脑深部电刺激对帕金森病二次手术的临床应用价值

目的探讨帕金森病(Parkinson'sdisease,PD)毁损术后再行脑深部电刺激术(deepbrainstimulation,DBS)的可行性、靶点选择、术中电生理学特点和治疗结果。方法应用MRI和微电极记录技术进行靶点定位,对13例毁损术后的PD患者行DBS手术,其中7例曾行单侧苍白球毁损术(posteroventralpallidotomy,PVP),5例曾行单侧丘脑毁损术,1例曾行双侧丘脑及左侧苍白球毁损术。DBS的靶点包括单侧丘脑底核(subthalamicnucleus,STN)6例,单侧丘脑腹中间核(ventralintermediatnucleus,Vim)1例,双侧STN4例,一侧STN及对侧苍白球(globuspallidusinternus,Gpi)2例。结果DBS对毁损术后的PD患者症状有不同程度的改善,其中单侧毁损术后行双侧DBS效果最明显。术后3个月的UPDRS运动及ADL评分较术前明显减少(P<0.05或0.01),美多巴的用量明显减少(P<0.05),无新的手术合并症。结论曾行毁损术的PD患者如面临二次手术,可以选择DBS手术,以双侧STN的DBS效果最好,并可减少药物用量,不加重原有的术后并发症。     

丘脑底核电刺激治疗帕金森病

目的 探讨脑深部电刺激（DBS）对原发帕金森病（PD）的治疗作用及手术方法。方法 应用微电极导向技术和手术计划系统进行靶点定位，对20例PD病人的丘脑底核（STN）进行电极植入，术后至少6个月的评价和随访。结果 15例单侧和5例双侧STN的DBS术后病人肢体僵直、震颤和运动迟缓等症状改善明显，术前术后UPDRS运动评分和日常生活能力评分均有显著下降（P＜0.01），服药量也有不同程度的减少，无严重及永久并发症。结论 STN的DBS手术治疗PD，对症状改善非常全面，可通过参数调整达到最佳治疗效果。服药量明显减少，是一种安全、有效的治疗方法。     

丘脑底核电刺激术治疗帕金森病的疗效观察

目的 探讨丘脑底核（STN）行脑深部电刺激术（DBS）治疗帕金森病（PD）的疗效。方法 回顾性分析2016年1月至2017年9月收治的64例PD的临床资料，均采用STN-DBS治疗。术后均随访3个月，使用统一帕金森病评定量表（UPDRS-Ⅲ）评分评估疗效。结果 64例手术顺利完成，平均用时（4.39±1.01）h。共置入128根刺激电极，术后CT计算移位距离为0~1.89 mm，平均（0.91±0.42）mm。术前检测64例改善率在37.20%~82.54%，平均（55.36±5.62）%。术后抗PD药物的左旋多巴等效剂量明显低于术前（P<0.05）；术后开机状态下UPDRS-Ⅲ评分明显低于术前（P<0.05）。术后出现颅内积气29例、颅内出血2例、延伸导线移位3例、情绪改变、构音障碍2例、异动9例，末次随访时均完全改善或症状消失。结论 STN-DBS治疗PD，能有效改善病人运动功能，减少抗PD药物的使用，但围术期并发症风险高，临床应重视操作技巧。     

丘脑底核电刺激治疗苍白球毁损术后的帕金森病(12例报告)

目的探讨帕金森病(Parkinson's disease,PD)苍白球腹后部毁损术(posteroventral pallidotomy,PVP)后再行丘脑底核(subthalamic nucleus,STN)脑深部电刺激术(deep brain stimulation,DBS)的可行性、术中电生理学特点和治疗结果。方法应用MR和微电极记录技术进行靶点定位,对12例单侧PVP术后症状再次加重的PD患者实施STN-DBS手术,其中4例行毁损灶对侧的STN-DBS,8例行双侧STN-DBS。结果STN-DBS对本组12例PD患者症状有不同程度的改善,双侧STN-DBS的效果尤为明显,术后3个月的UPDRS运动及ADL评分较术前明显减少(P<0．05或0．01),美多巴的用量明显减少(P<0．01),无明显术后并发症。术中电生理记录显示毁损灶同侧的细胞放电明显低于正常情况。结论曾行单侧PVP的PD患者如面临二次手术,可以选择DBS手术,以双侧STN的DBS效果最好,可减少药物用量。     

双侧丘脑底核脑深部电刺激术可改善中晚期帕金森病患者的症状

目的 探讨双侧丘脑底核(subthalamic nucleus,STN)脑深部电刺激(deep brain stimulation,DBS)术,对中晚期帕金森病(Parkinson's disease,PD)患者运动、生活质量、情绪、睡眠、认知及术后用药剂量的影响.方法 10例接受双侧STN-DBS治疗的中晚期PD患者分别于术前1周及术后3个月、6个月、12个月应用统一帕金森病评分量表(unified Parkinson's disease rating scale,UPDRS)、Hoehn&Yahr分级、帕金森病生活质量问卷(PDQ-39)、帕金森病睡眠评估量表中文版(PDSS-CV)、汉密尔顿抑郁量表(HAMD)、汉密尔顿焦虑量表(HAMA),简易智能状态检查(MMSE)评价其临床情况,同时记录各时间点抗帕金森病药物的剂量及其变化,并对相关结果进行描述性分析.结果 10例PD患者术后均获得了显著疗效,震颤、肌强直、动作迟缓等都有明显改善,术后6个月开机未服药状态下改善率分别为68%、53%、35%,开机服药状态下改善率分别为86%、78%、69%,其中以震颤改善最为显著.术后UPDRSⅢ评分及Hoehn&Yahr分级均降低,术后6个月服药状态下改善率分别为67%、32%;日常生活质量提高,PDQ-39术后6个月改善率为71%,睡眠质量较术前改善,焦虑抑郁情况较术前有不同程度减轻,认知功能尤明显影响.抗帕金森病药物用量术后6个月较术前减少45%.结论 双侧STN-DBS能明显改善中晚期PD患者的运动症状及非运动症状.     

丘脑底核脑深部刺激治疗帕金森病的并发症分析和处理

目的 总结丘脑底核（STN）脑深部刺激（DBS）治疗帕金森病（PD）的并发症和防治措施。方法 对72例PD行STN—DBS治疗，术后随访3个月一5年，对发生的并发症进行分析。结果 术后发生与手术相关的并发症：电极放置不准2例．胸部皮下积液5例，耳后导线接头处头皮破溃1例，胸部皮下感染1例；刺激相关并发症：肢体异动19例，感觉异常18例，情绪改变7例，睁眼困难3例，记忆轻度减退2例；硬件故障：脉冲发生器异常关闭2例，电池耗竭1例。全组无明显的致残性永久并发症发生。结论 STN—DBS并发症较轻，处理得当可获得良好结果。     

丘脑底核电刺激治疗帕金森病的临床应用

目的探讨丘脑底核(STN)脑深部电刺激术(DBS)治疗帕金森病(PD)的手术方法和脉冲发生器的程控调节。方法行STN DBS治疗PD61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UPDRS运动评分评价刺激效果。结果术后随访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5.2%;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STN DBS能有效控制PD症状,手术并发症少,术后可调节参数,已成为治疗PD的重要手术方法。     

丘脑底核脑深部电刺激治疗原发性帕金森病的不良事件

目的观察原发性帕金森病(Parkinson disease,PD)患者行丘脑底核脑深部电刺激术(deep brain stimulation of subthalamic nucleus,STN DBS)的不良事件。方法纳入行STN DBS的原发性帕金森病45例,收集患者一般临床资料,术后随访至3~9年,观察术后不良事件。结果手术相关不良事件:微毁损效应44例、囊袋积液2例、颅内出血1例、嗜睡1例;未观察到任何装置相关不良事件;刺激或疾病相关不良事件:异动症15例、步态平衡障碍12例,焦虑抑郁状态6例,构音障碍与多巴胺失调综合征各4例,智能减退2例,少数患者出现体重增加、幻觉、睁眼困难等。7例患者因共存疾病死亡。结论 STN DBS大部分不良事件可以控制,术后个体化调整参数及药物,有利于减少STN DBS不良事件。     

丘脑底核脑深部刺激术的参数设置及调整

目的 探讨帕金森病（PD）丘脑底核（STN）脑深部刺激术（DBS）术中、术后脉冲发生器的参数调整。方法 回顾采用STN—DBS治疗的62例帕金森病病人的病历资料．对病人术中及术后刺激参数的调整进行分析。结果 32例行单侧手术者均接受单极刺激；30例行双侧手术病人中，接受双侧双极刺激25例，双侧单极刺激2例．一侧单极刺激、另一侧双极刺激3例。7例触点调整均为上移。统一帕金森病评定量表（UPDRS）运动评分改善率双侧刺激优于单侧刺激。本组刺激参数为：电压双极14V．单极1～3．5V；脉宽60-120μs；频率180～190HZ。结论 STN—DBS术后病人采用适当刺激参数可获得安全可靠的疗效。电压调整对PD症状控制作用明显。脉宽及频率的调整相对较少；双侧刺激效果更佳。     

帕金森病脑深部电刺激术治疗的术后药物调整与程控配合

目的分析丘脑底核-脑深部电刺激术(STN-DBS)治疗帕金森病患者的术后程控工作及相关情况,为STN-DBS术后刺激参数的设置、药物的调整提供参考依据。方法病例选自2005年3月至2006年12月在北京天坛医院接受双侧STN-DBS植入术治疗的57例帕金森病患者。分析手术前后药物的用量和调整情况,评估不同刺激参数对震颤、运动徐缓和僵直等PD运动症状的改善作用。结果与术前相比PD患者DBS术后服用多巴胺类药物的剂量明显减少,术前平均707.59mg,术后平均253.62mg,平均减少63%,其中8例不再服用左旋多巴类药物。刺激频率为10Hz时无治疗作用,130Hz以上时症状可得到显著改善。除3例发生对侧肢体痉挛性收缩外,频率达到185Hz时能够获得最佳治疗效果。电压为2V-3V时可较好的改善运动,并随着电压值的增加治疗作用逐渐增强。结论本研究证实STN-DBS是一种安全、有效的治疗帕金森病的方法,STN-DBS能够显著减少左旋多巴类药物用量及药物引起的异动症、运动波动等并发症的发生。刺激电压是术后程控的主要调节参数。     

Bilateral subthalamic stimulation monotherapy in advanced Parkinson's disease: long-term follow-up of patients.

Bilateral subthalamic nucleus stimulation (STN-DBS) is used to improve parkinsonian symptoms and attenuate levodopa-induced motor complications. In some patients, such clinical improvement allows antiparkinsonian medication (ApMed) withdrawal. We show the clinical outcome at the long-term follow-up of patients with advanced Parkinson's disease (PD) in which STN-DBS was used in monotherapy, and compare the clinical results of patients without medication with those obtained in parkinsonian patients in which ApMed were reduced but could not be totally displaced after surgery. We analyzed clinical outcome of ten patients with PD in which all ApMed was withdrawn after bilateral subthalamic stimulation and 16 parkinsonian patients still taking antiparkinsonian medication after surgery. After 1.5 years, STN-DBS monotherapy produced UPDRS motor scores similar to those observed in the on-drug condition before surgery without the inconvenience of motor fluctuations and dyskinesias. No significant differences were seen in most of clinical outcome measures when comparing patients still taking ApMed with patients in STN-DBS monotherapy but a few patients still taking ApMed presented mild dyskinesias and motor fluctuations and patients with STN-DBS monotherapy did not. STN-DBS is useful in the treatment of advanced PD and in some patients it is possible to maintain this therapy alone in the long term. The therapeutic effect of STN-DBS on motor signs can be equipotent to that of levodopa with the additional benefit of avoiding motor fluctuations and dyskinesias.     

Subthalamic DBS replaces levodopa in Parkinson's disease: two-year follow-up

BACKGROUND: Subthalamic nucleus (STN) deep brain stimulation (DBS) of patients with PD allows reduction of antiparkinsonian medication but has only a mild direct effect on dyskinesia. Since antiparkinsonian medication has short- and long-term effects that may prevent an estimate of the maximal possible impact of STN DBS, such medication was used at the lowest possible dosage after DBS implantation. OBJECTIVE: To study the maximal and long-term effects of STN DBS using the lowest dose of medication. METHODS: Twenty consecutive patients with PD with motor fluctuations and dyskinesia underwent bilateral implantation under stereotactic guidance, microrecording, and clinical control. All medications were stopped before implantation and reintroduced, at the lowest dosage needed, only if the postoperative motor score did not reach the baseline level. Unified PD Rating Scale (UPDRS) motor (subscale III) scores were measured at baseline and after 3, 6, 12, and 24 months. RESULTS: After 21 plus minus 8 months, the UPDRS III "off-medication" score was decreased by 45% and was similar to the preoperative UPDRS III "on" score. Overall, medication was reduced by 79%, being completely withdrawn in 10 patients. Fluctuations and dyskinesia showed an overall reduction of >90%, disappearing completely in patients without medication. These improvements were maintained for 2 years. CONCLUSIONS: These results show that STN DBS could replace levodopa and allowed all antiparkinsonian medication to be discontinued in 50% of patients with PD. Fluctuations and dyskinesia disappeared completely in these patients but persisted in those still on medication. These improvements were maintained for 2 years.     

Bilateral effects of unilateral subthalamic nucleus deep brain stimulation in advanced Parkinson's disease

To investigate the bilateral effects of unilateral subthalamic nucleus deep brain stimulation (STN-DBS), we prospectively studied 9 consecutive advanced Parkinson's disease (PD) patients (2 men and 7 women) who underwent unilateral STN-DBS. Patients were evaluated preoperatively and at 3 and 6 months postoperatively with and without dopaminergic medications ('on' and 'off' medication, respectively). Postoperatively, patients were assessed with and without stimulation. We found that, when compared with baseline, the 'off' medication scores of the Unified Parkinson's Disease Rating Scale motor part (UPDRS III) and activities of daily living (UPDRS II) were improved by 37% (p = 0.028) and 50% (p = 0.046) at 6 months after surgery, respectively. Stimulation while 'off' medication improved the total UPDRS score by 42% (p = 0.028) at 6 months. At 6 months after surgery, the subscore of UPDRS III of body parts contralateral to the DBS implantation had improved by 48% (p = 0.028), and the ipsilateral subscore of UPDRS III and the axial subscore of UPDRS III had improved by 20% (p = 0.027) and 39% (p = 0.028), respectively. Daily dosage of levodopa was reduced by 15% at 6 months. No patient exhibited permanent side effects. These findings indicate that unilateral STN-DBS may be a reasonable surgical procedure for selected PD patients who have markedly asymmetric parkinsonism.     

Clinical and neuropsychological follow up at 12 months in patients with complicated Parkinson's disease treated with subcutaneous apomorphine infusion or deep brain stimulation of the subthalamic nucleus

BACKGROUND: The clinical condition of advanced Parkinson's disease (PD) patients is often complicated by motor fluctuations and dyskinesias which are difficult to control with available oral medications. OBJECTIVE: To compare clinical and neuropsychological 12 month outcome following subcutaneous apomorphine infusion (APO) and chronic deep brain stimulation of the subthalamic nucleus (STN-DBS) in advanced PD patients. METHODS: Patients with advanced PD and medically untreatable fluctuations underwent either APO (13 patients) or STN-DBS (12 patients). All patients were clinically (UPDRS-III, AIMS, 12 h on-off daily) and neuropsychologically (MMSE, Hamilton-17 depression, NPI) evaluated at baseline and at 12 months. APO was discontinued at night. RESULTS: At 12 months APO treatment (74.78+/-24.42 mg/day) resulted in significant reduction in off time (-51%) and no change in AIMS. Levodopa equivalent medication doses were reduced from 665.98+/-215 mg/day at baseline to 470+/-229 mg/day. MMSE, NPI, and Hamilton depression scores were unchanged. At 12 months STN-DBS resulted in significant clinical improvement in terms of reduction in daily off time (-76%) and AIMS (-81%) as well as levodopa equivalent medication doses (980+/-835 to 374+/-284 mg/day). Four out of 12 patients had stopped oral medications. MMSE was unchanged (from 28.6+/-0.3 to 28.4+/-0.6). Hamilton depression was also unchanged, but NPI showed significant worsening (from 6.58+/-9.8 to 18.16+/-10.2; p<0.02). Category fluency also declined. CONCLUSIONS: Both APO and STN-DBS resulted in significant clinical improvement in complicated PD. STN-DBS resulted in greater reduction in dopaminergic medications and provided 24 h motor benefit. However, STN-DBS, unlike APO, appears to be associated with significant worsening on NPI resulting from long term behavioral problems in some patients.     

微电极导向核团毁损术和脑深部电刺激术治疗帕金森病的疗效分析

目的 观察微电极导向核团毁损术和脑深部电刺激术（DBS）治疗帕金森病的临床疗效。方法 对380例接受微电极导向立体定向核团毁损术和25例脑深部电刺激丘脑底核（STN—DBS）治疗的帕金森病患者进行随访和神经功能评估，分别获得术前、术后和DBS开启后1周、6个月、2年及5年的不同服药状态下统一帕金森病量表（UPDRS）评分资料，采用威尔科克森检验（Wilcoxontest），比较不同术后时间点UPDRS运动评分与术前评分的差异。结果 核团毁损术和DBS在术后1周、6个月及2年随访中均能明显改善术前帕金森病患者的UPDRS运动评分，减轻左旋多巴诱发的运动波动及异动症。在5年随访时间点上仅DBS治疗组较术前比较仍显示差异性。而且DBS组患者术后左旋多巴服药的剂量较术前减少。核团毁损组总体并发症的发生率为5．8％，永久性并发症的发生率为1．2％。DBS组未发生严重并发症。结论 核团毁损术和DBS两者被证实是中晚期帕金森病安全、有效的治疗方法，能显著改善术前帕金森病患者的UPDRS运动评分，减轻左旋多巴诱发的运动波动及异动症。STN—DBS较毁损术更具有独特的可控性、安全性和长效性。     

Levodopa response in long-term bilateral subthalamic stimulation for Parkinson's disease.

Subthalamic nucleus deep brain stimulation (STN-DBS) is effective in advanced Parkinson's disease (PD), but its effects on the levodopa response are unclear. We studied the levodopa response after long-term STN-DBS, STN-DBS efficacy and predictive value of preoperative levodopa response to long-term DBS benefit in 33 PD patients with bilateral STN-DBS. Patients were assessed using the Unified Parkinson's Disease Rating Scale preoperatively (with and without medications) and postoperatively (without medications or stimulation, with only medications or stimulation, and with both medications and stimulation). Levodopa response significantly decreased postoperatively by 31.1% at 3 years and 32.3% at 5 years, possibly related to the reduction in medication requirement, direct STN stimulation effect or PD progression. STN-DBS alone significantly improved motor scores (37.2% at 3 years and 35.1% at 5 years) and activities of daily living scores (27.1% at 3 years and 19.2% at 5 years). Anti-PD drugs were significantly reduced by 47.9% at 3 years and 39.8% at 5 years. However, the magnitude of the preoperative response to levodopa did not predict DBS benefit at 3 and 5 years.     

Effects of subthalamic nucleus stimulation on striatal dopaminergic transmission in patients with Parkinson’s disease within one-year follow-up

The mechanisms by which deep brain stimulation (DBS) of the subthalamic nucleus (STN) leads to clinical benefit in Parkinson's disease (PD), especially with regard to dopaminergic transmission, remain unclear. Therefore, the objective of our study was to evaluate alterations of synaptic dopaminergic signaling following bilateral STN-DBS in advanced PD within a one-year follow-up. We used [(123)I]FP-CIT single-photon emission computed tomography (SPECT) to measure dopamine transporter (DAT) availability and [(123)I]IBZM SPECT to assess dopamine D(2) receptor (D2R) availability (stimulator ON condition).Patients (n=18) showed a tendency towards a better suppression of symptoms after STN-DBS (Unified Parkinson's Disease Rating Scale motor score with medication decreased from 24.1+/-16.1 to 15.4+/-7.45; p=0. 002) while medication was strongly reduced (61% reduction of levodopa equivalent units; p<0. 0001). No changes of striatal [(123)I]FP-CIT binding and an increase of [(123)I]IBZM binding up to 16% (p<0. 05) between pre-surgery and follow-up investigations were noticed. These data show that clinical improvement and reduction of dopaminergic drugs in patients with advanced PD undergoing bilateral STN-DBS are paralleled by stable DAT and recovery of striatal D2R availability 12 months after surgery.     

Variance in effects of subthalamic nucleus stimulation]

Chronic stimulation of subthalamus nucleus (STN) is effective in treating severe motor fluctuation and levodopa induced dyskinesia as well as parkinsonian motor symptoms. The improvement of peak-dose/diphasic dyskinesias of STN stimulation is considered to be due to the decrease in the daily dosage of antiparkinsonian drugs. However one report pointed out that STN stimulation improved directly levodopa induced dyskinesia. Moreover the timing of the improvement for levodopa induced dyskinesia is not yet obvious. In the present study, we have assessed variance in the latency of improvement of levodopa induced dyskinesia due to STN stimulation. In addition, we would clarify an issue which cite of STN stimulation improved parkinsonian symptoms and motor complication (motor dyskinesias and motor fluctuation). We have studied seven patients diagnosed with advanced idiopathic Parkinson's disease with motor fluctuations and levodopa induced dyskinesias. Before and after the implantation of stimulating electrode, patients were assessed by the Unified Parkinson's Disease Rating Scale and % 'OFF' motor state. The dosage of the antiparkinsonian medication was not modified for one month prior to implantation. Following implantation, dosage of the medication and strength of stimulation was adjusted, if necessary. Symptoms of motor fluctuation and dyskinesia improved in all patients six month after surgery. The mean off-time duration and dyskinesia disability improved compared with presurgical conditions. However, the time course of the improvement of dyskinesias was not the same among patients. Contralateral limb dyskinesias in three patients improved immediately after the stimulation without modification of medication. In contrast, the stimulation worsened contralateral limb dyskinesias in other three patients immediately following the surgery. In two of the three patients, dyskinesias gradually improved within one month after surgery without reducing the dosage of medication. Dyskinesias of the other patient improved following a reduction in the dosage of medication one month after the surgery. Improvement of parkinsonian symptoms of the patients with longer latency of stimulation effect for dyskinesias was better than that of the patients with shorter latency. Stimulation cite of the former group appeared to locate more central than that of the latter group. Latency and strength of the effects of STN stimulation are variable.