丘脑底核电刺激治疗帕金森病12例

目的 探讨丘脑底核（STN）的脑深部电极刺激（DBS）治疗帕金森病（PD）的疗效、适应证及术后程控.方法 采用微电极记录STN电刺激术,对5例PD患者行双侧STN的DBS手术;7例PD患者行单侧STN的DBS手术,右侧2例、左侧5例（其中有3例同时给予对侧苍白球毁损术）.结果 12例患者经术中确定靶点定位,DBS后患者震颤停止,肌僵直明显改善,改善率达75％～85％.结论 DBS治疗PD有可逆性、可调节性的优点,效果理想、安全可靠,手术无明显并发症.     

丘脑底核深部脑刺激术对帕金森病非运动症状影响效果的研究进展

正脑深部电刺激术(DBS)被广泛应用于帕金森病(PD)等锥体外系疾病的治疗。长期以来,PD的四大核心运动症状-静止性震颤、肌强直、运动迟缓、姿势步态异常已为人们所熟知,且通过丘脑底核(STN)DBS能明显改善以上症状。而PD的非运动症状(NMS)如自主神经功能障碍、神经精神症状、感觉障碍、睡眠障碍等症状未得到足够重视,而且会随着帕金森病晚期运动症状的进展而加重。虽然NMS不能作为STN DBS靶症状,但是许多研究表明,STN DBS能产生对NMS有益的多种效果,还进一步提高了生活质量,使手术达到更满意     

脑深部电刺激参数调整和随访治疗帕金森病震颤及强直的疗效研究

目的观察脑深部电刺激(DBS)治疗帕金森病(PD)术后症状改善,并应用电流脉冲发生器(IPG)进行参数调整以达最佳临床效果。方法2例PD患者进行了手术,采用立体定向系统,以微电极引导将刺激电极植入相应靶点,例1选择丘脑腹中间核(Vim),例2选择丘脑底核(STN)为靶点。结果术后各种参数相对稳定,在反复启动和关闭IGP前后,差别明显。结论DBS治疗PD安全有效,副作用可逆,,IGP参数调整和随访是DBS手术是否成功的重要部分。     

深部脑电刺激后帕金森病患者运动症状改善与黑质纹状体不同亚区的相关性

目的 观察深部脑电刺激(DBS)后帕金森病(PD)患者运动症状改善与黑质纹状体不同亚区的相关性。方法 回顾性分析6例经丘脑底核(STN)-DBS后运动症状改善的PD患者，分别于STN-DBS前及后7个月采用PD统一评分量表第Ⅲ部分(UPDRS-Ⅲ)及Hoehn-Yahr(H-Y)分级进行评估，计算运动症状改善值；同时行多巴胺转运蛋白(DAT)PET脑显像，以SPM12软件于双侧尾状核、壳核前部、壳核后部及黑质勾画ROI,获得各ROI内平均放射性计数，并以小脑为参考，计算双侧尾状核、壳核前部、壳核后部及黑质的DAT摄取及DAT摄取改善率；采用Spearman相关分析观察运动症状改善值与STN-DBS后7个月DAT摄取显著增高脑区治疗前DAT摄取及DAT摄取改善率的相关性。结果 STN-DBS前UPDRS-Ⅲ评分及H-Y分级与其后7个月差异均有统计学意义(P均<0.05)。STN-DBS后7个月双侧壳核后部部分区域及起病侧黑质致密部DAT摄取显著高于STN-DBS前(P均<0.01),而双侧尾状核及壳核前部部分区域DAT摄取显著低于STN-DBS前(P均<0.01)。ST...     

~(18)F-FDGPET/CT脑显像鉴别帕金森病和多系统萎缩的临床价值

目的探讨~(18)F-FDG PET/CT脑显像对帕金森病(PD)和多系统萎缩(MSA)的鉴别诊断价值。方法回顾性分析临床诊断为PD(15例)和MSA(11例)的~(18)F-FDG PET/CT脑显像资料,首先对患者的脑代谢表现进行定性分析,然后使用Neuro Q软件进行定量分析其代谢模式差异。结果 15例PD患者~(18)F-FDG PET/CT脑显像,定性分析显示13例(86.7%)表现为皮层代谢减低;3例(20%)单侧壳核代谢减低,15例均未显示小脑代谢减低;定量分析显示全部患者均表现为大脑皮层受累,8例(53.3%)单侧壳核代谢减低,2例(13.3%)双侧壳核代谢减低,15例均未显示小脑代谢减低。11例MSA患者~(18)F-FDG PET/CT脑显像,定性分析显示全部患者表现为皮层代谢减低,4例(36.4%)壳核代谢减低;3例(27.3%)小脑代谢减低;定量分析显示全部患者表现为大脑皮层受累以及双侧壳核代谢减低;5例(45.5%)双侧小脑代谢减低。结论 ~(18)F-FDG PET/CT脑显像PD和MSA患者的基底节和小脑代谢模式存在差异,有助于临床进行鉴别诊断。     

双侧丘脑底核脑深部电刺激对原发性帕金森病患者震颤、步态及姿势稳定性的改善作用

目的:探讨双侧脑深部电刺激(deepbrainstimulation,DBS)治疗原发性帕金森病的效果,研究DBS丘脑底核(subthalamicnucleus,STN)的慢性电刺激对帕金森病患者的震颤、肢体僵硬和运动迟缓的疗效。方法:2001/2003解放军第四军医大学唐都医院神经外科收治12例有双侧肢体症状或有轴性症状的帕金森病患者,应用CT影像学与微电极电生理定位结合的方法进行靶点定位,为12例患者进行24枚电极植入,经过3～41个月(平均为13个月)的随访,在“开”的状态和“关”的状态下,刺激器开启时进行统一帕金森病评定量表(unifiedParkinson'sdiseaseratingscale,UPDRS运动评分和震颤、强直、运动迟缓、步态、姿)势稳定性、语言、吞咽及流涎等主要症状评分,计算运动评分和各个症状改善率。结果:除刺激无效者1例外,11例双侧STN电极植入的患者术后的震颤、肢体僵硬、运动迟缓症状有明显改善,刺激器开启时,在“关”的状态下,UPDRS运动评分症状平均改善率61.6%,在“开”的状态下UPDRS运动评分症状改善率23.9%,未发现任何并发症。同时多巴胺类药物用量明显减少。结论:STN目前是电极植入的理想靶点,双侧电极植入在改善肢体症状的同时可以明显控制中轴症状,因DBS所引起的副反应可以逆转。     

双侧丘脑底核脑深部电刺激对原发性帕金森病患者震颤、步态及姿势稳定性的改善作用

目的：探讨双侧脑深部电刺激(deep brain stimulation，DBS)治疗原发性帕金森病的效果，研究DBS丘脑底核(subthalamic nucleus，STN)的慢性电刺激对帕金森病患者的震颤、肢体僵硬和运动迟缓的疗效。方法：2001／2003解放军第四军医大学唐都医院神经外科收治12例有双侧肢体症状或有轴性症状的帕金森病患者，应用CT影像学与微电极电生理定位结合的方法进行靶点定位，为12例患者进行24枚电极植入，经过3-41个月(平均为13个月)的随访，在“开”的状态和“关”的状态下，刺激器开启时进行统一帕金森病评定量表(unified Parkinson’s disease rating scale，UPDRS)运动评分和震颤、强直、运动迟缓、步态、姿势稳定性、语言、吞咽及流涎等主要症状评分，计算运动评分和各个症状改善率。结果：除刺激无效者1例外，11例双侧STN电极植入的患者术后的震颤、肢体僵硬、运动迟缓症状有明显改善，刺激器开启时，在“关”的状态下，UPDRS运动评分症状平均改善率61．6％，在“开”的状态下UPDRS运动评分症状改善率23．9％，未发现任何并发症。同时多巴胺类药物用量明显减少。结论：STN目前是电极植入的理想靶点，双侧电极植入在改善肢体症状的同时可以明显控制中轴症状，因DBS所引起的副反应可以逆转。     

脑深部电刺激对帕金森病认知功能的影响

帕金森病(Parlkinson's disease,PD)是中老年人常见的神经系统变性疾病.脑深部电刺激(deep brain stimulation,DBS)可以改善中晚期或药物难治性PD患者的运动症状、生活质量,并且丘脑底核脑深部电刺激(subthalamic nucleus deep brain stimulat...     

脑立体定向术治疗60例帕金森病的临床研究

目的：本研究旨在运用脑立体定向技术治疗帕金森病(PD)，研究靶点的选择、影像学定位、电生理刺激，评估手术疗效。方法：通过GT或MR导向，辅以电生理刺激矫正靶点，对60例帕金森病患者行丘脑(Vim)或苍白球腹后部(PVP)进行射频术；或对底丘脑核(STN)进行脑深部刺激(DBS)。根据术前、术后Webster和UPDRS评分比较临床治疗效果。结果：在60例的手术治疗中，包括2例进行了对侧：二次PVP手术，5例进行了DBS。结果：显示有效率100％，术后1个月Webster评分下降了30％，UPDRS评分下降了37％；术后3个月Webster评分下降了31％，UPDRS评分下降了39％。患者生活质量明显提高，无永久性手术并发症和死亡。结论：从治疗效果来看，PD的手术治疗优于单纯的药物治疗；通过MR导向，术中运用电生理刺激和微电极定位使靶点更加准确；对于PD的主要症状的控制，选择Vim或PVP是最佳的靶点；DBS对PD症状的控制较毁损疗效持久，且并发症少；PD患者第二次手术靶点应首选PVP。     

丘脑底核脑深部电刺激对帕金森病认知功能影响

目的 :评估丘脑底核(subthalamic nucleus,STN)脑深部电刺激术(deep brain stimulation,DBS)对帕金森病(Parkinson's disease,PD)患者认知功能的影响,并探讨其潜在的发生机制。方法 :40例PD患者中,20例PD接受双侧STN-DBS治疗(DBS组);另20例因拒绝手术,采用最佳药物进行治疗(药物治疗组),设20例健康者作为对照(对照组)。采用神经心理学方法对STN-DBS前1周、术后1年及药物治疗患者随访1年前、后的认知功能进行评估,并与20例匹配的健康对照者进行比较。结果:STN-DBS术后患者运动症状明显改善,但执行错误率明显升高(P<0.05),言语流畅性明显下降(P<0.05)。结论:STN-DBS可引起PD患者执行功能及言语流畅性的下降,但对于术前无严重认知功能障碍的患者,STN-DBS术后短期内引起的认知改变并不影响其生活质量。     

Frequency-correlated decreases of motor cortex activity associated with subthalamic nucleus stimulation in Parkinson's disease

According to the classical model of basal ganglia organization, deep brain stimulation (DBS) in the subthalamic nucleus (STN) for the treatment of Parkinson's disease (PD) blocks overactive excitatory projections to inhibitory basal ganglia output structures. This would release the break on thalamofrontal neurons alleviating the poverty of movement, the hallmark of PD. Such parallels to a functional lesion certainly simplify the mechanism of STN DBS. Here, we applied parametric analyses of H2(15)O positron emission tomography (PET) scans at rest while systematically varying stimulation frequency in 6 patients with STN DBS for akinetic PD. A strong positive correlation of rCBF to increasing stimulation frequency was detected around the STN bilaterally. More importantly, we show that gradual increases in STN stimulation frequency are tightly correlated with decreases in motor cortex activity. This demonstrates an active modulation of resting activity within the subcortical stimulation target and within motor cortex by STN DBS. Rather than a possible downstream effect, we propose to consider the tight correlations between DBS frequency and motor cortex activity in the context of an upstream modulation of direct efferents to the STN from primary motor and premotor cortices.     

Focal changes of oxygen consumption in cerebral cortex of patients with Parkinson's disease during subthalamic stimulation

Motor symptoms of Parkinson's disease (PD) are substantially improved by bilateral high-frequency electrical stimulation of the subthalamic nucleus (STN). Altered cerebral blood flow (CBF) in a network of frontal cortical and subcortical structures has been reported in numerous studies of patients undergoing subthalamic stimulation. However, CBF is a controversial indicator of brain activation because measures of blood flow bear a variable relation to measures of brain work and energy metabolism. We hypothesized that STN stimulation would alter the rate of oxygen consumption (CMRO(2)) in cerebral cortical areas in proportion to previously reported changes in CBF in patients undergoing stimulation at rest. We used quantitative PET to map CMRO(2) in brain of seven patients with Parkinson's disease, first in a baseline condition with pause of stimulation and medication for a period of 12 h, and again after 4 h of stimulation. Comparison of these two conditions revealed activation of CMRO(2) in the cerebellum, and in specific posterior neocortical regions, most notably in the left lingual gyrus and in the right lateral occipitotemporal gyrus, both of which latter regions are linked to higher-order visual processing. CMRO(2) was unaffected in the frontal cortex. Thus, the present findings do not support the original hypothesis, but suggest that STN stimulation increases energy metabolism in the posterior cerebral cortex, especially in regions involved in perception of movement and the direction of movement to visual cues.     

Indication of surgical therapy for Parkinson's disease

We review the current status of surgical treatment of Parkinson's disease (PD). The advantages of deep brain stimulation (DBS) over ablative surgery include reversibility and controllability of stimulation. In addition, DBS carries a smaller risk of side effects, especially when employed bilaterally. DBS of the thalamus is useful to control tremor which is unresponsive to medication. DBS of the globus pallidus internus (GPi) or the subthalamic nucleus (STN) is useful to control wearing off of motor symptoms which is difficult to manage with medication alone. DBS of STN and GPi improves motor function mainly during the off-period. DBS of STN attenuates levodopa-induced dyskinesia through reduction of dopa requirement, whereas DBS of GPi attenuates dopa-induced dyskinesia directly. DBS of STN is also useful to control symptoms of PD in patients who are intolerant to dopa. However, DBS of either STN or GPi cannot reverse advanced symptoms of PD, which are unresponsive to dopa.     

Network modulation by the subthalamic nucleus in the treatment of Parkinson's disease

Deep brain stimulation of the subthalamic nucleus (STN DBS) has become an accepted tool for the treatment of Parkinson's disease (PD). Although the precise mechanism of action of this intervention is unknown, its effectiveness has been attributed to the modulation of pathological network activity. We examined this notion using positron emission tomography (PET) to quantify stimulation-induced changes in the expression of a PD-related covariance pattern (PDRP) of regional metabolism. These metabolic changes were also compared with those observed in a similar cohort of patients undergoing STN lesioning. We found that PDRP activity declined significantly (P < 0.02) with STN stimulation. The degree of network modulation with DBS did not differ from that measured following lesioning (P = 0.58). Statistical parametric mapping (SPM) revealed that metabolic reductions in the internal globus pallidus (GPi) and caudal midbrain were common to both STN interventions (P < 0.01), although declines in GPi were more pronounced with lesion. By contrast, elevations in posterior parietal metabolism were common to the two procedures, albeit more pronounced with stimulation. These findings indicate that suppression of abnormal network activity is a feature of both STN stimulation and lesioning. Nonetheless, these two interventions may differ metabolically at a regional level.     

Free-living energy expenditure reduced after deep brain stimulation surgery for Parkinson's disease

Background: The clinical picture in Parkinson’s disease (PD) is characterized by bradykinesia, rigidity, resting tremor and postural instability. In advanced stages of the disease, many patients will experience reduced efficacy of medication with fluctuations in symptoms and dyskinesias. Surgical treatment with deep brain stimulation in the subthalamic nucleus (STN‐DBS) is now considered the gold standard in fluctuating PD. Many patients experience a gain of weight following the surgery. The aim of this study was to identify possible mechanisms, which may contribute to body weight gain in patients with PD following bilateral STN‐DBS surgery. Methods: Ten patients with PD were studied before bilateral STN‐DBS surgery, and seven patients were studied again 3 and 12 months postoperatively. Clinical examination and resting metabolic rate with and without medical treatment was measured before and after STN‐DBS. Furthermore, free‐living energy expenditure, body composition, energy intake, peak oxygen consumption, maximal workload and leisure time physical activity were measured before and 3 and 12 months after surgery. Results: The STN‐DBS operated patients had a significant weight gain of 4·7 ± 1·6 kg (mean ± SE) 12 months postoperatively, and the weight gain was in the fat mass. The free‐living energy expenditure decreased postoperatively 13 ± 4% even though the reported dietary intake was reduced. A decreased energy expenditure took place in the non‐resting energy expenditure. The reported daily leisure time activity, peak oxygen consumption and maximal workload were unchanged. Conclusion: The STN‐DBS operated patients have a significant postoperative weight gain, as a result of a decrease in free‐living energy expenditure concomitant with an insufficient decrease in energy intake.     

Probabilistic analysis of activation volumes generated during deep brain stimulation

Deep brain stimulation (DBS) is an established therapy for the treatment of Parkinson's disease (PD) and shows great promise for the treatment of several other disorders. However, while the clinical analysis of DBS has received great attention, a relative paucity of quantitative techniques exists to define the optimal surgical target and most effective stimulation protocol for a given disorder. In this study we describe a methodology that represents an evolutionary addition to the concept of a probabilistic brain atlas, which we call a probabilistic stimulation atlas (PSA). We outline steps to combine quantitative clinical outcome measures with advanced computational models of DBS to identify regions where stimulation-induced activation could provide the best therapeutic improvement on a per-symptom basis. While this methodology is relevant to any form of DBS, we present example results from subthalamic nucleus (STN) DBS for PD. We constructed patient-specific computer models of the volume of tissue activated (VTA) for 163 different stimulation parameter settings which were tested in six patients. We then assigned clinical outcome scores to each VTA and compiled all of the VTAs into a PSA to identify stimulation-induced activation targets that maximized therapeutic response with minimal side effects. The results suggest that selection of both electrode placement and clinical stimulation parameter settings could be tailored to the patient's primary symptoms using patient-specific models and PSAs.     

Deep brain stimulation for advanced Parkinson's disease

Deep brain stimulation (DBS) is a new and promising technique for the treatment of movement disorders. Medically intractable Parkinson's disease (PD) is one of the most common indications for DBS. There are three possible subcortical targets for PD, depending on the symptomatology (i.e., the motor subdivision of the thalamus, the globus pallidus internus, the subthalamic nucleus [STN]). Thalamic stimulation has been well established as a safe and effective treatment for essential tremor and the tremor associated with PD. Globus pallidus internus and STN DBS are being investigated for the treatment of all the cardinal signs of PD. This article describes the pathophysiology of PD, the surgical treatment history of PD, surgical techniques used for DBS implants, and the role the perioperative nurse has in the care of the patients undergoing these procedures.     

多巴胺转运蛋白显像剂18F-FP-CIT脑PET显像评价脑内多巴胺能系统功能

目的本研究应用放射性显像剂18F-FP-CIT进行脑PET显像来评价脑内的DA能系统的功能变化,并从安全性、有效性等方面对本方法进行评价.方法分别对猴、正常人和不同程度的帕金森病患者应用18F-FP-CIT进行脑PET显像,观察其安全性和在不同程度PD患者的图像表现.结果正常猴1 h断层图像上脑内双侧尾状核和壳核出现较高的放射性浓聚;3 h双侧纹状体放射性相对更为浓聚.正常人15 min和30 min脑断层图像上双侧尾状核和壳核出现放射性摄取,同时大脑皮层有一定程度的放射性摄取,2 h图像已非常清晰,仅尾状核和壳核清晰可见.57例PD患者PET图像中,PD患者症状与对侧脑后壳核放射性的降低明显相关.结论 DAT显像可从分子水平评价多巴胺递质系统功能的客观情况,是有很好临床价值的分子影像学手段.     

脑深部电刺激治疗帕金森病的围手术期护理

目的 探讨脑深部电刺激（DBS）治疗帕金森病的护理方法及效果.方法 对我院2006年8月至2008年11月脑深部电刺激治疗的12例原发性帕金森病患者进行严谨的围手术期护理,重点加强患者的心理护理和知识宣教,严密观察病情,积极防范并发症的发生.结果 12例共植入22根电极（单侧2例,双侧10例）,刺激电极植入靶点均为丘脑底核（STN）,全部术后无颅内血肿出现,无感染及永久神经系统并发症,无刺激相关的不良反应;12例患者随访时间2～28个月,术后6个月UPDRSⅢ评分在开机不服药和开机服药的改善率分别是50%和67%.结论 周到细致的围手术期护理是STN-DBS治疗帕金森病良好疗效的保障.     

High-frequency stimulation of the subthalamic nucleus for the treatment of Parkinson's disease--a team perspective.

Parkinson's disease (PD) is a debilitating neurodegenerative disorder affecting more than 1.2 million people in the United States. Genetic and environmental toxins are believed to be risk factors in acquiring the disease. PD is characterized by tremors, rigidity, bradykinesia, poor gait, and postural instability. These cardinal symptoms improve with medication such a levo-dopa (L-dopa). However, over time, as the disease progresses, the patient becomes refractory to medication, or medication produces debilitating side effects. When this occurs or when there are worsening of symptoms, neurosurgical treatment is recommended, particularly deep brain stimulating (DBS) electrodes implanted in the subcortical subthalamic nucleus (STN). Over the last 5 years STN DBS has gained acceptance and become the neurosurgical treatment of choice for PD. To achieve maximum beneficial effects with minimum adverse effects from the surgery, the expertise of an integrated team of physicians and nurses is essential. A clear understanding of the different aspects of the procedure, including the risks and benefits of the treatment, assists neuroscience nurses in communicating with the PD patient, and providing the most appropriate, knowledge-based pre- and postoperative care.