深部电刺激脑内靶点在帕金森病中的应用

本综述脑深部电剌激(DBS)治疗帕金森病常用靶点的临床应用，目前常用靶点包括丘脑腹中间核(Vim)，苍白球内侧(GHi)和丘脑底核(STN)，根据病人症状可选择不同靶点。Vim DBS对单纯震颤的帕金森病有显疗效，GPi DBS和STN DBS适用于既有震颤和僵硬的帕金森病病人，又适用于运动迟缓和异动症病人，术后可逐渐减少服用多巴胺的剂量。目前认为STN DBS缓解震颤和僵硬疗效要优于GPi和Vim DBS，研究表明STN DBS具有一定的神经保护作用，它抑制了STN的过度兴奋，使谷氨酸的释放减少，降低对投射区域的神经毒性作用，减少了多巴胺能神经元的变性，延缓帕金森病的进展，可作为DBS治疗帕金森病的首选靶点。     

全麻下机器人辅助脑深部电刺激术治疗帕金森病

目的 研究全麻下机器人辅助脑深部电刺激术(deep brain stimulation,DBS)治疗帕金森病(Parkinson's disease,PD)的疗效.方法 回顾性分析87例PD病例资料,均采用全麻下机器辅助DBS植入电极,并进行刺激参数调试.靶点选择丘脑底核(subthalamic nucleus,STN...     

不同靶点脑深部电刺激治疗帕金森病患者的疗效 特点

帕金森病（PD）严重影响着中老年患者的生活质量,目前PD患者行脑深部电刺激术（DBS） 的常用靶点包括丘脑腹中间核（Vim）、丘脑底核（STN）、苍白球内侧核（GPi）和桥脑脚核（PPN）,由于Vim对 PD患者症状的改善局限于震颤,目前已被STN和GPi靶点所替代,这两个靶点解决了PD患者的震颤、僵 硬、运动迟缓以及异动症的症状,近十几年来,PPN靶点的应用解决了PD患者步态失调和姿势不稳等中 轴症状,现根据不同靶点DBS后PD患者症状改善情况进行综述。     

神经电刺激治疗神经精神疾病的应用进展

应用脑深部电刺激（deepbrain stimulation，DBS）治疗运动障碍疾病以来，神经电刺激的适用范围逐渐增加，最初DBS仅用于对药物治疗效果不佳的帕金森病、肌张力障碍、特发性震颤等患者。自90年代开始，随着对新的临床指证，解剖靶点和手术技术认识的不断深入，     

陶氏DBS手术评分法在帕金森病疗效评估的应用

目的 研究陶氏DBS手术评分法是否可有效评估深部电刺激术(deep brain stimulation,DBS)与预估疗效.方法 回顾性分析73例帕金森病(Parkinson's disease,PD)病例资料,均在ROSA机器人辅助下完成DBS,靶点选择丘脑底核(subthalamic nucleus,STN)42例...     

微电极引导立体定向核团毁损和脑深部电刺激治疗帕金森病

目的研究微电极引导立体定向颅内核团毁损和脑深部电刺激手术(deep brain stimulation,DBS)治疗帕金森病的临床疗效。方法分析我院116例应用微电极引导立体定向核团毁损术和85例应用脑深部电刺激术治疗的帕金森病患者的临床资料,获得术前、术后和DBS开启后6个月、1年、3年及5年的不同服药状态下帕金森病联合评分量表(UPDRS)的评分,比较手术前后UPDRS运动评分的差异。结果核团毁损术和DBS在术后6个月、1年和3年的随访中均能显著改善患者术前UPDRS运动评分,在第5年仅DBS组UPDRS运动评分较术前有改善,同时DBS组患者术后抗帕金森病药物用量较术前减少。结论核团毁损和脑深部电刺激手术均能显著改善帕金森病患者的UPDRS运动评分,DBS疗效更为长久。     

帕金森病及运动障碍性疾病的脑深部电刺激术治疗研究现状

脑深部电刺激术（deep brain stimulation，DBS）的出现是帕金森病及其他运动障碍性疾病治疗的一个里程碑。它采用立体定向的方法进行精确定位，在脑内特定的靶点植入刺激电极进行高频电刺激，从而改变相应核团的兴奋性以达到改善症状、控制癫痫发作、缓解疼痛，是一种微侵袭神经外科手术方法。自1987年法国的Benabid等应用脑深部电刺激术刺激丘脑腹外侧核治疗帕金森病震颤和特发性震颤获得成功后，至今全世界已有500余家医疗中心实施脑深部电刺激手术治疗运动障碍性疾病，植入电极超过35000例次。[第一段]     

脑深部电刺激治疗帕金森病近期疗效的初步探讨

目的 探讨脑深部电刺激(deep brain stimulation,DBS)治疗帕金森病近期的治疗效果和良好的手术方法.方法 分析我院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的临床资料,术前进行左旋多巴冲击试验,采用核磁共振(MRI)、微电极记录(microelectrode recording,MER)技术和术中测试结果共同确定最后靶点,并经过MRI复查验证位置准确,同期植入脉冲发生器,比较手术前后统一帕金森病评定量表运动评分(UPDRSⅢ).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(subthalamic nucleus,STN),MRI复查电极均位于STN背侧,全部术后早期有微毁损效应,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 STN-DBS治疗帕金森病的近期疗效显著,严谨的手术流程是DBS良好疗效的保障.     

60例帕金森病脑立体定向术的临床研究

目的：本研究旨在运用脑立体定向技术,治疗帕金森病,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CT或MR导向,辅以电生理刺激矫正靶点,对60例帕金森病（PD）患者行丘脑（Vim)或苍白球（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例进行了二侧手术,5例进行了DBS,结果显示有效率100%,术后1月Wwebster评分下降了30%,UP-DRS评分下降了37%,患者生活质量明显提高,无永久性手术并发症和死亡。结论：从长期的治疗效果来看,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毁损更加准确;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。     

脑深部电刺激治疗帕金森病

药物治疗对早期帕金森病患者是有效的,但随着疾病的进展,药物疗效减退并出现日益增多的严重的不良反应.其中包括运动波动、药物导致的不自主运动或运动障碍.即使接受最好的药物疗法,患者仍然出现严重的功能障碍时,就需要考虑替代措施.正是在这种情况下,慢性脑深部电刺激(deep brain stimulation,DBS)开始作为一种有效的方法用于治疗帕金森病. 1 有关原理 帕金森病由于神经变性和受体缺乏而使神经环路的功能严重受损,在非人的灵长类帕金森病实验模型所得到的证据表明:在帕金森病病理状态下,包括苍白球内侧核(GPi)[1,2]和丘脑底核(STN)[3]在内的运动系统环路中具有病理性神经活动的特征.通过毁损或慢性电刺激对异常活动所产生的抑制能够使帕金森病实验模型和帕金森病人得到改善[4～7].目前治疗帕金森病所应用的三个主要靶点为丘脑腹中间核(Vim)、GPi和STN,其中Vim用于震颤,GPi或STN用于治疗运动徐缓、肌强直、震颤、姿势和步态障碍和药物产生的不自主运动.     

Parkinson's disease: deep brain stimulation

The effects of deep brain stimulation (DBS) of the subthalamic nucleus (STN) or the internal pallidum (GPi) on the parkinsonian triad and on levodopa-induced dyskinesias are very similar. The antiakinetic effect of STN DBS seems to be slightly better. On the contrary to pallidal DBS, stimulation of the STN allows to reduce dopaminergic treatment by more than 50p.100 on average. Moreover, the current drain is smaller in STN. Thus, the STN is a low budget target compared to the GPi. STN DBS seems to be as effective on PD tremor as stimulation of the classic thalamic target, the ventral intermediate nucleus (Vim), whereas Vim stimulation has no effect on akinesia and very little on levodopa-induced dyskinesias. Thus, the STN has become the main target nucleus for DBS in PD, which is most often performed bilaterally in one surgical procedure. There is a good correlation of the preoperative response to levodopa and postoperative effects of bilateral STN DBS and this defines the patient population. Given the large patient population, simple guidelines for patient selection are developed. The referring physician can preselect patients based mainly on age (less than 70), absence of dementia and presence of severe disability related to motor fluctuations or dyskinesias. It is the responsibility of the operating centre to determine the levodopa response, to confirm the diagnosis, to rule out contraindications and to make sure that the medical treatment cannot be further optimised. Severe surgical complications with permanent sequels are relatively rare, about 1p.100 per implanted side. The patient selection, the precision of the surgery and the quality of the postoperative follow-up are the three main determinants of success.     

Stimulation of the subthalamic nucleus in a patient with Parkinson disease and essential tremor

BACKGROUND: The preferred surgical target for the treatment of Parkinson disease (PD) is either the internal globus pallidus or the subthalamic nucleus (STN); the target for treatment of essential tremor (ET) is the thalamic subnucleus ventralis intermedius (Vim). Some patients with PD have coexistent ET, and the identification of a single surgical target to treat both parkinsonian motor symptoms and ET would be of practical importance. OBJECTIVE: To describe the use of the STN target in deep brain stimulator (DBS) surgery to treat PD motor symptoms and the action-postural tremor of ET. DESIGN: Case report. PATIENT: A 62-year-old man had a greater than 30-year history of action-postural tremor in both hands, well controlled with beta-blockers for more than 20 years. He developed resting tremor, bradykinesia, and rigidity on his right side that progressed to his left side during the past 10 years. Dopaminergic medication improved his rigidity and bradykinesia, with only mild improvement of his resting tremor and no effect on his action-postural tremor. INTERVENTIONS: Left pallidotomy followed by placement of a left DBS in the Vim and subsequent placement of a right STN DBS. MAIN OUTCOME MEASURES: Control of symptoms of PD and ET. RESULTS: The left pallidotomy controlled the patient's parkinsonian motor symptoms on the right side of his body, but did not affect the action-postural component of his tremor. The symptoms on the left side of the body, including both an action-postural and a resting tremor (as well as the rigidity and bradykinesia), improved after placement of a single right STN DBS. CONCLUSION: Placement of an STN DBS should be considered as the procedure of choice for surgical treatment of patients with a combination of PD and ET.     

Deep brain stimulation in the management of Parkinson's disease

Deep brain stimulation (DBS) is a neurosurgical treatment of Parkinson's disease and other movement disorders. This surgical technique is applied to three brain targets: the ventral intermediate nucleus of the thalamus (Vim), the globus pallidus internus (Gpi) and the subthalamic nucleus (STN). Vim DBS improves contralateral parkinsonian tremor. STN and GPi DBS improve contralateral bradykinesia, rigidity, parkinsonian tremor and also levodopa-induced dyskinesia. There is little comparative data between bilateral STN and bilateral GPi procedures but the improvement with bilateral STN DBS seems more pronounced than with bilateral GPi DBS. Moreover, only STN BDS allows a significant decrease of antiparkinsonian medication. The other advantage of STN over GPi DBS is the lower consumption of current. The DBS procedure contrary to ablative surgery has the unique advantage of reversibility and adjustability over time. Patients with no behavioral, mood and cognitive impairments benefit the most from bilateral STN DBS. The stimulation-induced adverse effects related to DBS are reversible and adjustable. More specific adverse effects related do hardware are: disconnection, lead breaking, erosion or infection. The disadvantage of DBS is a relatively high cost. The setting of stimulation parameters to achieve the best clinical result may be very time-consuming. Most authors agree that DBS is a safer and more favorable procedure than ablative surgery.     

Deep brain stimulation therapy for involuntary movements]

During the last decade, it has become clear that deep brain stimulation (DBS) therapy provides a dramatic improvement in the symptoms of movement disorders. We have experienced DBS in 110 patients with various types of involuntary movements, and confirmed the benefits of stimulation of the thalamic nucleus ventralis intermedius (Vim), internal globus pallidus (GPi) and subthalamic nucleus (STN) in these patients. DBS therapy affords the best effect on tremor when the Vim is selected as the stimulation site. DBS therapy is also useful for controlling rigidity when the GPi or STN is stimulated. Improvements of bradykinesia and gait disturbance are often induced by DBS therapy involving the GPi or STN. Dopa-induced dyskinesia can be attenuated effectively by the direct and/or indirect effects of DBS therapy. DBS of the Vim also provides excellent control of post-stroke involuntary movements, including hemiballism and hemichoreoathetosis. Dystonia in young patients is controlled effectively by DBS of GPi. Ablative procedures for control of involuntary movement disorders, such as thalamotomy and pallidotomy, always carry a risk associated with creating additional lesions in an already damaged brain. In contrast, there is not such a risk in DBS therapy. This modality of therapy is an important option in treating involuntary movements.     

Stereotactic neurosurgery for movement disorders

Stereotactic neurosurgery for the treatment of movement disorders focuses primarily on the treatment of Parkinson's disease (PD), essential tremor (ET), and dystonia. The surgical targets in use are the subthalamic nucleus (STN) and the globus pallidus internus (GPi) for PD, GPi for dystonia, and ventralis intermedius (Vim) nucleus of the thalamus for ET. Following target selection, procedures include the generation of lesions or the placement of deep brain stimulating electrodes in the selected target. Additionally, transplantation has been used in the treatment of PD. The indications, outcomes, and risks of the various procedures are reviewed.     

Psychiatric and Cognitive Effects of Deep Brain Stimulation for Parkinson’s Disease

Deep brain stimulation (DBS) is effective for Parkinson’s disease (PD), dystonia, and essential tremor (ET). While motor benefits are well documented, cognitive and psychiatric side effects from the subthalamic nucleus (STN) and globus pallidus interna (GPi) DBS for PD are increasingly recognized. Underlying disease, medications, microlesions, and post-surgical stimulation likely all contribute to non-motor symptoms (NMS).     

Stimulation of the subthalamic region facilitates the selection and inhibition of motor responses in Parkinson's disease

The aim of the present study was to specify the involvement of the basal ganglia in motor response selection and response inhibition. Two samples were studied. The first sample consisted of patients diagnosed with Parkinson's disease (PD) who received deep-brain stimulation (DBS) of the subthalamic nucleus (STN). The second sample consisted of patients who received DBS for the treatment of PD or essential tremor (ET) in the ventral intermediate nucleus of the thalamus (Vim). Stop-signal task and go/no-go task performances were studied in both groups. Both groups performed these tasks with (on stimulation) and without (off stimulation) DBS to address the question of whether stimulation is effective in improving choice reaction time (RT) and stop-signal RT. The results show that DBS of the STN was associated with significantly enhanced inhibitory control, as indicated by shorter stop-signal RTs. An additional finding is that DBS of the STN led to significantly shorter choice RT. The effects of DBS on responding and response inhibition were functionally independent. Although DBS of the Vim did not systematically affect task performance in patients with ET, a subgroup of Vim-stimulated PD patients showed enhanced stop-signal RTs in on stimulation versus off stimulation. This result suggests that the change in performance to stop signals may not be directly related to STN function, but rather results from a change in PD function due to DBS in general. The findings are discussed in terms of current functional and neurobiological models that relate basal ganglia function to the selection and inhibition of motor responses.     

Combined deep brain stimulation and thalamotomy for tremor-dominant Parkinson’s disease

Although deep brain stimulation (DBS) is an established treatment for Parkinson’s disease, the long-term suppression of tremor is still a challenging issue. We report two patients with tremor-dominant Parkinson’s disease (PD) treated with unilateral thalamotomy of the ventralis intermedius nucleus (Vim) combined with the subthalamic nucleus (STN)-DBS or the posterior subthalamic area (PSA)-DBS. One year after the surgery, thalamotomy of the area from the Vim to the PSA showed improvement not only in tremor but also in rigidity and akinesia. PSA- or STN-DBS with low intensity stimulation eliminated residual PD symptoms. Combined DBS and thalamotomy may provide long-term improvement of the majority of PD symptoms using lower therapeutic stimulation voltages.     

Deep brain stimulation for the treatment of Parkinson's disease.

Deep brain stimulation (DBS) is increasingly accepted as an adjunct therapy for Parkinson's disease (PD). It is considered a surgical treatment alternative for patients with intractable tremor or for those patients who are affected by long-term complications of levodopa therapy such as motor fluctuations and severe dyskinesias. Thalamic stimulation in the ventral intermediate nucleus (Vim) leads to a marked reduction of contralateral tremor but has no beneficial effect on other symptoms of Parkinson's disease. The subthalamic nucleus (STN) and the internal segment of the globus pallidus (GPi) are targeted for the treatment of advanced Parkinson's disease. Several studies have proven the efficacy of STN-DBS and GPi-DBS in alleviating off motor symptoms and dyskinesias. Sub-thalamic nucleus deep brain stimulation is currently considered superior to GPi-DBS because the antiakinetic effect seems to be more pronounced, allows a more marked reduction of antiparkinsonian medication, and requires less stimulation energy. More recently, however, a number of reports on possible psychiatric and behavioral side effects of STN-DBS have been a matter of concern. Given the chronic nature of PD and the noncurative approach of DBS, both targets will need to be reevaluated on the basis of their long-term efficacy and their impact on quality of life. Despite the rapidly increasing numbers of DBS procedures, surprisingly few controlled clinical trials are available that address important clinical issues such as: When should DBS be applied during the course of disease? Which patients should be selected? Which target should be considered? Which guidelines should be followed during postoperative care? Here is summarized the available evidence on DBS as a therapeutic tool for the treatment of Parkinson's disease and the current state of debate on open issues.     

Combination targeting of subthalamic nucleus and ventral intermediate thalamic nucleus with a single trajectory in deep brain stimulation for tremor-dominant Parkinson’s disease

Deep brain stimulation (DBS) has traditionally been used to target the subthalamic nucleus (STN) or globus pallidus internus (GPi) to treat Parkinson’s disease (PD) and the ventral intermediate thalamic nucleus (VIM) to treat essential tremor (ET). Recent case reports have described targeting both the STN and VIM with a single trajectory and electrode to treat patients with tremor-dominant PD, yet outcome data for this procedure remains sparse. Our objective is to determine the safety and efficacy of combination STN-VIM DBS. We conducted a single-center retrospective case series of all patients who underwent combined STN-VIM DBS. Demographic, perioperative, and outcome data, including Unified Parkinson Disease Rating Scale-III (UPDRS) and tremor scores (OFF-medication), and levodopa equivalent daily dose (LEDD), were collected and analyzed. Nineteen patients underwent this procedure. Patients were 89% male and 11% female, with a mean age of 63.6 years. Mean preoperative UPDRS was 24.1, and LEDD was 811.8. At a mean follow-up of 33.8 months, UPDRS and LEDD decreased by an average of 9.2 (38.2%) and 326.3 (40.2%), respectively. Tremor scores decreased by 4.9 (59.0%), and 58% were able to decrease total medication burden. One patient developed transient left-sided weakness, yielding a complication rate of 5.3%. Combined targeting of STN and VIM thalamus via a single frontal trajectory for tremor-dominant Parkinson’s Disease results in similar UPDRS outcomes to STN DBS and improved control of tremor symptoms. Larger multicenter studies are necessary to validate this as the optimal DBS target for tremor-dominant PD.