Emergence of complex, involuntary movements after gamma knife radiosurgery for essential tremor.

Gamma knife radiosurgery is generally considered a safer alternative to traditional pallidotomy or thalamotomy. We report the case of a 59-year-old patient with essential tremor who developed a complex, disabling movement disorder following gamma knife thalamotomy. This case illustrates the need for long-term follow-up to fully evaluate the potential for complications following radiosurgery.     

分期立体定向双侧多靶点毁损术治疗帕金森病

目的:探讨分期双侧多靶点毁损术的疗效、适应证、靶点的选择及并发症。方法:对比第一次手术350例与第二次手术387例患者的UPDRS评分、评分改善率、并发症及主要症状改善率，进行统计学分析。结果两次手术均有显著近期疗效，二次手术单项症状改善率为震颤95．3％、僵直94．6％、运动迟缓82．9％、步态62．4％、平衡65．3％、异动症和痛性痉挛96．4％，总有效率97．2％。第二次手术总体改善率较第一次低，一过性特异性并发症增多，能于短期内恢复，永久性并发症发生率为5．43％。美多巴用量较术前减少。结论:分期双侧多靶点毁损术治疗帕金森病是一种有效、安全的方法，术前选好手术适应证、手术方式至关重要，两次手术间隔时间以半年以上为宜。     

分期双侧多靶点毁损术治疗帕金森病疗效的相关因素分析

目的　探讨分期双侧多靶点毁损术治疗帕金森病 (PD)疗效的相关因素。方法　将 387例需手术治疗的PD患者按年龄、手术方式、两次手术的间隔时间、毁损电极粗细 4项进行分组 ,探讨上述因素与疗效、并发症的关系。结果　二次手术近期疗效显著 ,分期双侧苍白球腹后内侧部 (PVP)毁损术是应用最多的术式 ;双侧丘脑腹中间 (Vim)核毁损术并发症的发生率高 (10 0 % ) ;5 5岁以上的患者并发症发生率 (2 9 70 % )明显高于 5 5岁以下的患者 (12 6 6 % ) (P <0 0 5 ) ;二次手术间隔时间在半年以内者并发症的发生率 (41 6 7% )高于间隔半年以上者 (P <0 0 5 ) ;1 8mm电极的治疗效果 (98 0 1% )好于 1 1mm电极 (96 6 1% ) ,但并发症的发生率却高于 1 1mm的电极 ,达 2 8 4 8% (P <0 0 5 )。结论　分期双侧PVP毁损术相对安全 ;分期一侧PVP加对侧Vim核毁损可减少并发症 ;术前选好手术适应证、术中控制毁损灶大小可减少并发症的发生 ;二次手术应以单靶点毁损为宜 ,时间间隔宜在半年以上。     

微电极引导的苍白球腹后部毁损术与中医药治疗帕金森病的对比研究

目的 :通过微电极引导的苍白球腹后部毁损术和中医药疗法治疗帕金森病的对比研究 ,探讨手术疗法和中医药疗法各自的疗效特点和治疗适应证。方法 :应用微电极引导的苍白球腹后部毁损术治疗帕金森病 34例 ,手术包括同期双侧、分期双侧和单侧手术。针刺配合中药治疗帕金森病 5 6例。Webster帕金森病功能障碍记分法评分 ,将治疗前后和两组之间治疗结果进行对比。结果 :手术治疗组 34例帕金森病病人中 ,有 33例患者在手术过程中震颤、僵直、运动迟缓等主要症状均有不同程度的缓解 ,手术后这些症状也持续好转 ,但其症状缓解程度在不同的病人中有所不同。Webster帕金森病功能障碍记分法评分 ,术后 1周进步率为 5 0 %～ 99%者 2 6例 ,1%～ 49%者 7例 ,<1%者 1例 ,总有效率 97%。中医药治疗组 80 %以上的患者治疗一个月后主观症状改善 ,主要体征好转 ,基本生活能力得到提高。治疗 3个月后Webster帕金森病功能障碍记分法评分 ,进步率为 5 0 %～ 99%者 6例 ,1%～ 49%者 39例 ,<1%者 11例 ,总有效率为 80 4%。两组患者治疗前、后评分结果进行t检验 ,P <0 0 1,两组之间治疗结果的总有效率进行 χ2 检验校正 ,P <0 0 5。结论 :微电极引导的苍白球腹后部毁损术和中医药治疗帕金森病均可取得较为满意的疗效。手术组对     

微电极记录技术在帕金森病手术治疗价值

目的　总结微电极导向立体定向手术治疗帕金森病的临床经验及治疗效果。方法　自 1 999年 4月至 2 0 0 1年 2月采用微电极导向立体定向手术治疗帕金森病 350例 ,其中苍白球腹后部毁损术 (PVP) 2 78例 ,丘脑腹中间核 (Vim)毁损术 35例 ,同期同侧PVP和Vim毁损术 1 5例 ,行同期双侧PVP 1 1例 ,分期双侧PVP 8例 ,分期一侧PVP或另一侧Vim毁损术 3例。对手术前后的“关”状态和“开”状态进行生活能力评分、UPDRS评分 ,并进行门诊随访。结果　术后日常生活能力评分“关”状态提高 2 9.8% ,“开”状态提高 2 5 .9%。UPDRS :在“关”状态下 ,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 %。结论　PVP对震颤效果不如Vim毁损术 ,对震颤明显 ,无明显僵直的患者可选择Vim毁损术 ,对震颤僵直型患者可分期双侧PVP毁损术。     

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。     

苍白球毁损术和丘脑毁损术对帕金森病病人发音的影响

目的研究帕金森病（PD）病人在单侧苍白球腹后部毁损术（PVP）、丘脑腹中间核（Vim）毁损术前后的发音状况。方法12位PD病人在手术前后分别发持续元音／a：/、／i：／、／u：/，记录发音，提取发音参数基频（F_0）及第1、2、3、4共振峰（F_1、F_2、F_3、F_4）。结果男性病人行Vim毁损术后，元音/i：/的第1共振峰升高，与术前有显著性差异（P〈0．05）。其他各参数无显著性差异。结论单侧PVP和Vim毁损术对PD病人近期发音无明显影响，长期影响仍需进一步观察。     

Posteroventral pallidotomy: its effect on motor symptoms and scores of MMPI test in patients with Parkinson's disease

Stereotaxic pallidotomy for Parkinson's disease (PD) is an old concept, which was gradually and mostly replaced by thalamotomy. Recently, posteroventral pallidotomy (PVP), originally proposed by Leksell et al., was reintroduced; this paper examines PVP in terms of its historical background, technical aspect and location of the surgical lesion, as well as clinical effects on motor and psychological symptoms. Posteroventral pallidotomy has been shown to be satisfactory in relieving rigidity and secondary akinesia, but not powerful enough in alleviating severe tremor. These are similar observations to those made in classical pallidotomy. For this reason, all PVP-treated cases reported in this paper have an additional small thalamic lesion for control of tremor. Also, it must be recognized that most of the surgically treated patients are continuing to take medication at the same or slightly lowered dose compared with preoperatively. Dopa-induced dyskinesia is alleviated well by PVP, similar to thalamotomy. The most important question is whether PVP has more effect on truncal symptoms, such as postural imbalance, and on gait than thalamotomy, a question that is still not satisfactorily answered in both clinical and basic analysis. Parkinson's disease-induced changes in emotional status, such as depression or hypochondriacal complaints, are favorably influenced by PVP, but not by thalamotomy. The role of stereotaxic surgery in the era of pharmacological treatment is discussed, as is the possible importance of the role of the limbic-motor circuit in research on PD.     

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。     

Ablative stereotactic surgery improves manual performance time in Parkinson's disease

The objective of this study was to determine the influence of stereotactic ablative surgical interventions on the time required for the performance of manual tasks (i.e. performance time) in patients with Parkinson's disease (PD). We studied 28 patients after pallidotomy and pallido-thalamotomy who were evaluated at four time: before the operation, and 2 days, 3 and 6 months postoperatively. The speed of performance of handwriting and drawing were assessed by means of a chronometer using certain parts of an international standard scale (modified by Fahn). The patients were also assessed according to the Unified Parkinson's Disease Rating Scale (UPDRS) part III. The patients were divided into two groups. Those in group A had relief of all main Parkinsonian symptoms after pallidotomy including tremor. The patients in group B had no relief of tremor straight after pallidotomy. For them the pallidotomy was completed with thalamotomy in the same sitting, which had resulted in cessation of tremor. The time of performance of the manual tasks diminished significantly in all cases in both groups (Student's t-test: p<0.0001). No complications developed following pallidotomy. Pallido-thalamotomy caused transient adverse effects in two patients, and one patient developed permanent adverse effects such as dysarthria and dysequilibrium. Significant improvements were observed in the speed of handwriting and drawing in both groups, but pallido-thalamotomy was accompanied with complications.     

The changing landscape of surgery for Parkinson's Disease

Neurosurgical interventions have been used to treat PD for over a century. We examined the changing landscape of surgery for PD to appraise the value of various procedures in the context of advances in our understanding and technology. We assessed the number of articles published on neurosurgical procedures for PD over time as an albeit imprecise surrogate for their usage level. We identified over 8,000 publications associated with PD surgery. Over half the publications were on DBS. The field of DBS for PD showed a rapid rise in articles, but is now in a steady state. Thalamotomy and, to a lesser extent, pallidotomy follow a biphasic publication distribution with peaks approximately 30 years apart. Articles on gene therapy and transplantation experienced initial rapid rises and significant recent declines. Procedures using novel technologies, including gamma knife and focused ultrasound, are emerging, but are yet to have significant impact as measured by publication numbers. Pallidotomy and thalamotomy are prominent examples of procedures that were popular, declined, and re‐emerged and redeclined. Transplantation and gene therapy have never broken into clinical practice. DBS overtook all procedures as the dominant surgical intervention and drove widespread use of surgery for PD. Notwithstanding, the number of DBS articles appears to have plateaued. As advances continue, emerging treatments may compete with DBS in the future. © 2017 International Parkinson and Movement Disorder Society     

Current therapies for parkinson's disease. Part II: surgical treatment

Surgical treatment of Parkinson's disease (PD) is indicated in patients with severe neurological symptoms (tremor, bradykinesia, rigidity)--who do not benefit from nor tolerate pharmacological therapy. Surgery for PD modifies the motor system function by lesioning or electrostimulation of thalamic, pallidal or subthalamic nuclei. The technological progress together with refined CNS monitoring enabled wider application of deep brain stimulation (DBS). The efficacy of DBS is comparable with lesioning techniques (thalamotomy or pallidotomy) however bears less adverse effects. Both lesioning and DBS are generally well tolerated by patients. The side effects are mostly transient and neurological complications, if occur, usually do not affect quality of patient's life. Unfortunately, the modern surgery for PD is still very expensive and demanding for a large team of specialists and high technology.     

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。     

脑深部电刺激术治疗毁损术后帕金森病的疗效

目的 探讨脑深部电刺激术（DBS）治疗苍白球或丘脑毁损术后帕金森病的疗效与安全性。方法 回顾性分析2013年1月至2021年3月毁损术后复发或出现新症状而行DBS治疗的33例帕金森病的临床资料。DBS后6个月,采用统一帕金森病量表（UPDRS）运动功能（UPDRS Ⅲ）评分和生活能力（UPDRS Ⅱ）评分、H-Y分期、简明精神量表评分（MMSE）以及左旋多巴等效日剂量（LEDD）评估疗效以及用药情况;记录刺激频率、脉宽、电压、阻抗,并计算刺激能量。结果 术后随访6个月~8.25年,未出现言语障碍、眼球活动障碍、偏瘫、颅内出血或梗死、癫痫发作、颅内感染病例,无硬件故障;5例因电池耗竭行脉冲发生器置换术。DBS后6个月,UPDRS Ⅲ评分、UPDRS Ⅱ评分、H-Y分期、LEDD均较术前明显降低（P<0.05）,而MMSE评分较术前无明显变化（P>0.05）;和非毁损侧相比,毁损侧肢体震颤评分改善率明显增高（P<0.05）,但僵硬评分改善率、运动迟缓评分改善率均无明显变化（P>0.05）;和非毁损侧相比,毁损侧刺激电压和刺激能量明显降低（P<0.05）,但刺激频率、脉宽和阻抗无明显变化（P>0.05）。结论 PD病人神经核团毁损术后复发或出现新症状,DBS是安全、有效的,毁损侧DBS后电刺激所需能量及电压更低。     

Efficacy and safety of simultaneous bilateral pallidotomy in advanced Parkinson's disease

BACKGROUND: Although unilateral pallidotomy is generally considered a safe and effective neurosurgical treatment for advanced Parkinson's disease (PD), controversies concerning efficacy and adverse effects of bilateral posteroventral pallidotomy (PVP) exist and need to be resolved. METHODS: We studied 8 patients with advanced PD who underwent simultaneous bilateral PVP. The patients were assessed preoperatively, immediately after surgery, and 6 and 12 months later. RESULTS: Dyskinesia was almost entirely abolished immediately after surgery, as well as being significantly lower 1 year later (p < 0.05). The 'off' medication score of the Unified Parkinson's Disease Rating Scale motor part (UPDRS III) was significantly improved after surgery (p < 0.05) but increased gradually after 6 months. The off medication score of activities of daily living tended to improve immediately after surgery, but it returned to preoperative levels at 12 months. There were no major complications of surgery. CONCLUSIONS: Simultaneous bilateral PVP may be a safe and highly effective method of reducing levodopa-induced dyskinesia. Our results suggest that simultaneous bilateral PVP may be a reasonable therapeutic option for advanced PD with severe levodopa-induced dyskinesia.     

帕金森病核团毁损术疗效与并发症的关系

目的：进一步总结帕金森病的微电极导向苍白球腹后部毁损术和丘脑腹中间核毁损术疗效。方法：微电极导向立体定向核团毁损术治疗帕金森病患者300例。对近期进行的100例患者在手术靶点选择、手术方法、手术疗效和并发症等方面进行总结，并与早期进行的100例手术患者比较。结果：近期进行的100例患者手术效果较好，并发症发生率低。结论：根据患者症状选择合适的毁损术能提高手术疗效；对靶点采用磁共振成像（MRI）图像和座标相结合的定位方法,可减少个体差异引起的误差；适当减少微电极记录针道数，降低毁损温度，能减轻电极与脑组织粘连，减少脑出血等并发症。     

微电极导向多靶点毁损术治疗帕金森病

目的　评估微电极导向多靶点毁损术的手术疗效及不同手术方式的适应证选择。方法　应用微电极导向多靶点毁损术治疗帕金森病 83例 ,其中同期双侧苍白球毁损 1 0例 ,同期同侧苍白球加丘脑毁损 3 0例 ,分期双侧多靶点毁损43例。以术前及术后 1周UPDRS积分计算改善率评价疗效。结果　 83例均有显著近期疗效 ,其中同期双侧毁损的改善率为 83 4% ,同期同侧毁损的改善率为 78 5% ,分期双侧毁损的改善率为 85 2 %。术后 3 6%出现轻度并发症。单项症状改善率最高为僵直 (95 7% ) ,余依次为震颤 (95 1 % )、行动迟缓 (90 9% )、步态 (70 % )、平衡 (68% )。平均随访 1年 ,除 1例复发外 ,余疗效均稳定。结论　微电极导向多靶点毁损术是治疗帕金森病的最有效方法 ,根据手术适应证选择手术方案有助于提高疗效。     

A comparison of neuropsychological effects of thalamotomy and thalamic stimulation

OBJECTIVE: The neuropsychological effects of thalamotomy and thalamic stimulation in patients with severe drug-resistant tremor due to PD, essential tremor (ET), or MS were compared in a randomized trial. METHODS: Complete neuropsychological evaluations at baseline and 6 months after surgery were obtained in 62 patients who underwent thalamotomy (n = 32: 21 PD, 6 ET, 5 MS) or thalamic stimulation (n = 30: 19 PD, 7 ET, 4 MS). RESULTS: Six months after thalamotomy, a decline was seen in the scores of the Stroop Color-Word Test, with the exception of the interference score. In the thalamic stimulation group, no significant changes were found on any of the cognitive tests. Age, diagnosis, disease severity, and baseline cognitive status were not correlated to cognitive changes. A difference in score changes between right- and left-sided surgery was found in verbal fluency and Stroop Test scores after both thalamotomy and thalamic stimulation. CONCLUSIONS: Both thalamotomy and thalamic stimulation are associated with a minimal overall risk of cognitive deterioration. Verbal fluency decreased after both left-sided thalamotomy and thalamic stimulation.     

Review of the functional surgical treatment of dystonia

A review of functional surgery for dystonia is presented. Recently renewed interest in stereotaxy for dystonia has followed the resurgence of pallidotomy and the introduction of deep brain stimulation (DBS) in Parkinson's disease (PD) in the early 1990s. However, even since the 1950s, small series of patients treated with ablative surgery have been carefully studied, providing useful information, notably regarding the tolerability of surgery. In the setting of dystonia, thalamotomy was first performed with substantial benefits, but some authors outlined the great variability in outcome, and the high incidence of operative side-effects. In the 'modern' era of functional surgery for movement disorders, the globus pallidus internus (GPi) has emerged to be currently the best target for dystonia, based on small series of patients published in the last few years. Both bilateral posteroventral pallidotomy (PVP) and bilateral pallidal stimulation, performed by several teams, have benefited a variety of patients with severe dystonia, the most dramatic improvements being seen in primary dystonia with a mutation in the DYT1 gene. Whereas patients with secondary dystonia have often shown a lesser degree of improvement, some publications have nevertheless reported major benefit. There is today a strong need for carefully controlled studies comparing secondary and primary dystonia, DYT1 and non-DYT1 dystonia, ablative surgery and DBS, with additional assessment of neuropsychological changes, especially in children treated with bilateral pallidal procedures.     

颅内核团射频毁损治疗帕金森病若干问题探讨

目的：探讨和研究颅内射频毁损治疗帕金森病的方法,效果,术后并发症与反应等有关问题。方法：回顾性分析我院近一年来收治的104例帕金森病,应用CT解剖定位和微电极电生理记录细胞定位方法,行丘脑腹外侧核或／和苍白球腹后内侧部射频毁损治疗,术前,术后3月,半年和一年采用Webster记分,改善在1％－19％为好转,20％－59％为有效,60％以上为显效。结果：104例患中,术后3月内改善98例,总有效率达94．2％,6例症状改善不明显。67例随访6－12月,症状改善54例,有效率80．6％,16例出现一过性嗜睡,呃逆;2例出现一过性偏瘫,5例出现颅内少量出血,其中2例术后立即发生毁损点少量出血,3例术后6d内出现针道周围出血,1例术后3月因肺部感染死亡。结论：微电极电生理定位颅内核团毁损是治疗帕金森病安全的和有效的方法,但应注意掌握适应症,精确定位,提高治愈率。