脑深部电刺激治疗肌张力障碍

目的 探讨脑深部电刺激术(deep brain stimulation, DBS)治疗全身性、偏身性和节段性肌张力障碍的有效性和安全性,肌张力障碍患者治疗和术后程控的策略.方法 采用微电极记录下丘脑底核(subthalamic nucleus, STN)、苍白球内侧部(globus pallidus intemus, GPi)和丘脑腹中间核(ventrointermediate nucleus, Vim)埋置脑深部刺激器治疗肌张力障碍患者15例,同时记录患者对侧受累肌肉的电活动.其中13例患者的刺激靶点为STN(11例为双侧,2例为单侧),1例刺激靶点为单侧GPi,1例为Vim.结果 除1例严重全身肌张力障碍患者外,其余患者因随访时间长短,均有不同程度改善,改善率从22.0%～95.8%不等.其中随访时间超过12个月的患者症状改善率均大于48.6%.1例因全身扭动造成电极外露,颈、胸腹部切口感染,最终将DBS装置取出.另有1例患者因双侧上端的两个触点断路,再次手术将电极位置上移.所有患者均未出现因穿刺造成的颅内出血的永久并发症.结论 通过对现有DBS治疗肌张力障碍病例资料有效性和安全性的总结,DBS成为治疗肌张力障碍的一种新方法.     

脑深部电刺激苍白球内侧部治疗肌张力障碍

目的 探讨脑深部电刺激(DBS)苍白球内侧部(GPi)治疗肌张力障碍的有效性和安全性,以及术后程控策略.方法 采用微电极记录GPi的电生理信号,埋置脑深部刺激器治疗肌张力障碍患者8例,同时记录患者对侧受累肌肉的电活动.所有患者的刺激靶点均为双侧GPi.结果 除1例继发性全身肌张力障碍患者外,其余患者因随访时间长短,均有不同程度改善,随访时间12-36个月,改善率35.5％～87.5％.其中随访超过18个月的患者症状改善率均＞59.6％.1例因全身扭动造成电极外露,锁骨下切口感染,最终将DBS装置取出.另有1例术后靶点区域少量出血,血肿吸收后原有症状仍有改善.结论 通过对现有DBS刺激GPi治疗肌张力障碍病例资料有效性和安全性的总结,DBS成为治疗肌张力障碍的一种有效方法.GPi是治疗肌张力障碍较为有效的靶点.     

微电极记录在脑深部电刺激术治疗肌张力障碍中的应用

目的 评价微电极记录在脑深部电刺激手术中的应用价值.方法 21岁的年轻女性,进行性肌张力障碍病史6年,从颈部向四肢发展,曾经行肉毒杆菌素治疗,半年后症状重新出现.MRI定位后行双侧苍白球内侧部刺激手术,术中通过微电极记录确定靶点指导手术.结果 在不同深度,微电极记录到不同脑组织的放电频率和幅度,根据放电频率和幅度的差异,指导电极精确定位.术后行MRI检查显示定位准确.术后1个月开机,肌张力障碍功能评分症状显著改善(从40降至7).结论 深部脑刺激术过程中的微电极记录能够指导手术定位.     

脑深部电刺激治疗肌张力障碍的研究进展

近年来,脑深部电刺激应用于治疗肌张力障碍并取得飞快发展。苍白球内侧核电刺激治疗药物难治性原发性肌张力障碍已有大量文献报道,但其对继发性肌张力障碍的治疗效果仍不确定。一些文献报道采用丘脑底核电刺激治疗肌张力障碍取得较好的治疗效果,并具有症状改善迅速,刺激参数相对较低的优点。本文对脑深部电刺激治疗肌张力障碍的靶点、疗效、并发症等进行综述。     

脑深部电刺激术治疗肌张力障碍的临床应用进展

脑深部电刺激术(DBS)目前已被广泛应用于治疗肌张力障碍,临床上常选择苍白球内侧部或丘脑底核作为电极植入靶点。针对不同类型的肌张力障碍患者,靶点选择、参数设置等皆不尽相同。另外,由于刺激器开启后的临床效果呈渐进式,程控比较复杂。本文针对DBS治疗肌张力障碍的靶点选择、开机参数设置、长期程控管理方法、程控相关不良事件及治疗效果等进行综述。     

脑深部电刺激治疗肌张力障碍研究进展

肌张力障碍是由于多种原因造成的脑内一些神经递质的代谢及传导出现异常,从而直接或间接增加了运动神经突触间的兴奋性,削弱了其抑制性,最终产生的以全身或局部的异常动作和（或）姿势为主要特征的综合征。其病因及发病机理尚不明确,故临床对其处理的重点主要为对症治疗。随着立体定向功能神经外科的深入发展,脑深部电刺激治疗肌张力障碍已显示出良好的应用前景。本文综述肌张力障碍的发病机制、治疗方法、疗效及相关并发症。     

脑深部电刺激治疗肌张力障碍

脑深部电刺激(deep brain stimulation,DBS)作用于基底神经核通路的不同靶点已成为治疗肌张力障碍(dystonia,DT)的一种重要的外科处理方法。DBS的优势在于其可逆、可调、可控,对基底核通路的作用是持续的。本文对DBS治疗肌张力障碍的作用机制、外科处理的技术要点、临床应用,特别对肌张力障碍常见类型包括原发性肌张力障碍、颈肌张力障碍(cervical dystonia,CD)等进行文献综述。     

丘脑底核电刺激治疗继发性肌张力障碍

目的 探讨丘脑底核（STN）的脑深部电剌激（DBS）治疗继发性肌张力障碍的可行性、适应证和并发症。方法 5例行双侧STN—DBS，1例行单侧STN—DBS。结果 术中利用微电极记录的电信号获得STN的准确靶点定位，电刺激后患者肌张力有不同程度下降，但扭转改善不明显。随访半年至3年，6例患者中，药物引起的迟发性肌张力障碍及外伤性肌张力障碍的患者疗效理想，BFMDRS评分改善均在90％以上，且随着随访时间的延长，效果持续不断改善；其余4例患者疗效不佳，4例均肌张力略有改善，其中1例扭转略改善，1例语言及步态略有改善。手术后患者均无明显合并症，但1例术后16个月发现左侧电极折断，后取出。结论 DBS治疗迟发性和外伤性继发性肌张力障碍效果理想，而对于缺氧或脑基底节区弥漫性损害的继发性肌张力障碍效果不佳；STN可以成为治疗本病的理想靶点；术中应根据电生理记录结果和肌张力的轻度改善作为靶点定位的指标；手术无明显合并症。     

脑深部电刺激双侧苍白球治疗Meige综合征3例并文献回顾

目的： Meige综合征是一种特发性累及头面部的肌张力障碍,有时也会影响到颈部。脑深部电刺激（DBS）双侧苍白球内侧部（GPi）治疗肌张力障碍的报道比较多,但治疗Meige综合征的很少。方法对3例双侧GPi-DBS术后的Meige综合征患者进行随访4、6和60个月。所有患者术前术后均采用国际通用的Burke-Fahn-Marsden Dystonia Rating 量表（BFMDRS）评分,包括BFMDRS-Ⅰ（Movement 量表）和BFMDRS-Ⅱ（Disability量表）两个部分。结果3例Meige综合征患者手术后症状均有明显改善,BFMDRS第一部分和第二部分评分的改善率分别为（78±3．1）％（范围75％～83％）和100％。结论双侧GPi-DBS是治疗原发性Meige综合征的一种有效安全的手术方式。     

脑深部电刺激手术治疗肌张力障碍的护理配合

肌张力障碍是指由于肌肉过度收缩导致身体局部或全身出现持续性扭转或姿势异常的一组病症.脑深部电刺激术(deep brain stimulation,DBS)目前为肌张力障碍外科的首选治疗方法.2010年1月-12月,北京天坛医院开展DBS治疗肌张力障碍33例,效果满意,现将护理配合报道如下.     

Low-frequency deep brain stimulation for movement disorders

IntroductionTraditionally, deep brain stimulation (DBS) for movement disorders (MDs) is provided using stimulation frequencies equal to or above 100 Hz. However, recent evidence suggests that relatively low-frequency stimulation (LFS) below 100 Hz is an option to treat some patients with MDs.ObjectivesWe aimed to review the clinical and pathophysiological evidence supporting the use of stimulation frequencies below 100 Hz in different MDs.ResultsStimulation of the subthalamic nucleus at 60 Hz has provided benefit in gait and other axial symptoms such as swallowing and speech. Stimulation of the pedunculopontine nucleus between 20 and 45 Hz can provide benefit in freezing of gait, cognition, and sleep quality in select patients with Parkinson's disease. Stimulation of the globus pallidus internus below 100 Hz in patients with dystonia has provided benefit at the beginning of the therapy, although progressively higher stimulation frequencies seem to be necessary to maintain the clinical benefit. Relative LFS can lower energy requirements and reduce battery usage—a useful feature, particularly in patients treated with high current energy.ConclusionsDBS at frequencies below 100 Hz is a therapeutic option in select cases of Parkinson's disease with freezing of gait and other axial symptoms, and in select patients with dystonia and other hyperkinetic movements, particularly those requiring an energy-saving strategy.     

脑深部电刺激治疗运动障碍性疾病的疗效观察

目的探讨脑深部电刺激（DBS）治疗运动障碍性疾病（MD）的疗效及安全性。方法对49例运动障碍性疾病的患者进行丘脑底核（STN）、苍白球内侧部（Gpi）、丘脑腹中间核（Vim）刺激电极植入术,术前采用1.0 TMR和3.0 TMR T2加权靶点扫描,在直视下行靶点直接定位。手术前后应用统一帕金森病评分量表评分（UPDRS）及Burke Fahn-Marsden运动障碍评分（BFMs）评价临床效果。结果本组手术前帕金森病患者UPDRS：药物＂关＂状态25-80分,平均55分;药物＂开＂状态19-53分,平均34分。术后在开机的情况下UPDRS：药物＂关＂状态17-24分,平均22分,改善率60.0%;药物＂开＂状态15-24分,平均19分,改善率44.0%。4例肌张力障碍患者BFMs平均改善率55.0%。41例患者术后症状迅速改善,肌张力降低,震颤及异动症消失。结论DBS能明显改善MD患者的临床症状,改善其生活质量,且具有安全性。     

Treating post-traumatic tremor with deep brain stimulation: Report of five cases

BackgroundPost-traumatic tremor is one of the most common movement disorders resulting from severe head trauma. However, literature regarding successful deep brain stimulation (DBS) treatment is scarce, resulting in ambiguity regarding the optimal lead location. Most cases support the ventral intermediate nucleus, but there is evidence to defend DBS of the zona incerta, ventral oralis anterior/posterior, and/or a combination of these targets. We report five patients with disabling post-traumatic tremor treated with DBS of the ventral intermediate nucleus and of the globus pallidus internus.MethodsPatients were referred to the Vanderbilt Movement Disorders Division, and surgical intervention was determined by a DBS Multidisciplinary Committee. Standard DBS procedure was followed.ResultsPatients 1–4 sustained severe diffuse axonal injuries. Patients 1–3 underwent unilateral ventral intermediate nucleus DBS for contralateral tremor, while Patient 4 underwent bilateral ventral intermediate nucleus DBS. Patients 1–3 experienced good tremor reduction, while Patient 4 experienced moderate tremor reduction with some dystonic posturing of the hands. Patient 5 had dystonic posturing of the right upper extremity with tremor of the left upper extremity. He was treated with bilateral DBS of the globus pallidus internus and showed good tremor reduction at follow-up.ConclusionUnilateral or bilateral DBS of the ventral intermediate nucleus and bilateral DBS of the globus pallidus internus may be effective and safe treatment modalities for intractable post-traumatic tremor. Further studies are needed to clarify the optimal target for surgical treatment of post-traumatic tremor.     

Deep brain stimulation of the internal globus pallidus for refractory tardive dystonia

We report a rapid, dramatic and sustained improvement following bilateral pallidal stimulation in two patients affected by intractable generalized tardive dystonia. Both patients had a chronic psychiatric disorder and developed chronic disabling generalized dystonic symptoms persisting despite prolonged withdrawal of neuroleptics and all available symptomatic treatment. The clinical benefit in both patients persisted throughout all the follow up period of 13 and 7 months. The favorable and prolonged response in our two patients suggests that deep brain stimulation may be an effective treatment for medically refractory tardive dystonia.     

The persistent effects of unilateral pallidal and subthalamic deep brain stimulation on force control in advanced Parkinson's patients

The persistent effects of unilateral deep brain stimulation (DBS) of the globus pallidus interna (GPi) or subthalamic nucleus (STN) on specific movement parameters produced by Parkinson's disease (PD) patients are poorly understood. The aim of this study was to determine the effects of unilateral GPi and STN DBS on the force-producing capabilities of PD patients during maximal efforts and functional bimanual dexterity. Clinical and biomechanical data were collected from 14 unilaterally implanted patients (GPi=7; STN=7), at least 13 months post-DBS surgery, during On and Off stimulation in the absence of medication. Unilateral DBS of either location produced a 33% improvement in UPDRS motor scores. Significant gains in maximum force production were present in both limbs during unimanual efforts. The greatest increase in maximum force, for both limbs, was under bimanual conditions. Force in the contralateral limb increased more than 30% during bimanual efforts while ipsilateral force increased by 25%. Unilateral DBS improved grasping force control and consistency of digit placement during the performance of a bimanual dexterity task. The clinical and biomechanical data indicate that unilateral DBS of GPi or STN results in persistent improvements in the control and coordination of grasping forces during maximal efforts and functional dexterous actions. Unilateral DBS implantation of either site should be considered an option for those patients in which bilateral procedures are contraindicated.     

Deep brain stimulation in the treatment of severe dystonia

A retrospective study of a consecutive series of 19 patients with medically intractable dystonia treated with uni- or bilateral deep brain stimulation (DBS) is reported. A minimal follow-up of 6 months was available, up to eleven years in one patient. The first twelve consecutive patients (4 with primary and 8 with secondary dystonia) were treated with chronic stimulation of the posterior part of the ventrolateral thalamic nucleus (VLp). In this group global functional outcome was improved in 8 patients, although dystonia movement and disability scale scores did not show significant improvement. Of the 12 patients treated first by VLp DBS, three (1 primary and 2 secondary dystonia) underwent pallidal (GPi) DBS after the VLp DBS failed to improve their symptoms. The last seven consecutive patients (5 primary and 2 secondary dystonia) were treated directly with GPi DBS. Extracranial infection prevented chronic GPi DBS in one patient. In another GPi patient, preliminary negative tests with the electrodes discouraged implantation of the stimulators, and the patient was not treated with chronic DBS. In the remaining group of eight patients including those previously treated with VLp DBS, chronic GPi DBS resulted in a significant improvement in the dystonia movement scale and disability scores. Although this is a retrospective study dealing with dystonia of heterogeneous etiology, the results strongly suggest that GPi DBS has a better outcome than VLp DBS Received: 22 January 2001 / Received in revised form: 28 February 2001 / Accepted: 1 March 2001     

脑深部电刺激术治疗成人抽动秽语综合征长期疗效观察

目的 研究苍白球腹后内侧部(Gpi)脑深部电刺激术(DBS)治疗成人抽动秽语综合征(TS)的长期疗效. 方法 首都医科大学宣武医院功能神经外科自2007年5月至2008年5月应用Gpi DBS治疗5例药物难治性TS患者,分别于术前,术后3月、6月、1年及1年以上应用耶鲁综合抽动严重程度评分量表(YGTSS)进行症状评估. 结果 患者随访时间21～33月.与术前比较,患者最后随访时运动、发声、总体损害程度、YGTSS评分均降低,差异有统计学意义(P＜0.05);与术前、术后3月比较,患者其余各个时间点YGTSS评分均降低,差异有统计学意义(P＜0.05).所有患者症状逐渐改善,前6月症状改善明显,6月后基本平稳,仍会有轻度改善.术后3月、6月、1年、1年以上YGTSS评分的最终改善率分别为28.5％、52.35％、57.62％、62.88％.最后随访时YGTSS评分中运动抽动改善率为51.38％,发声抽动改善率为46.16％,总体损害程度改善率为71％.没有严重并发症. 结论 Gpi DBS是一种治疗成人药物难治性TS安全有效的方法,能够全面缓解TS运动抽动、发声抽动及总体损害,长期效果稳定.