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1.
Long-term evaluation of deep brain stimulation of the thalamus   总被引:4,自引:0,他引:4  
OBJECT: The effects of thalamic deep brain stimulation (DBS) on essential tremor (ET) and Parkinson disease (PD) have been well documented, but there is a paucity of long-term data. The aim of this study was to evaluate the long-term safety and efficacy of DBS of the ventralis intermedius nucleus (VIM) of the thalamus for PD and ET. METHODS: Thirty-eight of 45 patients enrolled at five sites completed a 5-year follow-up study. There were 26 patients with ET and 19 with PD undergoing 29 unilateral (18 ET/11 PD) and 16 bilateral (eight ET/eight PD) procedures. Patients with ET were evaluated using the Tremor Rating Scale, and patients with PD were evaluated using the Unified Parkinson's Disease Rating Scale. The mean age of patients with ET was 70.2 years and 66.3 years in patients with PD. Unilaterally implanted patients with ET had a 75% improvement of the targeted hand tremor; those with bilateral implants had a 65% improvement in the left hand and 86% in the right compared with baseline. Parkinsonian patients with unilateral implants had an 85% improvement in the targeted hand tremor and those with bilateral implants had a 100% improvement in the left hand and 90% improvement in the right. Common DBS-related adverse events in patients receiving unilateral implants were paresthesia (45%) and pain (41%), and in patients receiving implants bilaterally dysarthria (75%) and balance difficulties (56%) occurred. Device-related surgical revisions other than IPG replacements occurred in 12 (27%) of the 45 patients. CONCLUSIONS: Thalamic stimulation is safe and effective for the long-term management of essential and Parkinsonian tremors. Bilateral stimulation can cause dysarthria and incoordination and should be used cautiously.  相似文献   

2.
We assessed the long-term effect of thalamic deep brain stimulation (DBS) on motor symptoms and progression of Parkinson's disease (PD) in PD patients treated for resting and postural/action tremor. Thalamic DBS was performed in 17 patients with treatment-resistant resting and postural/action tremor. Nine patients were available for follow-up examination a mean of 5.5 years after surgery. Three had tremor-dominant PD. DBS produced marked improvement in resting and postural/action tremor in target upper extremity in all 9 patients, which persisted unchanged at the time of the last follow-up visit 5.5 years after surgery. PD severity with DBS 'on' and 'off' 1 year after surgery was compared to PD severity at the last follow-up visit using UPDRS (Unified Parkinson's Disease Rating Scale) III motor scores and individual motor item subscores. Patients were tested while on medication. There was no significant worsening of tremor, rigidity, speech, postural stability, gait, or axial bradykinesia with DBS either on or off at the last follow-up visit compared to the 12-month visit. UPDRS III motor scores were unchanged. However, global assessment of PD progression and increased mean L-dopa dose and L-dopa equivalent daily dose at the time of last follow-up visit indicated that a progression of PD had occurred.  相似文献   

3.
Thalamic stimulation in patients with multiple sclerosis   总被引:3,自引:0,他引:3  
OBJECTIVE: To assess tremor control and side effects in patients with multiple sclerosis (MS) treated with chronic thalamic stimulation for relief of upper extremity tremor. METHODS: Five patients were studied before and after thalamic placement of a deep brain stimulation (DBS) system. Preoperative and postoperative evaluation included magnetic resonance imaging, Extended Disability Status Scale (EDSS), the Bain-Finchley visual analog scale for tremor, video recording and neuropsychological testing. Stereotactic targeting of the Vim nucleus was done using computed tomography; intraoperative testing was done under local anesthesia before permanent implantation. RESULTS: Functionally useful tremor suppression was obtained in 3/5 patients. Neuropsychological deficits of higher cortical function, memory and visuospatial coordination were observed in all patients before surgery; in 1 patient with improved postoperative visuospatial coordination, worsened memory was found. New brainstem plaque formation was seen several weeks after surgery in 1 patient who had an acute worsening of MS which improved after high-dose intravenous steroids. CONCLUSIONS: Chronic thalamic stimulation may help selected patients with MS-induced tremor. Given the complexity of their underlying illness, patients must be selected carefully, and long-term follow-up is vital to evaluate the true utility of DBS.  相似文献   

4.
The place for neurosurgical management of movement disorders in multiple sclerosis is unclear. To evaluate the potential benefits of unilateral thalamic deep brain stimulation (DBS) a prospective study was performed. Fifteen patients with confirmed MS and chronic, severe, drug-resistant movement disorders underwent stereotactic surgery to implant a thalamic DBS electrode using CT image guidance and intra-operative neurophysiological testing. The primary outcome measures were reduction in tremor severity and improvement in tests of hand function when the DBS electrode was turned on, 12 months after surgery. Secondary outcome measures included indices of disability, handicap, neuropsychological function and independence. Thirty-seven patients were assessed for treatment, but only 15 underwent surgery. In the 10 patients in whom implantation of the complete DBS system was carried out there was a significant reduction in the severity of tremor (p = 0.02) and improvement in hand function (p = 0.02). There were no benefits in any of the secondary outcome measures. Two patients had thalamocapsular haemorrhages at the site of electrode implantation and two had seizures in the follow-up period. Thalamic stimulation significantly reduced the tremor associated with MS and improved hand function in the targeted upper limb. However, there can be difficulties with identifying an optimal implantation site during operation, significant procedural morbidity and difficulty in predicting immediate outcome. It is also likely that the insignificant benefits of DBS on disability and handicap reflect persisting cerebeller dysmetria, and both the severity and diffuse nature of the disease process in this patient cohort.  相似文献   

5.
BACKGROUND/AIMS: Subthalamic deep brain stimulation (STN-DBS) for Parkinson's disease (PD) improves motor symptoms and quality of life (QOL). Because depression is a potent correlate of QOL, and STN-DBS may be associated with changes in mood, this study sought to determine whether QOL improvement is a direct or indirect consequence of motor improvement. METHODS: 26 patients with PD, free of dementia and major depression, who consecutively underwent bilateral, microelectrode-guided STN-DBS, underwent preoperative and 3-month postoperative neuropsychological evaluation, including measures of QOL (PD Questionnaire -39) and depressive symptoms (Beck Depression Inventory). RESULTS: Motor score in the Unified Parkinson's Disease Rating Scale (UPDRS Part III) improved significantly with STN-DBS relative to preoperative 'on' and 'off' scores, as did QOL and depressive symptoms. Extent of QOL improvement tended to be associated with improvement in motor score from presurgical on to postsurgical on stimulation and on medication state. QOL improvement was significantly related to amelioration of depressive symptoms. Partial correlations revealed that the association between QOL improvement and depression remained significant when influence of motor improvement on QOL and depression was controlled for. The motor-QOL association was no longer significant when effects of depression were controlled for. CONCLUSIONS: Significant QOL improvements after STN-DBS are associated with improved motor 'on' state and depressive symptoms. The influence of motor improvement on QOL may be largely indirect by reducing depression.  相似文献   

6.
BACKGROUND: We assessed the long-term effect of deep brain stimulation (DBS) in patients with multiple sclerosis (MS). METHODS: Nine patients with MS-induced tremor underwent placement of a DBS electrode in the thalamus. All patients were referred from the tertiary MS center at the New Jersey Medical School. Intraoperative macrostimulation was performed under local anesthesia before permanent implantation. Preoperative and postoperative evaluation included magnetic resonance imaging (MRI), the Extended Disability Status Scale (EDSS), the Bain-Finchley tremor scale, neuropsychological testing and patient assessment of the benefit from surgery. RESULTS: There were no surgical complications. Follow-up ranged from 9 to 48 months (mean 32 months). EDSS scores averaged 7.2 before surgery, 6.8 at 6 months after surgery and 7.8 at late follow-up. Tremor scores averaged 5.4 before surgery, 1.7 at 6 months after surgery and 2.1 at late follow-up. Four patients who had significant tremor reduction at 6 months had severe MS progression afterwards, and one was lost to late follow-up. Another patient, in whom excellent tremor control was obtained, developed increasing stimulation-induced fatigue, and the implant was removed at his request. The 3 other patients have maintained a worthwhile benefit from DBS. MRI scans did not show any new MS plaques in relation to the electrode, although imaging was consistent with disease progression in all patients. Neuropsychological testing showed a mild to moderate decline in cognitive function consistent with disease progression. CONCLUSIONS: Chronic thalamic stimulation decreases tremor in patients with MS. However, this improvement does not correlate with improvement in objective measures of function. Any actual benefit may be limited in most patients by the progression of underlying disease. DBS for relief of tremor in patients with MS should be considered only in carefully selected patients with relatively stable disease, in whom upper extremity tremor is a disabling symptom.  相似文献   

7.
Levodopa responsiveness has been shown to be the best predictor of improvement after subthalamic nucleus (STN) deep brain stimulation (DBS) for Parkinson's disease (PD). The objective of this study was to assess the effect of STN DBS on PD patients intolerant to levodopa due to severe acute side effects such as intolerable nausea. There were 10 patients in the study who received STN DBS for PD. Five patients who were intolerant to levodopa were matched based on age, disease duration, sex and presurgical disease severity to 5 patients taking levodopa and demonstrating a good levodopa response. Both groups had a significant improvement in Unified Parkinson's Disease Rating Scale activities of daily living and motor subscales as well as tremor, rigidity and bradykinesia scores at 3, 6 and 12 months after surgery compared to baseline, and these improvements were equivalent between the two groups. Patient global ratings also indicated significant improvements at all follow-up visits. There were no differences in stimulator settings between the two groups at the 3-, 6- or 12-month follow-up visits. In conclusion, although levodopa responsiveness is the best predictor for outcome after STN DBS, carefully selected PD patients intolerant to levodopa can have significant improvement.  相似文献   

8.
OBJECT: In published series of patients who undergo deep brain stimulation (DBS) of the thalamus the effects of unilateral stimulation on contralateral limb tremor have been reported. The authors detail their experience with bilateral thalamic DBS in the treatment of head, voice, and bilateral limb tremor and compare it with earlier studies of unilateral stimulation. METHODS: Twenty-three patients (six with Parkinson's disease, 15 with essential tremor, and two with multiple sclerosis) underwent 19 bilateral DBS procedures (nine staged, 10 simultaneous) and four procedures contralateral to thalamotomy to control tremor of the head in 10, voice in seven, and limbs in 20 patients. Limb tremor improvement was graded as follows: 4, no tremor; 3, stress-induced tremor; 2, functional improvement; 1, no functional improvement; and 0, persistent tremor. Improvement of head or voice tremor was graded as follows: 4, greater than 75%; 3, between 50% and 75%; 2, between 25% and 50%; 1, less than 25%; and 0, no improvement. The mean follow-up period was 10 months. Twenty-two patients (96%) demonstrated improved tremor at the last follow-up review. Of 20 patients with bilateral limb tremor, 17 (85%) improved to Grades 3 and 4, two patients (10%) with multiple sclerosis improved to Grade 2, and one (5%) exhibited tremor recurrence 8 months later. Nine (90%) of 10 patients with severe head tremor improved to Grades 4 or 3. Six (86%) of seven patients with voice tremor improved to Grade 3. Seven patients (30%) developed dysarthria, and seven (30%) developed disequilibrium; symptoms reversed in the majority of patients after the stimulation parameters were changed. One patient (4%) developed mild memory decline. There were no deaths. CONCLUSIONS: The following findings are reported: 1) bilateral thalamic DBS and stimulation contralateral to thalamotomy are safe; 2) staging the procedure does not reduce the risk of dysarthria or gait disequilibrium; and 3) head and voice tremor are primary indications for bilateral DBS.  相似文献   

9.
OBJECT: The goal of this study was to investigate the efficacy of long-term deep brain stimulation (DBS) of the posteroventral lateral globus pallidus internus (GPi) accomplished using a single-contact monopolar electrode in patients with advanced Parkinson disease (PD). METHODS: Sixteen patients suffering from severe PD and levodopa-induced side effects such as dyskinesias and on-off fluctuations were enrolled in a prospective study protocol. There were six women and 10 men and their mean age at surgery was 65 years. All patients underwent implantation of a monopolar electrode in the posteroventral lateral GPi. Initially, nine patients received unilateral stimulation. Three of these patients underwent contralateral surgery at a later time. Ten patients received bilateral stimulation (contemporaneous bilateral surgery was performed in seven patients and staged bilateral surgery in the three patients who had received unilateral stimulation initially). Formal assessments were performed during both off-medication and on-medication (levodopa) periods preoperatively, and at 3 and 12 months postoperatively. There were no serious complications related to surgery or to DBS. Two transient adverse events occurred: in one patient a small pallidal hematoma developed, resulting in a prolonged micropallidotomy effect, and in another patient a subcutaneous hemorrhage occurred at the site of the pacemaker. In patients who received unilateral DBS, the Unified Parkinson's Disease Rating Scale activities of daily living (ADL) score during the off-levodopa period decreased from 30.8 at baseline to 20.4 at 3 months (34% improvement) and 20.6 at 12 months (33% improvement) postoperatively. The motor score during the off period improved from 57.2 at baseline to 35.2 at 3 months (38% improvement) and 35.3 at 12 months (38% improvement) postoperatively. Bilateral DBS resulted in a reduction in the ADL score during the off period from 34.9 at baseline to 22.3 at 3 months (36% improvement) and 22.9 at 12 months (34% improvement). The motor score for the off period changed from 63.4 at baseline to 40.3 at 3 months (36% improvement) and 37.5 at 12 months (41% improvement). In addition, there were significant improvements in patients' symptoms during the on period and in on-off motor fluctuations. CONCLUSIONS: Pallidal DBS accomplished using a monopolar electrode is a safe and effective procedure for treatment of advanced PD. Compared with pallidotomy, the advantages of pallidal DBS lie in its reversibility and the option to perform bilateral surgery in one session. Comparative studies in which DBS is applied to other targets are needed.  相似文献   

10.
BACKGROUND: In patients with advanced Parkinson's disease (PD), deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been shown to improve motor function and decrease medication requirements in the short term. However, the long-term benefits of DBS are not yet established. OBJECTIVE: It was the aim of this study to evaluate long-term outcomes of patients with PD treated with bilateral DBS of the STN. DESIGN AND METHODS: Thirty-three subjects who had bilateral STN DBS were followed prospectively after surgery. We evaluated subjects, using the Unified Parkinson's Disease Rating Scale (UPDRS), preoperatively, 12 months after surgery and at a long-term follow-up visit. Ratings were performed on and off dopaminergic medications. We compared postoperative UPDRS scores, dyskinesia ratings and medication dosages with preoperative values. RESULTS: Twenty-seven subjects had evaluations beyond 18 months (median 33.7 months). Total UPDRS scores in the 'medication-off' state were improved by 37% (p < 0.001) at 12 months and 17.7% (p = 0.0051) at the long-term evaluation. Medication-off state UPDRS part III scores were significantly improved at both 1 year and at the last evaluation (37.6 and 29.3%; p < 0.001). Dopaminergic medication requirements were decreased by 35.3% (p < 0.001) during the first postoperative year and remained below preoperative levels at the long-term evaluation. Average duration of 'off' time remained decreased by about 40% at both 1 year and at the time of last evaluation. Subjects had a sustained reduction in dyskinesia severity (88.6% at 1 year and 68.8% at last evaluation). CONCLUSIONS: In this cohort of subjects with advanced PD, bilateral STN stimulation improved 'off' medication motor function, reduced time spent in the medication-off state and reduced medication requirements for up to 4 years after surgery. We conclude that STN DBS is an effective long-term therapy for selected patients with advanced PD.  相似文献   

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