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AIM: The aim of this study was to assess the results of unilateral subthalamic nucleus (STN) stimulation for the treatment of Parkinson"s disease (PD) with marked asymmetry of parkinsonian motor symptoms and early motor complications. MATERIAL AND METHODS: The clinical series consisted of 32 consecutive PD patients, in whom unilateral STN stimulation was performed. All patients were assessed according to the Unified Parkinson"s Disease Rating Scale (UPDRS), and Hoehn and Yahr staging. The patients were assessed preoperatively, and at 12, and 24 months after unilateral STN stimulation. 22 patients were followed for 2 years. RESULTS: Medication off/stimulation on total UPDRS motor scores were improved by 29% when compared to the baseline medication off motor scores. The contralateral motor scores improved by 49%, whereas the axial motor scores by 18% in medication off/stimulation on condition. The duration and severity of levodopa induced dyskinesia were reduced respectively by 73% and by 77%. The daily levodopa dose was decreased by only 10%. CONCLUSION: Unilateral STN stimulation is a safe and effective procedure for selected patients with marked asymmetry Parkinson"s disease motor symptoms and early motor complications.
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Antiparkinsonianos/administración & dosificación , Estimulación Encefálica Profunda/métodos , Discinesia Inducida por Medicamentos/terapia , Levodopa/administración & dosificación , Enfermedad de Parkinson/fisiopatología , Enfermedad de Parkinson/terapia , Núcleo Subtalámico , Cuidados Posteriores , Anciano , Antiparkinsonianos/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
AIM: Tardive dystonia (TD) represents a side effect of prolonged intake of neuroleptic drugs. TD can be a disabling movement disorder persisting despite available medical treatment. Deep brain stimulation (DBS) has been reported successful in this condition although the number of treated patients with TD is still limited to small clinical studies or case reports. In this study, we present 2 additional cases of patients after bilateral globus pallidus internus (GPi) stimulation. METHODS: The formal assessment included the Burke-Fahn-Dystonia Rating Scale (BFMDRS). The preoperative and postoperative functional and motor parts of this scale were compared in each patient. The postoperative assessments were done every 6 months. RESULTS: Both patients underwent successful bilateral GPi DBS for TD. The postoperative motor score improved by 78% at 24 months in patient 1 and 69% at 12 months in patient 2. There were no surgical or hardware-related complications over follow-up period. CONCLUSION: Our experience indicates that bilateral GPi DBS can be an effective treatment for disabling TD. The response of TD to bilateral GPi DBS is very rapid and occurs within days after the procedure.
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Antipsicóticos/efectos adversos , Estimulación Encefálica Profunda/métodos , Globo Pálido/fisiopatología , Haloperidol/efectos adversos , Discinesia Tardía/terapia , Adulto , Antipsicóticos/uso terapéutico , Trastorno Bipolar/tratamiento farmacológico , Trastorno Depresivo/tratamiento farmacológico , Haloperidol/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Discinesia Tardía/fisiopatología , Resultado del TratamientoRESUMEN
OBJECTIVES: Bilateral pallidal stimulation is an established surgical management for patients with primary generalised dystonia (PGD). The aim of this study was to present our long-term experience of bilateral pallidal stimulation in patients with PGD. METHODS: The study population is composed of 12 patients diagnosed with of PGD (six patients with DYT-1 positive PGD and six patients with DYT-1 negative PGD). The patients were operated under general anaesthesia with no intraoperative target refinement by means of microrecording. The stereotactic technique was based on a combination of the indirect targeting technique relative to the midcommisural point coordinates and direct image-guided MRI target refinement. The formal objective assessment included the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). The BFMDRS assessment was performed before and after it annually up to five years when bilateral pallidal stimulation was switched on and compared to baseline scores. Baseline BFMDRS scores and subsequent follow-up BFMDRS scores were compared with the use of a Wilcoxon signed-rank test for matched pairs. A two-tailed probability level of 5% (p<0.05) was considered significant. RESULTS: At the last follow-up visit, in patients with DYT-1 positive PGD the mean preoperative functional and motor scores of the BFMDRS decreased from 14.0 and 63.75 to postoperative scores of 5.75 (p=0.068) and 22.0 (p=0.066), respectively. In patients with DYT-1 negative PGD the mean preoperative functional and motor scores of the BFMDRS decreased from 13.0 and 46.5 to postoperative scores of 5.25 (p=0.066) and 22.75 (p=0.068), respectively. The hardware-related complications affected seven patients. CONCLUSIONS: Our results indicate that bilateral pallidal stimulation is an effective treatment for patients with DYT-1 positive and DYT-1 negative PGD. The most common hardware-related complication (DBS lead breakage) in our series was associated with the slippage of the connector to the cervical area. To prevent this complication after changing the surgical technique (suturing and placing the connector in parietal region) we did not observe these complications. Unilateral IPG failure resulted in the development of severe status dystonicus.
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Estimulación Encefálica Profunda/métodos , Trastornos Distónicos/terapia , Globo Pálido/fisiopatología , Adulto , Edad de Inicio , Estimulación Encefálica Profunda/efectos adversos , Estimulación Encefálica Profunda/instrumentación , Trastornos Distónicos/genética , Trastornos Distónicos/cirugía , Femenino , Estudios de Seguimiento , Globo Pálido/cirugía , Humanos , Masculino , Chaperonas Moleculares , Neuronavegación , Resultado del TratamientoRESUMEN
INTRODUCTION: Meige syndrome (MS) is characterized by blepharospasm, facial, oromandibular, and often cervical dystonia. The medical treatment of this condition is challenging and unsuccessful over long time. Recent case reports and small clinical series showed that bilateral deep brain stimulation (DBS) of globus pallidus pars interna (GPi) improves dystonic features of MS validated by Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). MATERIALS AND METHODS: We report on our experience in using bilateral GPi DBS in 3 cases of MS. We present short-term (3 months) follow-up as well long-term (from 8 months to 36 months) results. Preoperative and postoperative BFMDRS assessments were performed on each patient. The postoperative BFMDRS scores was done when both stimulators were switched on and compared to baseline scores. RESULTS: Bilateral GPi DBS reduced the BFMDRS total movement score by 66% at short-term follow-up, and by 75% at long-term follow-up when compared to baseline scores. The BFMDRS total disability score was reduced by 34% at short-term follow-up, and by 47% at long-term follow-up when compared to baseline scores. CONCLUSIONS: Our results showed that bilateral GPi DBS in MS is effective and safe, if conservative treatment options failed. The benefit is not only observed at short-term 3 months period but is maintained at long-term follow-up ranging from 8 to 36 months.
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Estimulación Encefálica Profunda/métodos , Globo Pálido/fisiología , Linfedema/terapia , Adulto , Evaluación de la Discapacidad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Índice de Severidad de la Enfermedad , Factores de TiempoRESUMEN
OBJECTIVE: The aims of this study were to assess the quality of life (QoL) using Parkinson's Disease Questionnaire PDQ-39 after bilateral subthalamic deep brain stimulation (STN DBS), and to identify correlations between changes in UPDRS score and separate PDQ-39 QoL dimensions and PDQ summary index (SI) score at long-term follow-up. METHODS: We evaluated 16 patients with advanced PD after bilateral STN DBS. All 16 patients were assessed 1 year after surgery and 14 were studied 2 years after surgery. The patients were assessed using Unified Parkinson's Disease Rating Scale (UPDRS) in medication-on and medication-off conditions, both preoperatively and postoperatively. All UPDRS evaluations were performed postoperatively during stimulation-on condition. QoL levels were determined by applying PDQ-39 questionnaire. RESULTS: The UPDRS scores after 1 and 2 years in medication-off and -on conditions when bilateral STN DBS was switched on showed a significant difference between baseline scores and follow-up scores (both in -off and -on conditions) in every UPDRS measurement except for mentation after 2 years. Most of P-values indicated that the differences were highly significant (P<0.01) based on Wilcoxon signed-rank test. All dimensions of PDQ-39 as well PDQ-39 SI score were highly significantly improved after 1 year. The same improvements were visible in 2 years follow-up with the exception of social support and communication. We found a positive correlation between ADL UPDRS, motor off UPDRS scores and PDQ-39 ADL and PDQ-39 SI scores. A further analysis of separate motor PD features revealed that tremor, bradykinesia and axial features were correlated with improvements mostly seen in PDQ-39 ADL and PDQ-39 SI scores. Moreover, in medication-on condition, we found a strong correlation between dyskinesia UPDRS score and PDQ-39 mobility, ADL, and PDQ-39 SI score. We observed a negative correlation between improved fluctuation UPDRS score and PDQ-39 mobility. We identified no correlation between the duration of the off period and levodopa dose and changes in PDQ-39. CONCLUSION: STN DBS significantly improved important aspects of QoL as measured by PDQ-39. The improvements were maintained at 2 years follow-up except for social support and communication. We demonstrated a positive correlation between changes in the off condition of motor UPDRS scores and dyskinesia UPDRS scores in several PDQ-39 dimensions, whereas fluctuation UPDRS scores were negatively correlated with PDQ-39 mobility scores.
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Estimulación Encefálica Profunda/métodos , Enfermedad de Parkinson/terapia , Calidad de Vida , Núcleo Subtalámico/fisiología , Adulto , Anciano , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Núcleo Subtalámico/cirugía , Resultado del TratamientoRESUMEN
The authors report a case of bilateral globus pallidus internus (GPi) stimulation for treatment of medically intractable isolated lower limb dystonia. The 14-year-old girl developed dystonic movements in her left lower limb. At the age of 17, the patient was handicapped by dystonic movements in her lower limbs, and became wheelchair-bound. Pharmacological therapy and botulinum toxin injection resulted in transient and modest benefit. Moreover, the patient was diagnosed with histologically proven coeliac disease and Langerhans cell histiocytosis. Genetic testing revealed the presence of DYT-1 mutation. The 17-year-old girl underwent bilateral implantation of deep brain stimulation leads. Bilateral GPi stimulation resulted in remarkable improvement of phasic dystonic movements, and dystonic posture of lower limbs. Over 2 years postoperative follow-up, the patient is able to walk independently. Bilateral GPi stimulation appears to be an effective treatment modality for isolated lower limb dystonia.
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Enfermedad Celíaca/terapia , Estimulación Encefálica Profunda/instrumentación , Distonía/terapia , Electrodos Implantados , Globo Pálido/fisiopatología , Histiocitosis de Células de Langerhans/terapia , Adolescente , Enfermedad Celíaca/complicaciones , Distonía/complicaciones , Femenino , Estudios de Seguimiento , Histiocitosis de Células de Langerhans/complicaciones , Humanos , Procedimientos Neuroquirúrgicos/métodos , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: Primary generalized dystonia (PGD) is a medically refractory progressive disease of the brain causing near total handicap of affected patients. The aim of the study was to assess the efficacy and safety of bilateral pallidal stimulation in patients with PGD. MATERIAL AND METHODS: The study population is composed of 5 patients with PGD. The formal objective assessment included the Burke-Fahn-Marsden dystonia rating scale (BFMDRS). All stereotactic procedures were performed in general anaesthesia using a Leksell G stereotactic head frame without electrophysiological guidance. Immediately after insertion of deep brain stimulation (DBS) leads, the internal pulse generators (Itrel II or Soletra) were implanted subcutaneously in the chest wall or abdominal region. RESULTS: There were no complications related to the stereotactic procedures. The hardware-related complications (two broken DBS leads) were replaced successfully. There were no infections or erosions of implanted hardware. It has been observed that in the long-term follow-up period primary set bipolar stimulation mode lost its benefit achieved previously. Various stimulation combinations were investigated. Monopolar cathodal or especially multi-contact cathodal stimulation was the most effective one. The efficacy of bilateral pallidal stimulation was proved by the objective validated BFMDRS at long-term follow-up. CONCLUSIONS: Response to DBS may improve with the number of activated cathodal contacts within the globus pallidus internus.
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Estimulación Encefálica Profunda/métodos , Trastornos Distónicos/terapia , Globo Pálido/fisiopatología , Neuroestimuladores Implantables , Procedimientos Neuroquirúrgicos/instrumentación , Adulto , Estimulación Encefálica Profunda/instrumentación , Femenino , Estudios de Seguimiento , Humanos , Masculino , Procedimientos Neuroquirúrgicos/métodos , Recuperación de la Función , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Adulto JovenRESUMEN
BACKGROUND AND PURPOSE: The objective of the study was to assess bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) for patients with advanced Parkinson disease (PD). MATERIAL AND METHODS: The study population included 5 patients with bilateral STN DBS who completed a 5-year postoperative follow-up period. In all patients electrodes (Model 3387 or 3389) were stereotactically bilaterally inserted into the STN using a Leksell stereotactic G frame. The clinical rating tests included Unified Parkinson's Disease Rating Scale (UPDRS) and two motor-timed tests derived from CAPIT (rapid movements between two points and stand-walk-sit test). All patients were assessed in off and on condition before implantation and 1, 3 and 5 years in medication on and off condition and stimulation on condition and stimulation off condition. To compare preoperative to postoperative UPDRS scores, only mean values and standard deviations are presented because of the small study population. RESULTS: The stimulation effect was noted in the off state, resulting in a 59% improvement in motor scores of UPDRS at 5-year follow-up, when compared to preoperative scores. In the on state the stimulation improved motor scores by 17%. At 5-year follow-up, reduction of daily levodopa dose was 50%. CONCLUSIONS: Bilateral STN DBS is an effective and safe treatment for patients with advanced PD. Bilateral STN DBS contributes to improvement of parkinsonian symptoms in the off state and levodopa-induced dyskinesia. This can be correlated with a 50% reduction of daily levodopa dose 5 years postoperatively.
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Estimulación Encefálica Profunda/métodos , Electrodos Implantados , Enfermedad de Parkinson/terapia , Técnicas Estereotáxicas , Núcleo Subtalámico , Anciano , Femenino , Estudios de Seguimiento , Lateralidad Funcional , Humanos , Masculino , Persona de Mediana Edad , Procedimientos Neuroquirúrgicos/métodos , Polonia , Resultado del TratamientoRESUMEN
The aims of the study were to present the surgical technique of bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) and to analyze our experience with the MedtronicStealthStation Treon neuronavigation system and Framelink 4.1 software in targeting STN using single-unit extracellular action potentials (microrecording). The prospective study included 2 patients with bilateral STN DBS. The STN boundaries were mapped using microrecording, without microstimulation and recording of kinesthetic cells. For macrostimulation the longest trajectory with neuronal activity characteristic of STN was chosen. The patients were assessed using Unified Parkinson's Disease Rating Scale UPDRS version 3 and Schwab and England Scale. Postoperatively we did not notice intracerebral haemorrhage. Also there were no transient or permanent side effects. The mean number of microelectrode tracts was 4 per STN. Framelink 4.1 software is reliable to plan individual microelectrode trajectories and help avoid the intraparenchymal vessels.
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Estimulación Encefálica Profunda/métodos , Enfermedad de Parkinson/terapia , Núcleo Subtalámico/cirugía , Adulto , Humanos , Cuidados Intraoperatorios , Masculino , Persona de Mediana Edad , Núcleo Subtalámico/fisiopatología , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: Essential tremor is the most common tremorogenic movement disorder. In the majority of patients the progression of the disease is slow and the pharmacological treatment effectively alleviates tremor. In rare cases of increased essential tremor the surgical treatment (ventrolateral thalamotomy) is indicated. The goal of this study was to assess the effectiveness of unilateral thalamotomy in the treatment of essential tremor. MATERIAL AND METHODS: 10 stereotactic ventrolateral thalamotomies were performed in 9 patients for pharmacologically intractable essential tremor. Right thalamotomy was done in 5 patients and left thalamotomy in 4 patients. The study included five men and four women. Patients were assessed according to the Clinical Rating Scale for Tremor (CRST) before surgery and at 3, 12 and 24 months after thalamotomy. RESULTS: In the postoperative period there was a marked reduction of essential tremor in the contralateral arm and, to a lower extent, in the contralateral leg. The mean presurgery value for contralateral upper extremity postural tremor (scores 5/6 CRST) decreased from 3.5 to mean postsurgery value of 0.6. The tremor reduction contributed to 59% improvement in specific motor tasks of upper extremities (Part B of CRST) at 2 years follow-up. There was also improvement of functional disabilities (Part C of CRST) by 62% when compared to preoperative value 2 years postoperatively. CONCLUSIONS: Ventrolateral thalamotomy is a highly effective method in the treatment of essential tremor. The side effects related to surgery are rare and most of them are transient.
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Temblor Esencial/cirugía , Tálamo/cirugía , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Técnicas Estereotáxicas , Resultado del TratamientoRESUMEN
BACKGROUND AND PURPOSE: To assess the effectiveness of unilateral thalamotomy for the treatment of parkinsonian tremor and other motor signs of Parkinson's disease (PD). MATERIAL AND METHODS: Between 1999 and 2004, 41 patients with idiopathic tremor dominant PD were treated surgically in the Neurosurgical Department of Postgraduate Medical Center in Warsaw. Stereotactic thalamotomy was performed with Leksell stereotactic frame (model G) using intraoperative macrostimulation. The patients were assessed according to the Unified Parkinson's Disease Rating Scale version 3. (UPDRS) before and after thalamotomy in the off state. The progression of PD was also evaluated according to the Hoehn and Yahr scale in the off state and also Schwab and England was used to assess the disability of the patients. The patients were evaluated before thalamotomy in the off state, and 3, 12, 24 and 36 months after surgery, according to the above mentioned clinical rating scales. RESULTS: The authors report their results among 41 patients who underwent stereotactic thalamotomy 3 years postoperatively. At 3 years follow-up (in the group of 19 patients) the contralateral tremor from the presurgical value of 11.2 (items 20 - 21 UPDRS) decreased to 2.6. The rigidity in contralateral limbs at 3 years follow-up was 1.7 (item 22 UPDRS) when compared to 2.8 (item 22 UPDRS) preoperative value. Thalamotomy had no effect on bradykinesia or other manifestations of PD such as balance or gait disturbance. There were 13 transient and 6 permanent complications. CONCLUSIONS: Thalamotomy using intraoperative macrostimulation in carefully selected patients is a beneficial operation for the control of medically refractory parkinsonian resting and postural tremor. The effect of unilateral thalamotomy on tremor is long lasting.