy in 18 patients with advanced Parkinson's disease. In seven patients, the first subthalamotomy pre-dated the second by 12-24 months (staged surgery). Subsequently, a second group of 11 patients received bilateral subthalamotomy on the same day (simultaneous surgery). Patients were assessed according to the CAPIT (Core Assessment Program for Intracerebral Transplantation) protocol, a battery of timed motor tests and neuropsychological tests. Evaluations were performed in the off and on drug states before surgery and at 1 and 6 months and every year thereafter for a minimum of 3 years after bilateral subthalamotomy. Compared with baseline, bilateral subthalamotomy induced a significant (P < 0.001) reduction in the 'off' (49.5 percent) and on (35.5 percent) Unified Parkinson's Disease Rating Scale (UPDRS) motor scores at the last assessment. A blind rating of videotape motor exams in the off and on medication states preoperatively and at 2 years postoperatively also revealed a significant improvement...(AU)

Bilateral subthalamotomy in Parkinson's disease: initial and long-term response.

We conducted an open label pilot study of the effect of bilateral subthalamotomy in 18 patients with advanced Parkinson's disease. In seven patients, the first subthalamotomy pre-dated the second by 12-24 months ('staged surgery'). Subsequently, a second group of 11 patients received bilateral subthalamotomy on the same day ('simultaneous surgery'). Patients were assessed according to the CAPIT (Core Assessment Program for Intracerebral Transplantation) protocol, a battery of timed motor tests and neuropsychological tests. Evaluations were performed in the 'off' and 'on' drug states before surgery and at 1 and 6 months and every year thereafter for a minimum of 3 years after bilateral subthalamotomy. Compared with baseline, bilateral subthalamotomy induced a significant (P < 0.001) reduction in the 'off' (49.5%) and 'on' (35.5%) Unified Parkinson's Disease Rating Scale (UPDRS) motor scores at the last assessment. A blind rating of videotape motor exams in the 'off' and 'on' medication states preoperatively and at 2 years postoperatively also revealed a significant improvement. All of the cardinal features of Parkinson's disease as well as activities of daily living (ADL) scores significantly improved (P < 0.01). Levodopa-induced dyskinesias were reduced by 50% (P < 0.01), and the mean daily levodopa dose was reduced by 47% at the time of the last evaluation compared with baseline (P < 0.0001). Dyskinesias occurred intraoperatively or in the immediate postoperative hours in 13 patients, but were generally mild and short lasting. Three patients developed severe generalized chorea that gradually resolved within the next 3-6 months. Three patients experienced severe and persistent postoperative dysarthria. In two, this coincided with the patients exhibiting large bilateral lesions also suffering from severe dyskinesias. No patient exhibited permanent cognitive impairment. The motor benefit has persisted for a follow-up of 3-6 years. This study indicates that bilateral subthalamotomy may induce a significant and long-lasting improvement of advanced Parkinson's disease, but the clinical outcome was variable. This variability may depend in large part on the precise location and volume of the lesions. Further refinement of the surgical procedure is mandatory.

Neurorrehabilitación en la esclerosis múltiple / Neurorehabilitation in multiple sclerosis

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[An automatic system for anatomophysiological correlation in three planes simultaneously during functional neurosurgery]. / Sistema automático para la correlación anatomofisiológica en tres planos simultáneos durante la neurocirugía funcional.

INTRODUCTION: The Neurosurgical Deep Recording System (NDRS) using a personal computer takes the place of complex electronic equipment for recording and processing deep cerebral electrical activity, as a guide in stereotaxic functional neurosurgery. It also permits increased possibilities of presenting information in direct graphic form with automatic management and sufficient flexibility to implement different analyses. OBJECTIVE: This paper describes the possibilities of automatic simultaneous graphic representation in three almost orthogonal planes, available with the new 5.1 version of NDRS so as to facilitate the analysis of anatomophysiological correlation in the localization of deep structures of the brain during minimal access surgery. MATERIAL AND METHODS: This new version can automatically show the spatial behaviour of signals registered throughout the path of the electrode inside the brain, superimposed simultaneously on sagittal, coronal and axial sections of an anatomical atlas of the brain, after adjusting the scale automatically according to the dimensions of the brain of each individual patient. This may also be shown in a tridimensional representation of the different planes themselves intercepting. RESULTS: The NDRS system has been successfully used in Spain and Cuba in over 300 functional neurosurgery operations. The new version further facilitates analysis of spatial anatomophysiological correlation for the localization of brain structures. CONCLUSION: This system has contributed to increase the precision and safety in selecting surgical targets in the control of Parkinson s disease and other disorders of movement.

Sistema automático para la correlación anatomofisiológica en tres planos simultáneos durante la neurocirugía funcional / An automatic system for anatomophysiological correlation in three planes simultaneously during functional neurosurgery

Introducción. El sistema de programas NDRS (Neurosurgical Deep Recording System) sustituye con un ordenador personal el complejo equipamiento electrónico para el registro y procesamiento de la actividad eléctrica cerebral profunda, como guía de la neurocirugía funcional estereotáxica; asimismo, permite mayores posibilidades de representación de la información de forma gráfica directa, su manejo automático y la flexibilidad suficiente para implementar diferentes análisis. Objetivo. Este trabajo describe las posibilidades automáticas de representación gráfica simultánea en tres planos casi ortogonales, ofrecidas por la nueva versión 5.1 del NDRS, para facilitar los análisis de correlación anatomofisiológica en la localización de estructuras cerebrales profundas durante esta cirugía de mínimo acceso. Material y métodos. Esta nueva versión puede mostrar automáticamente el comportamiento espacial de la amplitud de las señales registradas a lo largo del trayecto del electrodo dentro del cerebro, superpuesta simultáneamente sobre los correspondientes cortes sagital, coronal y axial de un atlas anatómico cerebral, tras su escalamiento automático de acuerdo con las dimensiones del cerebro de cada paciente. Ello también puede mostrarse en una representación tridimensional de los diferentes planos interceptados entre sí. Resultados. El sistema NDRS se ha utilizado con éxito en España y Cuba en más de 300 intervenciones neuroquirúrgicas funcionales. Esta nueva versión facilita aún más los análisis de correlación espacial anatomofisiológica para localizar las estructuras cerebrales. Conclusión. El sistema ha contribuido a incrementar la exactitud y seguridad en la selección de los blancos quirúrgicos para el control de diferentes síntomas de la enfermedad de Parkinson y otros trastornos del movimiento (AU)

Dorsal subthalamotomy for Parkinson's disease.

We report our experience of unilateral subthalamotomy in patients with Parkinson's disease (PD). Eleven patients were included in a pilot, open-labeled study to assess the effect of unilateral lesion of the subthalamic nucleus (STN) with a minimum of 12 months of follow-up. The guidelines of CAPIT (Core Assessment Program for Intracerebral Transplantation) were followed for recruitment into the study and follow-up assessment. Levodopa equivalents daily intake (mean 967 mg) were unchanged during the first 12 months in all but one patient who stopped medication. The sensorimotor region of the STN was defined by semimicrorecording and stimulation and a thermolytic lesion was placed accordingly. There was a significant reduction in both UPDRS parts II and III in the "off" state at 1-, 6-, and 12-month follow-up. This effect was maintained in four patients up to 24 months. The dyskinesia score did not change postoperatively. Lesion-induced dyskinesias were not a management problem except in one patient who developed a large infarction several days postsurgery. This initial study indicates that a lesion of the STN is not generally associated with hemiballismus in PD. Subthalamotomy may induce considerable motor benefit and could become another surgical option under specific circumstances.

Sistema automático para la correlación anatomofisiológica en tres planos simultáneos durante la neurocirugía funcional / An automatic system for anatomophysiological correlation in three planes simultaneously during functional neurosurgery

Introducción. El sistema de programas NDRS (Neurosurgical Deep Recording System) sustituye con un ordenador personal el complejo equipamiento electrónico para el registro y procesamiento de la actividad eléctrica cerebral profunda, como guía de la neurocirugía funcional estereotáxica; asimismo, permite mayores posibilidades de representación de la información de forma gráfica directa, su manjeo automático y la flexibilidad suficiente para implementar diferentes análisis. Objetivo. Este trabajo describe las posiblidades automáticas de representación gráfica simultánea en trs planos casi ortogonales, ofrecidas por la nueva versión 5.1 del NDRS, para facilitar los análisis de correlación antomofisiológica en la localización de estructuras cerebrales profundas durante esta cirugía de mínimo acceso. Material y métodos. Esta nueva versión puede mostrar automáticamente el comportamiento espacial de la amplitud de las señales registradas a lo largo del trayecto del electrodo dentro del cerebro, superpuesta simultáneamente sobre los correspondientes cortes sagital, coronal y axial de un atlas anatómico cerebral, tras su escalamiento automático de acuerdo con las dimensiones del cerebro de cada paciente. Ello también puede mostrarse en una representación tridimensional de los diferentes planos interceptados entre sí. Resultados. El sistema NDRS se ha utilizado con éxito en España y Cuba en más de 300 intervenciones neuroquirúrgicas funcionales. Esta nueva versión facilita aún más los análisis de correlación espacial anatomofisiológica para localizar las estructuras cerebrales. Conclusión. El sistema ha contribuido a incrementar la exactitud y la seguridad en la selección de los blancos quirúrgicos para el control de diferentes síntomas de la enfermedad de Parkinson y otros trastornos del movimiento(AU)

Personal-computer-based system for three-dimensional anatomic-physiological correlations during stereotactic and functional neurosurgery.

This paper describes the automatic three-dimensional (3D) graphic possibilities that are supplied by the Neurosurgical Deep Recording System (NDRS) to facilitate anatomic-physiological targeting during stereotactic and functional neurosurgery using depth recording. This software has been developed to substitute the complex electronic equipment ordinarily used for deep brain electrical recording, display and processing by a personal computer. It may also help to improve on-line graphic analysis, automatic management of the recorded information and flexibility to implement different forms of signal analysis. It can automatically show a 2D or 3D representation of the electrode track, with the electrophysiological findings superimposed as well as the corresponding sagittal, coronal and axial views of a brain atlas using automatic scaling. The NDRS has already successfully been applied during more than 300 neurosurgeries in Spain and Cuba, enabling improved targeting accuracy and safety.