微电极导向立体定向手术治疗原发性震颤

目的：探讨丘脑腹外则Vim核中与震颤症状相关的神经细胞电活动的规律,总结丘脑毁损术治疗原性震颤（ET）的临床效果和安全性。方法：对42例ET患者行单侧微电极导向的丘脑毁损术。采用FAHN的临床震颤评分法对其中11例患者术前及术后进行定量评估和分析。结果：Vim核中神经细胞的簇状电活动节律与肢体震颤的节律有肯定的一致性,毁损这些与震颤症状相关的神经细胞后,所有ET患者手术对侧肢体的震颤完全消失;震颤的整体改善率52％,特殊动作和功能改善54％,功能残疾改善率77％,长期随访疗效稳定,其中40例患者的震颤症状密切相关,毁损这些细胞能完全永久性地消除震颤症状。     

立体定向选择性Vim核和(或)PVP核毁损术治疗帕金森病疗效观察

目的观察应用立体定向脑内核团毁损术治疗帕金森病的临床疗效。方法 2012年7至2013年12月采用立体定向丘脑腹中间核(Vim核)和或苍白球腹后外侧部(PVP核)毁损术治疗帕金森病45例。术前、术后1个月进行UPDRS评分,比较手术前后评分的变化和症状改善情况。结果 45例帕金森病患者的肢体震颤、僵硬及运动迟缓均得到明显改善,术后1个月的UPDRS评分较术前明显减少(P0.01),术后无明显并发症。结论立体定向脑内核团毁损术治疗帕金森病疗效显著,靶点定位、毁损范围及程度与手术疗效及并发症密切相关。     

微电极引导丘脑Vim切开治疗震颤麻痹40例报告

目的:探讨微电极引导下丘脑Vim核切开治疗震颤麻痹的作用和效果.方法:采用微电极引导下立体定向丘脑Vim射频切开术治疗40例患者,用CRW定向仪,应用MR1扫描,在冠状位、轴位像可直接确定解剖靶点,读出靶点坐标.术中微电极记录细胞电活动异常信号,协助确定靶点,然后进行射频毁损术.结果:本组无死亡,随访至今2例分别在术后1周,20天震颤复发,2例遗留口周及对侧手指麻木,其余震颤完全消失,肌强直及运动迟缓改善,远期疗效在随访中.结论:使用MR1导向,保证手术定位精确性,微电极可在Vim核记录到震颤同步的震颤细胞异常电活动,达到功能定位,对提高手术疗效,降低并症具有重要的作用.     

低温多靶点定向毁损术治疗帕金森病临床研究

目的：对震颤、僵硬及运动迟缓帕金森病患者。采用脑立体定向手术的临床疗效进行分析。方法：应用低温多靶点立体定向技术,对52例患者进行同侧丘脑腹外侧核（VL）（主要是Vim核）及苍白球腹后外侧部（VPLP）同期毁损术。结果：52例患者的肢体震颤,僵硬及运动迟缓得到明显改善。而且有利于改善患者的植物神经功能紊乱,提高患者生存质量,减少并发症。结论：应用低温多靶点定向毁损术对震颤,僵硬及运动迟缓,植物神经功能紊乱的PD患者,行同侧VL及VPLP联合毁损术,能克服传统的VL毁损术对运动迟缓无效,VPLP毁损对震颤改善不充分,全面改善PD患者的症状,多靶点能弥补低温破坏不完全之不足,减少并发症,降低手术危险性,手术成功关键是精确定位,精确定位则依赖于电生理验证。     

特发性震颤的微电极导向射频治疗

目的探讨丘脑Vim核中神经细胞的电活动与特发性震颤（ET）的关系,总结Vim核射频毁损（切开）术治疗ET的可行性、并发症及疗效。方法对72例ET行CT定位微电极导向Vim核射频,并进行FAHN评分。结果Vim核中存在与肢体震颤节律一致的细胞电活动,毁损这些细胞后震颤立即消失,有效率100％。整体评分改善率60．2％;震颤程度和部位改善率53．1％;特殊动作和功能改善率51．6％;功能残疾改善率76．2％。暂时性并发症19例,3—36个月随访疗效稳定。结论丘脑Vim核中存在与ET密切相关的细胞,射频毁损Vim核是治疗ET安全有效措施。     

帕金森病外科治疗的适应证及毁损部位的选择

目的介绍微电极导向立体定向毁损手术治疗帕金森病的适应证及毁损部位选择的经验.方法回顾607例帕金森病患者采用微电极导向立体定向毁损手术治疗经验,根据临床症状分型确定,单纯震颤型,选择丘脑腹外侧核(Vim,Vop)为靶点;僵直少动型选择苍白球腹后内侧部为靶点;混合型首先选择苍白球腹后内侧部为靶点,术中如肢体震颤改善不理想时,再加丘脑腹外侧核(Vim)毁损.结果手术有效率97.3%,术后患者Hoehn和Yah分级及UPDRS评分及药物所致运动障碍均有显著改善.术后1周开状态改善率62.3%±11.3%,关状态改善率76.1%±8.7%.总并发症的发生率为5.5%,永久性并发症为1.3%.结论微电极记录技术能显著提高手术定位准确率及成功率.合适的病例选择对于良好的手术疗效是第一位的,手术适应证的选择应该遵循一个基本原则,即诊断明确,手术操作有助于改善患者目前的生活质量.毁损靶点的选择,取决于患者的临床症状分型,根据病人的临床症状,灵活地选择毁损靶点.     

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。     

立体定向脑内核团毁损术治疗帕金森病(附52例报告)

目的探讨立体定向脑内核团毁损术治疗帕金森病的安全性及有效性。方法本组男29例,女23例;年龄41~77岁,病程3~15年,其中震颤型40例,肌强直型8例,混合型4例。在局麻下对这些患者行立体定向脑内核团射频毁损术,术后观察治疗的效果。结果本组44例行Vim核毁损术,8例行Gpi毁损术,手术有效率100%,术后出现毁损部位少量出血1例,出现术侧肢体偏瘫1例,经治疗1个月后症状均缓解。结论立体定向脑内核团毁损术治疗帕金森病疗效显著,且靶点选择、毁损范围及程度与手术疗效及并发症密切相关。     

微电极导向VL核和PVP核联合毁损治疗帕金森病

目的：对震颤、僵硬及运动迟缓帕金森病（ＰＤ）患者的立体定向手术方法学进行探讨。方法：应用微电极导向技术,对４３例ＰＤ患者,同侧丘脑腹外侧核（Ｖim/Vop)及苍白球腹后部（PVP）进行联合毁损术。结果：43例PD患者的肢体震颤、僵硬及运动迟缓均得到明显改善。术前术后Motor UPDRS积分,开状态及关状态均显著改善（P＜0．01）,无永久并发症。结论：应用微电极导向立体定向技术对伴有肢体震颤、强直及运动迟缓的ＰＤ患者,行同侧Ｖim核和PVP核联合毁损手术,能全面改善PD患者的症状,是一种安全有效的手术方法。     

微电极记录技术在治疗帕金森病手术中应用价值

目的总结微电极导向立体定向手术治疗帕金森病的治疗效果.方法采用微电极向立体定向手术治疗帕金森病380例,采用坐标和图像直接定位相结合.行苍白球腹后部毁损术(PVP)305例,丘脑腹中间核(Vim)毁损术34例,行同期同侧PVP和Vim毁损术16例,行同期双侧PVP11例,分期双侧PVP11例,分期单侧PVP或Vim毁损术3例,术前、术后的关状态和开状态进行生活能力评分、UPDRS评分.结果术后日常生活能力评分“关”状态提高29.8%,“开”状态提高25.9%.UPDRS总的改善率为57.3%,其中精神行为情绪改善率为50.8%,日常活动改善率59.1%,运动功能改善率58.2%;并发症颅内出血5例,全组无死亡.本组有220例术后随访4～18个月,其中显效130例(59%),改善75例(34%),无效15例(7%).结论用微电极记录可准确定位,了解周围结构,以提高疗效,减少并发症.在临床应用中观察到毁损灶偏向苍白球内侧对僵硬和运动障碍改善明显,而偏向苍白球外侧对震颤改善明显.PVP毁损对异动症、“开一关”症状及肌张力增高效果最好;对肌肉酸痛、震颤、步态、姿势、语言其次;对植物神经功能障碍无明显疗效.PVP对药物治疗反应较好的患者手术效果也较理想,Vim毁损术对药物治疗无效的震颤也有明显效果.     

Stereotactic selective thalamotomy for the treatment of tremor type cerebral palsy in adolescence

6 cases with tremor-athetotic type cerebral palsy and 2 cases with moderate dystonia-tremor type cerebral palsy were treated by selective stereotactic thalamotomy. In the former group, postural-movement type tremor in the upper limb gradually progressed with age while athetosis remained unchanged. In the latter group, dystonia in the truncal muscles predominated over the irregular tremulous movement of the upper limbs. In all cases, the intelligence was almost normal. Stereotactic selective thalamotomy (Vim for tremor athetosis, VL-Vim for dystonia tremor) was performed under local anesthesia with the aid of radiological and neurophysiological control methods. The results of the operations were satisfactory in regard to the tremor relief and concomitant improvement of motor performances in most of the cases. Stereotactic treatment might be an effective way to make possible a one-step progress in these handicapped cases. The importance of postoperative physical therapy is also emphasized.     

Vim thalamotomy for Holmes' tremor secondary to midbrain tumour

Holmes' (rubral or midbrain) tremor is an unusual combination of 2 Hz to 5 Hz rest, postural, and kinetic tremors of an upper extremity. This tremor has been considered to result from the lesions in the vicinity of the red nucleus in the midbrain. There has been no systematic analysis of the surgical target in the Holmes' tremor so far of nucleus ventrointermedius (Vim) or globus pallidus interna. This 26 year old man gradually developed a disabling midbrain tremor involving both the distal and proximal parts of the left upper arm. Additional neurological findings included oculomotor palsy and ataxia of the left arm. On the radiological studies, a mass lesion (germinoma) was found on the midbrain tegmentum, which was treated by conventional radiation therapy. Although there was improvement in the radiological imaging, his midbrain tremor became intolerable despite medical treatment. The authors performed MR guided stereotactic Vim thalamotomy. With radiofrequency lesioning in the right Vim, his resting, postural, and action tremors were much alleviated in both the distal and proximal parts of the left upper extremity. The authors consider that Vim thalamotomy is still an effective means of controlling midbrain tremors involving the proximal upper limb.     

微电极导向VL核和PVP核联合毁损治疗帕金森病

目的：对震颤、僵硬及运动迟缓帕金森病（ＰＤ）患者的立体定向手术方法学进行探讨。方法：应用微电极导向技术,对４３例ＰＤ患者,同侧丘脑腹外侧核（Ｖｉｍ／Ｖｏｐ）及苍白球腹后部（ＰＶＰ）进行联合毁损术。结果：４３例ＰＤ患者的肢体震颤、僵硬及运动迟缓均得到明显改善,术前术后ＭｏｔｏｒＵＰＤＲＳ积分,开状态及关状态均显著改善（Ｐ＜０．０１）,无永久并发症。结论：应用微电极导向立体定向技术对伴有肢体震颤、强直及运动迟缓的ＰＤ患者,行同侧Ｖｉｍ核和ＰＶＰ核联合毁损手术,能全面改善ＰＤ患者的症状,是一种安全有效的手术方法。     

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.     

Treatment of Parkinson tremor by chronic stimulation of the ventral intermediate nucleus of the thalamus

Stereotactic ventral intermediate nucleus (Vim) thalamotomy may improve drug resistant severe parkinsonian tremor. However, tremor may recur and bilateral thalamotomy is known to induce unacceptable side effects in a proportion of patients. A high frequency (130 Hz) chronic Vim stimulation was performed in 4 parkinsonian patients, 2 of them having previously undergone a thalamotomy on the other side. Tremor was suppressed in all patients at the price of slight paresthesias. This improvement has been lasting from 2 to 14 months. Beneficial and adverse effects were suppressed at once each time the stimulation was stopped. These preliminary results are encouraging but a longer delay and more patients are obviously needed.     

El papel de la tractografía en la localización del núcleo ventralis intermedius del tálamo y el haz dentatorrubrotalámico en el tratamiento del temblor

IntroductionThe ventralis intermedius (Vim) nucleus of the thalamus is the usual surgical target for tremor. However, locating the structure may be difficult as it is not visible with conventional imaging methods; therefore, surgical procedures typically use indirect calculations correlated with clinical and intraoperative neurophysiological findings. Current ablative surgical procedures such as Gamma-Knife thalamotomy and magnetic resonance-guided focused ultrasound require new alternatives for locating the Vim nucleus. In this review, we compare Vim nucleus location for the treatment of tremor using stereotactic procedures versus direct location by means of tractography.DiscussionThe most widely used cytoarchitectonic definition of the Vim nucleus is that established by Schaltenbrand and Wahren. There is a well-defined limit between the motor and the sensory thalamus; Vim neurons respond to passive joint movements and are synchronous with peripheral tremor. The most frequently used stereotactic coordinates for the Vim nucleus are based on indirect calculations referencing the mid-commissural line and third ventricle, which vary between patients. Recent studies suggest that the dentato-rubro-thalamic tract is an optimal target for controlling tremor, citing a clinical improvement; however, this has not yet been corroborated.ConclusionsVisualisation of the cerebello-rubro-thalamic pathway by tractography may help in locating the Vim nucleus. The technique has several limitations, and the method requires standardisation to obtain more precise results. The utility of direct targeting by tractography over indirect targeting for patients with tremor remains to be demonstrated in the long-term.     

Thalamic deep brain stimulation in the treatment of essential tremor

Background and purposeQuality of life can be severely impaired by essential tremor (ET) being the main cause of the patient's disability. The authors present a group of ET patients treated with deep brain stimulation of the ventral intermediate nucleus of the thalamus (Vim DBS). The aim of the study was to evaluate the efficacy and safety of Vim DBS in the treatment of ET.Material and methodsBetween 2006 and 2009, 8 female and 10 male ET patients were treated with Vim DBS. Mean age at implantation was 63 ± 15 years. ET lasted from 4 to 30 years (mean 12 years). Clinical condition of the group was evaluated before surgery and 3 months after implantation with spirography (spiral drawings), the modified Fahn (Tremor Rating Scale, TRS) scale, and the modified ADL (Activity of Daily Living) scale. The Vim was localized with CT and MRI. The procedures of implantation were performed under local and general anaesthesia. A bilateral procedure was performed in 11 cases and a unilateral procedure was performed in 7 cases.ResultsThe therapeutic effect of DBS was maintained at the follow-up in the third month following surgery. Mean contralateral limb tremor reduction was 79%. Head tremor reduction was reported by 75% of patients in the bilateral Vim DBS subgroup and 50% of patients in the unilateral Vim DBS subgroup. Mean ADL score improved by 61%.ConclusionsVim DBS is a safe and effective method of ET treatment. Vim DBS improves activities of daily living of ET patients.     

立体定向丘脑腹中间核毁损术治疗书写痉挛的疗效评估

目的探讨丘脑腹中间(Vim)核毁损术治疗书写痉挛的有效性和安全性。方法采用微电极引导下左侧丘脑Vim核毁损治疗书写痉挛(WC)患者47例,其中男32例,女15例;年龄15~64岁,平均(28.9±10.7)岁;病程2~21年。在术前和术后,采用书写痉挛评分量表(the writer's cramp rating scale,WCRS)对患者进行评分。结果全部患者毁损手术当时症状就明显改善,肘部、腕部和手指痉挛明显缓解,写字的流利程度和速度明显提升。其中2例患者(4.2%)出现一过性的右手指尖麻木;另有3例患者(6.4%)出现一过性言语不流利;上述并发症在3个月内完全恢复,没有永久性并发症发生。术后对患者进行电话随访,随访时间6~36个月,平均23个月;结果显示,患者的症状改善稳定;其中有3例患者失随访。另外,有1例患者因症状反复,再次行丘脑Vim核毁损术,术后症状改善明显。结论丘脑Vim核毁损术治疗书写痉挛是一种有效、安全的手术方式。