电生理功能定位在帕金森病手术治疗中的应用

目的：探讨神经元电生理功能定位在手术治疗帕金森病中的应用价值。方法：120例帕金森病患，在微电极导向立体定向手术中分别应用运动电刺激和光反射电刺激检测方法，确定手术靶点位置，而后施行热频毁损术。手术后1年根据URDRS评分评估疗效；手术后2周－3个月行MR检查比较手术前影像学定位与实际毁损靶点的偏差范围。结果：在手术中，微电极可在苍白球外侧和苍白球内侧记录到特征性的神经元电活动，有效确定靶点。手术前MRI解剖定位实际毁损靶点偏差＜3mm，手术后1年UPDRS评分下降32．10％（P＜0．01），症状改善程度依次为对侧肢体异动症（95％）、僵硬（72％）、震颤（72％）、运动迟缓及行走姿势（54％）。结论：微电极记录能有效地反映苍白球内侧的电生理学特征，提供细胞水平的“功能定位”。“有效针道”可以应用于苍白球腹后部切开术治疗帕金森病，从而提高治疗靶点的准确性，减少并发 症的发生。     

立体定向射频颅内靶点毁损治疗帕金森病

目的总结立体定向射频毁损丘脑腹中间核(Vim)和苍白球内侧部(GPi)治疗帕金森病的经验。方法对28例帕金森病病人行MRI、CT定位,微电极引导,配合术中测量阻抗和电刺激确定Vim、GPi靶点,以80℃、90s毁损。结果术后89.3%的病人即刻症状消除,10.7%症状减轻。手术后帕金森病统一量表(UPDRS)评分显著性下降(P <0.01)。随访3～48个月,复发率10.7%。结论立体定向射频毁损Vim、GPi治疗帕金森病有效率高;准确定位是手术成功的关键因素。     

帕金森病外科治疗中苍白球内侧部神经元电生理记录的有效针道方法

目的探讨微电极记录技术在帕金森病(PD)苍白球切开术(Pallidotomy)治疗中的实际作用及应用方法。方法对120例PD苍白球内侧部神经元的电生理特征进行记录和分析，术中同时行电刺激检测，随后行射频毁损，术后2周～3月内行MR确认毁损灶位置．1年后病情随访。结果苍白球内侧部(Gpi)运动相关细胞分布具有规律性：下肢运动神经元位于Gpi的背侧．面及咀嚼肌相关运动神绎元位于Gpi最腹侧，上肢运动神经元位于其中，此结果为最终毁损治疗提供了患肢部位的信息：微电极记录在PD手术治疗中的作用主要是用于提供Gpi内神经元信息，即对所行针道异常电生理信号及视束光反应的确认，而非一定要多针道对Gpi或STN生理空间制图或边缘定位，由此提出“有效针道”的方法。结论对于GDi靶点位置的确定，除影象学定位外，微电极记录和电刺激同样重要；微电极记录技术的有效针道方法操作简单，易于临床上对神经核团定位，对GDi靶点定位十分重要。     

磁共振微电极记录辅助脑内核团毁损治疗帕金森病

目的：探讨磁共振（MRI）扫描定位结合术中微电极记录技术及靶点选择在帕金森病立体定向手术治疗中的作用。方法：MRI扫描定位结合微电极记录,脑立体定向毁损法治疗帕金森病89例,其中Vim毁损6例,Gpi毁损71例,Gpi Vim毁损12例,结果：根据MRI扫描确定的靶点坐标与通过微电极记录确定的最终毁损靶点坐标不符的9例,变更范围1-3mm,患者震颤、僵直及运动减少等症状改善显著,术前及术后UPDRS评分经t检验统计有显著差异。结论：选择合适的靶点,MRI扫描结合术中微电记记录技术,提高了帕金森病手术疗效,减少了手术并发症。     

微电极导向技术治疗帕金森病

目的探讨微电极导向技术治疗帕金森病方法、效果及评价.方法通过微电极导向记录技术对MRI定位靶点进行分析、调整和确认对27例帕金森病患者分别进行苍白球毁损术(17例),丘脑腹外侧核(Vim)毁损术(10例),评价手术后疗效.结果微电极导向技术治疗帕金森病总体有效率达98%,术后以UPDRS评分开关状态分别为12.3±9.1,13.2±8.9,较术前有明显改善.微电极确认功能靶点与MRI靶点存在差异,靶点调整率为40%.近期并发症为1%,无永久性并发症.结论微电极导向技术能显著提高手术定位准确率及成功率.     

微电极导向同期双侧腹后苍白球 毁损术治疗帕金森病

目的介绍微电极导向同期双侧腹后苍白球毁损术治疗帕金森病的方法与效果。方法应用微电极电生理记录技术术对毁损靶点进行确认定位,对３１例难治性帕金森病患者行同期双侧腹后内侧苍白球毁损治疗,术前及术后于开状态、关状态分别行改良Ｗｅｂｓｔｅｒ记分,计算改善率,评价其疗效。结果经微电极确认后的电生理靶点与ＣＴ定位靶点存在明显差异,靶点调整率８０６％。３１例手术均有效,其中治愈７例,明显进步２４例。Ｗｅｂｓｔｅｒ计分术后１周开状态改善率为７４２％±９５％,关状态改善率为８９１％±８９％。无永久性并发症。结论微电极导向同期双侧腹后苍白球毁损术安全、有效,具有明显临床治疗优势,微电极记录技术可使术中定位精确度大大提高。     

帕金森病的外科治疗现状

帕金森病的外科治疗经历了苍白球毁损术,丘脑腹外侧核毁损术,苍白球毁损术的复兴。深部电刺激术的出现,使得帕金森病的外科治疗向着丘脑底核刺激的方向发展,双侧丘脑底核电刺激,对帕金森病的疾病症状:震颤、僵直、运动缓慢、异动症及中线症状均有益。靶点的定位方法最初标准脑图谱法、微电极记录术的引入,使得靶点的定位进入细胞水平,高场强核磁共振的出现,使得靶点的定位更加直观和个体化。     

脑深部电刺激治疗帕金森病的程控

目的探讨丘脑底核脑深部电刺激术治疗帕金森病(PD)的手术方法和脉冲发生器程控调节。方法自2000年1月～2004年2月用脑深部电刺激丘脑底核(STN)治疗帕金森病61例,其中单侧30例,双侧31例。采用磁共振扫描结合微电极记录技术进行靶点定位。术后用帕金森病评定量表(UPDRS)运动评分评价刺激效果。结果61例PD患者术后随访6～36个月,平均11．3个月。脉冲发生器开启时,在“关”状态下,UPDRS运动评分改善率45．2％;在“开”状态下,UPDRS运动评分改善率20．7％,未发现任何并发症。结论脑深部刺激(DBS)能有效控制帕金森病患者的症状,手术并发症少,术后可根据患者的症状调节参数,丘脑底核(STN)已成为治疗帕金森病的最佳靶点。     

立体定向手术治疗帕金森病--附669例临床分析

目的 观察立体定向手术治疗帕金森病的疗效,探讨手术靶点与适应证的选择原则。方法对669例帕金森病患者实施微电极导向立体定向毁损与脑深部电刺激术,单靶点分别选择苍白球腹后部(314例)、丘脑腹外侧核(48例)及丘脑底核(48例);多靶点则为单靶点的结合(259例)。手术后采用UPDRS评分进行疗效评估和随访。结果 与手术前UPDRS评分相比:(1)丘脑底核切开术对“关”时相疗效最佳(P<0.05);(2)丘脑腹外侧核对震颤有效,改善率达97％,丘脑底核对僵直和运动迟缓有效,改善率分别为85％和57％;(3)多靶点手术对难治性帕金森病患者有显著疗效(P<0.01);(4)手术后丘脑底核切开组左旋多巴用量减少45％(P<0.05);(5)手术后总复发率为1.79％(12/669),永久性并发症发生率为2.39％(l6/669)。结论 外科手术对帕金森病有肯定而持久的疗效,手术前明确诊断及适应证、靶点选择是手术成功的重要前提。手术后仍须继续药物治疗。丘脑底核可能是最具潜力的治疗性核团。     

丘脑底核慢性电刺激与苍白球毁损术治疗帕金森病疗效比较

目的分别应用脑深部电刺激(deepbrainstimulation,DBS)和苍白球毁损术(posteroventralpallidot-omy,PVP)治疗原发性帕金森病(Parkinson'sdisease,PD),对照研究DBS和PVP对PD患者的震颤、肢体僵硬、运动迟缓的疗效。方法应用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11例帕金森病患者进行同期双侧丘脑底核电极植入,26例患者进行分期双侧苍白球腹后部毁损术,经过至少6个月的随访并行UPDRS评分。结果11例同期进行双侧丘脑底核电极植入及26例分期进行双侧苍白球毁腹后部毁损术患者术后的震颤、肢体僵硬、运动迟缓症状均不同程度的改善,但以DBS手术的改善程度更为明显,两组患者手术前后的UPDRS评分下降程度差异显著(P<0.05)。结论双侧同期DBS是目前治疗PD相对较好的方法,双侧电极植入在改善肢体症状的同时可以明显控制、改善中轴症状,在治疗中晚期PD患者方面较PVP有较大的优势。     

Bilateral GPi DBS is useful to reduce abnormal involuntary movements in advanced Parkinson's disease patients, but its action is related to modality and site of stimulation

In Parkinson's disease (PD) patients, internal globus pallidus (GPi) stimulation has been reported to produce good effects on abnormal involuntary movements (AIM); less improvement has been observed in extrapyramidal symptoms. We assessed the effect of monopolar dorsal (uppermost), ventral (lowest) and bipolar (uppermost vs. lowest) bilateral globus pallidus stimulation by quadripolar electrode on extrapyramidal symptoms and AIM induced by a dose of apomorphine. Six PD patients were studied in OFF therapy condition after surgery without stimulation (STIM OFF) and during stimulation (STIM ON) with the three different modalities. All patients were evaluated by the unified Parkinson's disease rating scale, section III (UPDRS) and by the AIM. Our results show that all three bilateral GPi stimulation modalities reduce the UPDRS score (between 49.7 and 31.5%), although the bipolar and lowest stimulation are the most effective. Similarly, bipolar and lowest stimulation were also the most effective in reducing the occurrence and intensity of the apomorphine-induced AIM. On the contrary, uppermost stimulation (UP ON) produced an AIM occurrence similar to that observed in the OFF stimulus condition. We suggest that bilateral GPi stimulation is an useful procedure to ameliorate extrapyramidal signs of advanced PD patients; however, it produces an antidyskinetic effect only if the ventral or the entire GPi is stimulated. On the contrary, the UP ON, most probably located in the external globus pallidus (GPe), does not modify the AIM occurrence.     

Long-term follow-up of globus pallidus chronic stimulation in advanced Parkinson's disease.

To assess the long-term follow-up of the globus pallidus internus (GPi) stimulation, six patients were evaluated every year by using the Unified Parkinson's Disease Rating Scale (UPDRS). Three years postoperatively, GPi stimulation led to a significant improvement of dyskinesia severity (50%, P = 0.05) and activities of daily living (subscore of quality of life scale, 9%, P = 0.05). However, the improvement induced by chronic pallidal stimulation on the mean daily duration in the off state was lost at the last assessment.     

苍白球腹后部毁损术中的靶点解剖定位和电生理定位

目的 总结苍白球腹后部毁损术中的靶点定位方法。方法 采用MRI扫描，前50例用坐标定位法计算靶点坐标，平均记录2．6个针道微电极信号；后191例采用坐标定位和图像定位相结合的方法计算靶点坐标，平均记录1．3个针道微电极信号。结果 MRI图像能显示苍白球各部分、内囊及视束等结构。微电极记录可确认苍白球内侧部边界、视束等结构。前50例患者坐标调整的百分数明显高于后191例患者。结论 MRI坐标定位和图像定位相结合，减少了个体差异引起的误差，使解剖定位更加准确。微电极记录技术是MRI定位方法的必要补充。     

双侧丘脑底核电刺激对帕金森病患者脑局部糖代谢的影响

目的 研究双侧丘脑底核(subthalamic nucleus,STN)慢性电刺激术(deep brain stimulation,DBS)对晚期帕金森病(Parkinson's disease,PD)患者静止期脑局部糖代谢的影响,并探讨其作用机制。方法 对5例进行双侧STN的DBS治疗的晚期帕金森病患者,分别在术前以及术后1个月电刺激条件下,进行静止期18F-脱氧葡萄糖(FDG)/PET检查和UPDRS运动评分,并通过SPM99统计学软件进行数据分析,比较STN的DBS治疗对脑内代谢的影响。结果 双侧STN的DBS治疗使PD患者临床症状明显改善,同时脑局部糖代谢也发生了明显变化:双侧豆状核、脑干(中脑、脑桥)、双侧顶枕部、运动前区(BA6)及扣带回的脑代谢增加,双侧前额叶底部海马的脑代谢明显减少(P<0.05)。结论 双侧STN的DBS治疗可能通过兴奋STN轴突的方式,使其投射区域的基底上行和下行通路以及相应的皮层高级中枢的代谢改善,从而使PD患者的临床症状改善。     

丘脑底核脑深部刺激术治疗帕金森病的手术方法和疗效分析

目的 总结帕金森病(PD)脑深部刺激术(DBS)治疗的手术方法和效果。方法 对25例帕金森病患者进行了丘脑底核DBS治疗,其中单侧17例,双侧8例。采用磁共振扫描结合微电极记录技术进行靶点定位。术后用UPDRS运动评分评价刺激效果。结果 25例PD患者术后随访5～34个月,平均8.3个月。脉冲发生器开启时,在“关”状态下,UPDRS运动评分改善率50.2％;在“开”状态下,UPDRS运动评分改善率20.7％,未发现任何并发症。结论 丘脑底核DBS是改善PD患者运动功能较为理想的治疗方法。     

Globus pallidus stimulation in advanced Parkinson's disease.

Deep brain stimulation (DBS) of the globus pallidus internus (GPi) has become an accepted therapeutic modality in selected Parkinson's disease (PD) patients with severe levodopa-induced dyskinesias (LID) and on-off motor fluctuations. In comparison to subthalamic nucleus DBS there is a paucity of data on GPi DBS outcomes. We present our experience with a group of 20 PD patients (9 unilateral, 11 bilateral) who underwent GPi stimulation. PD motor symptoms were assessed using the Unified Parkinson's Disease Rating Scale (UPDRS) part III scores and subscores, and dyskinesia using the Abnormal Involuntary Movement Scale (AIMS), UPDRS part IVa, and clinical global impression (CGI). At mean follow-up time of 7 months, bilateral stimulation reduced off-period motor scores by a mean of 46% and on-period motor scores by 18%. Unilateral stimulation reduced off-period motor scores by 18%. Dyskinesia severity was reduced by 76%, which was maintained after a mean follow-up time of 35 months. Antiparkinsonian medication dosage was unchanged. No major adverse effects were seen. Unilateral and bilateral GPi DBS provides lasting benefit in PD patients with severe LID. Beneficial effects on off-period motor symptoms are greater with bilateral stimulation; however, with maintenance of dopaminergic medication, unilateral procedures can also provide important and sustained benefits.     

Lesion therapy for Parkinson's disease and other movement disorders: update and controversies.

An analysis of the international literature on lesioning for movement disorders was undertaken to review lesion therapy for Parkinson's disease (PD) and other movement disorders and to highlight important controversies surrounding this surgical technique. Lesions have been placed throughout the neuraxis with varying approaches and success. Our understanding of the pathophysiological basis underlying the development of PD and other movement disorders has led to a better understanding of why lesioning certain portions of the nervous system should improve motor function. Advances in imaging technology and electrophysiological techniques used for localization of brain structures, such as microelectrode mapping, have improved the ability to accurately identify and lesion target structures deep in the brain. This improvement has led to an increase in the degree and consistency of clinical benefit. The major controversies in lesion therapy include: (1) which target for which disorder; (2) determination of the optimal lesion site and whether the external globus pallidus (GPe) should be included in the pallidotomy lesion for PD; (3) determination of the size of the lesion; (4) whether bilateral lesions can be placed without the high incidence of side effects reported by some investigators; (5) whether microelectrodes aid in the ability to improve clinical outcomes or increase the risk of side effects by making multiple microelectrode penetrations; (6) whether the subthalamic nucleus (STN) should be explored further as a lesioning target; and (7) whether lesioning should be abandoned entirely in favor of deep brain stimulation (DBS). Many important questions and controversies regarding lesion therapy remain unanswered. It is unlikely given the pro-DBS environment that these questions will be answered in the near future. We should, however, be careful not to abandon an effective therapy before fully exploring through randomized trials the relative effect of different surgical approaches for the treatment of patients with movement disorders.     

苍白球腹后部切开术治疗帕金森病靶点定位规律探讨

目的 研究苍白球腹后部切开术(PVP)治疗帕金森病(PD)的靶点定位方法及其规律。方法 45例原发PD患者接受手术．采用MRI进行靶点解剖定位，术中用电生理方法对靶点做必要的调整，同时在MRI操作台上准确测量ACPC线的长度(L)、三脑室的宽度(W)、头颅的长度和宽度。结果 本组患者UPDRS评分改善率大于35％，手术效果满意；依据术中电生理方法调整靶点20例．调整范围1～3mm；靶点横坐标(X)与L和W之间存在线性依从关系即：X=10．09 0．30L 0．48W．决定系数R^2=0．7258．结论 PVP术中应用电生理方法调整靶点是非常重要的，实现了靶点的功能定位；X坐标值随L和W的增加而增大，且W对X的贡献大于L，靶点Z坐标与L和W之间无相关性，靶点坐标与颅长、颅宽无相关性。     

Deep brain stimulation of globus pallidus internus for dystonia

Neuromodulation is the functional modification of neural structures through the use of electrical stimulation. Its most clinically applicable use is deep brain stimulation (DBS) of basal ganglia structures in Parkinson's disease (PD) and essential tremor (ET). More recently, it has been used as a means of treating dystonic movement disorders. The main target of DBS for dystonia is the posteroventral globus pallidus internus (GPi), although the thalamus has been used as an alternate target in a minority of cases. In comparison to the effects seen in PD, the improvement in dystonic postures appear to differ in several ways--delay of clinical benefit, higher voltage requirements, and varied stimulator settings. In this review, the authors discuss the clinical characteristics, pathophysiology, microelectrode recording (MER) signatures, optimal surgical targets, programming parameters and outcomes in dystonia.     

Does stimulation of the GPi control dyskinesia by activating inhibitory axons?

A 69-year-old woman with Parkinson's disease and levodopa-induced dyskinesias had a deep brain stimulation (DBS) electrode inserted into the right globus pallidus internus (GPi). During the operation, the GPi was mapped with dual microelectrode recordings. Stimulation through one microelectrode in GPi inhibited the firing of GPi neurons recorded with another microelectrode 600--1,000 microm distant. The inhibition could be obtained with pulse widths of 150 micros and intensities as low as 10 microA. Single stimuli inhibited GPi neurons for approximately 50 ms. Trains of 300 Hz stimuli inhibited GPi neuron firing almost completely. Postoperatively, stimulation through macroelectrode contacts located in the posterior ventral pallidum controlled the patient's dyskinesias. The effect could be obtained with pulse widths of 50 micros and frequencies as low as 70--80 Hz. We postulate stimulation of the ventral pallidum controls dyskinesias by activating large axons which inhibit GPi neurons.