Unilateral subthalamic nucleus deep brain stimulation contralateral to thalamic stimulation in Parkinson disease

The effects of unilateral subthalamic nucleus (STN) stimulation contralateral to thalamic stimulation in Parkinson disease (PD) have not been previously reported. We are reporting a patient who developed left arm tremor in 1994, at age 62, as her first PD symptom. She underwent right thalamic DBS surgery in 1999 that resulted in complete resolution of left arm tremor. Her PD symptoms progressed and she developed severe motor fluctuations and disabling dyskinesias. In 2003, she underwent left STN electrode implantation. Left STN stimulation improved contralateral motor scores in the medication OFF state, and allowed for reduced medication doses and less dyskinesia. However, there was no significant improvement in activities of daily living (ADL), motor scores in the medication ON state, gait, or postural stability.     

丘脑底核脑深部电刺激对帕金森病抑郁障碍的影响

目的探讨丘脑底核脑深部电刺激对帕金森病病人抑郁障碍的疗效及其机制。方法回顾性分析21例帕金森病合并抑郁障碍病人的临床资料,均行丘脑底核脑深部电刺激术,术前及术后3、6个月分别应用汉密尔顿抑郁量表(HAMD)评分和统一帕金森病评定量表(UPDRS)运动评分对抑郁障碍和运动功能进行临床评价并分析其相关性。结果术后UPDRS运动评分和HAMD评分均显著下降(均P0.05),但是抑郁症状的改善与运动功能的改善并没有明显的相关性(P0.05)。结论丘脑底核脑深部电刺激能够明显改善帕金森病病人的抑郁症状,其机制可能与丘脑底核受到刺激影响脑内神经递质的变化有关,术后运动功能的改善不是抑郁症状改善的主要原因。     

Instability of speech in Parkinson disease patients with subthalamic nucleus deep brain stimulation

IntroductionThe impact of deep brain stimulation (DBS) on speech rhythm and its mechanism remains unclear. We investigated speech rhythm characteristics of patients with Parkinson's disease (PD) treated with subthalamic nucleus (STN) DBS to understand the underlying pathophysiology better.MethodsWe enrolled a total of 105 participants and evaluated speech rhythm performances among patients with PD who had undergone STN-DBS (the PD-DBS group), patients with PD treated only with medication (the PD-Med group), patients with cerebellar ataxia (the CA group), and healthy controls (the HC group). Each participant was asked to repeat the syllable/pa/at a comfortable self-chosen steady pace. A widely-used software (the Motor Speech Profile) program performed an acoustic analysis.ResultsCompared to the PD-Med and HC groups, speech rate instability (DDKjit) was significantly higher in the PD-DBS and CA groups (p < 0.01). However, after DBS was turned off, the DDKjit of the PD-DBS group improved to a level comparable to that of the PD-Med and HC groups. In contrast to the significantly higher variability of speech volume (DDKcvi) in the CA group, the PD-DBS group showed similar DDKcvi to the PD-Med and HC groups.ConclusionsSTN-DBS affects the speech rate stability of patients with PD. Speech rhythm disorders caused by STN-DBS were phenotypically similar to that in CA in terms of interval variability but different regarding amplitude variability. Further studies are warranted to elucidate the underlying pathophysiology of speech rhythm disorders in PD patients treated with DBS.     

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。     

Chronic subthalamic deep brain stimulation improves pain in Parkinson disease

Background   

Pain is a well recognized feature of Parkinson disease (PD). Like motor fluctuations, pain in PD may fluctuate as ‘non-motor fluctuations’. Subthalamic deep brain stimulation (STN DBS) is an established treatment for motor fluctuations in PD. However, the effect of STN DBS on the pain in PD is only partially investigated.     

Efficacy of safinamide as add-on therapy after subthalamic nucleus deep brain stimulation in Parkinson disease

Neurological Sciences - Subthalamic nucleus deep brain stimulation (STN-DBS) is an effective surgical treatment for advanced Parkinson’s disease (PD). However, some patients still experience...     

Impulse control behaviors and subthalamic deep brain stimulation in Parkinson disease

To determine the clinical and demographic correlates of persistent, remitting, and new-onset impulse control behaviors (ICBs) before and after subthalamic deep brain stimulation (STN-DBS) in Parkinson’s disease (PD). We compared the pre- and post-surgical prevalence of ICBs, classified as impulse control disorders (ICD), dopamine dysregulation syndrome (DDS), and punding in 150 consecutive PD STN-DBS-treated patients and determined the association with motor, cognitive, neuropsychological, and neuropsychiatric endpoints. At baseline (before STN-DBS), ICBs were associated with younger age (p = 0.045) and male gender (85 %; p = 0.001). Over an average follow-up of 4.3 ± 2.1 years of chronic STN-DBS there was an overall trend for reduction in ICBs (from 17.3 to 12.7 %; p = 0.095) with significant improvement in hypersexuality (12–8.0 %; p = 0.047), gambling (10.7–5.3 %; p = 0.033), and DDS (4.7–0 %; p < 0.001). ICB remitted in 18/26 patients (69 %) and persisted in 8/26 (31 %); the latter group was characterized by higher levodopa equivalent daily dose. Patients who developed a new-onset ICB during follow-up (n = 11/150) were characterized by younger age (p = 0.042), lower dyskinesia improvement (p ≤ 0.035), and a gender distribution with higher prevalence of women (p = 0.018). In addition, new-onset ICB was more common among patients with borderline, schizoid, and/or schizotypal traits of personality disorders; persistent ICB in those with obsessive–compulsive traits. PD-related ICBs exhibit a complex outcome after STN-DBS, with a tendency for overall reduction but with age, gender, dopaminergic therapy, and neuropsychiatric features exerting independent effects.     

Initial cognitive dip after subthalamic deep brain stimulation in Parkinson disease

Although many studies have shown no significant change in global cognitive function after subthalamic brain stimulation (STN DBS) in patients with Parkinson disease (PD) and have concluded that STN DBS is generally safe from a cognitive standpoint, some studies have reported a decline in global cognitive function after STN DBS. Interestingly, in some studies, the decline in cognitive function appears to be greater during the initial short period after surgery (within 6 or 12 months after surgery) than the decline thereafter. To this end, we examined whether the rate of change in global cognitive function during the initial 6 months after STN DBS was different from the mean 6-month change that occurred between 6 and 36 months after surgery. Thirty-six PD patients who underwent bilateral STN DBS and were followed for more than 3 years were included. Change in Mini-Mental Status Examination (MMSE) score during the first 6 months after surgery was compared with the 6-month MMSE score change between 6 and 36 months after surgery. Mean MMSE change during the first 6 months after surgery was significantly greater than the mean 6-month MMSE change between 6 to 36 months after surgery. The levodopa equivalent daily dose at baseline and the score for Stroop Color-word test at baseline were significantly associated with the decline in MMSE score during the first 6 months after surgery. Our result showed that decline in global cognitive function was faster in the first 6 months after surgery, compared with that after 6 months.     

Medication and subthalamic nucleus deep brain stimulation similarly improve balance and complex gait in Parkinson disease

BackgroundDopaminergic medications and subthalamic nucleus deep brain stimulation (STN-DBS) alleviate motor symptoms in Parkinson disease, but balance and gait are more variably affected. Balance reports are particularly inconsistent. Further, despite their prevalence in daily life, complex gait situations including backward and dual task gait are rarely studied. We aimed to assess how medications, STN-DBS, and both therapies combined affect balance and complex gait.MethodsTwelve people with Parkinson disease were evaluated OFF medication with STN-DBS OFF and ON as well as ON medication with STN-DBS OFF and ON. Motor impairment was measured with the Movement Disorder Society Unified Parkinson Disease Rating Scale motor section (MDS-UPDRS-III). The Mini-Balance Evaluations Systems Test, timed-up-and-go, and dual task timed-up-and-go measured balance and mobility. Preferred-pace forward, fast as possible forward, backward, dual task forward, and dual task backward gait were also analyzed.ResultsMedication improved MDS-UPDRS-III scores, dual task timed-up-and-go, and stride length across all gait tasks. STN-DBS improved MDS-UPDRS-III scores, balance scores, dual task timed-up-and-go, and stride length and velocity across all gait tasks. Medication and STN-DBS combined did not provide additional benefits over either therapy alone.ConclusionsOverall, dopaminergic medications and STN-DBS provided similar improvements in balance and gait tasks, although the effects of STN-DBS were stronger, potentially due to reductions in medication doses after surgery. Lack of synergistic effect of treatments may suggest both therapies improve balance and gait by influencing similar neural pathways.     

Imaging-based programming of subthalamic nucleus deep brain stimulation in Parkinson's disease

BackgroundThe need for imaging-guided optimization of Deep Brain Stimulation (DBS) parameters is increasing with recent developments of sophisticated lead designs offering highly individualized, but time-consuming and complex programming.ObjectiveThe objective of this study was to compare changes in motor symptoms of Parkinson's Disease (PD) and the corresponding volume of the electrostatic field (VEsF) achieved by DBS programming using GUIDE XT™, a commercially available software for visualization of DBS leads within the patient-specific anatomy from fusions of preoperative magnetic resonance imaging (MRI) and postoperative computed tomography (CT) scans, versus standard-of-care clinical programming.MethodsClinical evaluation was performed to identify the optimal set of parameters based on clinical effects in 29 patients with PD and bilateral directional leads for Subthalamic Nucleus (STN) DBS. A second DBS program was generated in GUIDE XT™ based on a VEsF optimally located within the dorsolateral STN. Reduction of motor symptoms (Movement Disorders Society Unified Parkinson's Disease Rating Scale, MDS-UPDRS) and the overlap of the corresponding VEsF of both programs were compared.ResultsClinical and imaging-guided programming resulted in a significant reduction in the MDS-UPDRS scores compared to off-state. Motor symptom control with GUIDE XT™-derived DBS program was non-inferior to standard clinical programming. The overlap of the two VEsF did not correlate with the difference in motor symptom reduction by the programs.ConclusionsImaging-guided programming of directional DBS leads using GUIDE XT™ is possible without computational background and leads to non-inferior motor symptom control compared with clinical programming. DBS programs based on patient-specific imaging data may thus serve as starting point for clinical testing and may promote more efficient DBS programming.     

Functional imaging of subthalamic nucleus deep brain stimulation in Parkinson's disease

Deep brain stimulation of the subthalamic nucleus is an accepted treatment for the motor complications of Parkinson's disease. The therapeutic mechanism of action remains incompletely understood. Although the results of deep brain stimulation are similar to the results that can be obtained by lesional surgery, accumulating evidence from functional imaging and clinical neurophysiology suggests that the effects of subthalamic nucleus‐deep brain stimulation are not simply the result of inhibition of subthalamic nucleus activity. Positron emission tomography/single‐photon emission computed tomography has consistently demonstrated changes in cortical activation in response to subthalamic nucleus‐deep brain stimulation. However, the technique has limited spatial and temporal resolution, and therefore the changes in activity of subcortical projection sites of the subthalamic nucleus (such as the globus pallidus, substantia nigra, and thalamus) are not as clear. Clarifying whether clinically relevant effects from subthalamic nucleus‐deep brain stimulation in humans are mediated through inhibition or excitation of orthodromic or antidromic pathways (or both) would contribute to our understanding of the precise mechanism of action of deep brain stimulation and may allow improvements in safety and efficacy of the technique. In this review we discuss the published evidence from functional imaging studies of patients with subthalamic nucleus‐deep brain stimulation to date, together with how these data inform the mechanism of action of deep brain stimulation. © 2011 Movement Disorder Society     

Deep brain stimulation of the subthalamic nucleus enhances emotional processing in Parkinson disease

BACKGROUND: High-frequency electrical stimulation of the subthalamic nucleus is a new and highly effective therapy for complications of long-term levodopa therapy and motor symptoms in advanced Parkinson disease (PD). Clinical observations indicate additional influence on emotional behavior. METHODS: Electrical stimulation of deep brain nuclei with pulse rates above 100 Hz provokes a reversible, lesioning-like effect. Here, the effect of deep brain stimulation of the subthalamic nucleus on emotional, cognitive, and motor performance in patients with PD (n = 12) was examined. The results were compared with the effects of a suprathreshold dose of levodopa intended to transiently restore striatal dopamine deficiency. Patients were tested during medication off/stimulation off (STIM OFF), medication off/stimulation on (STIM ON), and during the best motor state after taking levodopa without deep brain stimulation (MED). RESULTS: More positive self-reported mood and an enhanced mood induction effect as well as improvement in emotional memory during STIM ON were observed, while during STIM OFF, patients revealed reduced emotional performance. Comparable effects were revealed by STIM ON and MED. Cognitive performance was not affected by the different conditions and treatments. CONCLUSIONS: Deep brain stimulation of the subthalamic nucleus selectively enhanced affective processing and subjective well-being and seemed to be antidepressive. Levodopa and deep brain stimulation had similar effects on emotion. This finding may provide new clues about the neurobiologic bases of emotion and mood disorders, and it illustrates the important role of the basal ganglia and the dopaminergic system in emotional processing in addition to the well-known motor and cognitive functions.     

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

目的评估丘脑底核脑深部电刺激(STN-DBS)对帕金森病的临床疗效。方法回顾性分析应用STN-DBS手术治疗的32例帕金森病病人的临床资料,在术前、术后3个月分别采用统一帕金森病评定量表(UPDRS)、抑郁自评量表(SDS)和症状自评量表(SCL-90)进行随访评估、心理状况问卷调查和分析。结果脉冲发生器开启后,32例病人的UPDRS日常活动和运动功能在"关"状态,平均改善率为51.7%和60.9%;在"开"状态下,平均改善率21.4%和22.3%。20例病人术前SDS评分50分,其SCL-90的抑郁、焦虑、躯体化、人际敏感、敌对、恐怖和偏执7个因子显著高于中国常模(P0.05)。术前与术后SCL-90抑郁、躯体化、恐怖、焦虑、精神病性因子有显著性差异(P0.05),人际敏感、偏执、敌对和强迫等因子无显著性差异(P0.05)。结论 STN-DBS可以改善帕金森病病人的运动功能,提高日常生活能力,还可以明显改善帕金森病伴抑郁病人的心理状况,是安全有效的治疗方法。     

The effects of bilateral subthalamic nucleus deep brain stimulation (STN DBS) on cognition in Parkinson disease

The effects of subthalamic nucleus (STN) stimulation on cognition and mood have not been well established. The authors estimated cognitive and mood effects of bilateral subthalamic nucleus deep brain stimulation (STN DBS) in patients with Parkinson's disease (PD) at 6 months and 1 year postoperatively. Forty-six patients were recruited from the Movement Disorder Center at Seoul National University Hospital. Neuropsychologic tests were performed three times, before, 6 months after, and 1 year after surgery. Mean patient age was 58 and mean education duration 8 years. Eighteen of the 46 patients were men. The instruments used for assessing cognitive functions were; the Mini-Mental Status Examination (MMSE), the Trail Making Test (TMT), the Korean Boston Naming Test (K-BNT), the Rey-Kim Memory Battery, the Grooved pegboard test, the Stroop test, a fluency test, the Wisconsin Card Sorting test (WCST), and the Beck depression inventory (BDI). Of these tests, the verbal memory test, the Stroop test, and the fluency test showed statistically significant changes. The verbal memory test using the Rey-Kim memory battery showed a decline in delayed recall and recognition at 6 months and 1 year postoperatively, whereas nonverbal memory showed no meaningful change. In terms of frontal lobe function tests, Stroop test and fluency test findings were found to be aggravated at 6 months and this continued at 1 year postoperatively. Previous studies have consistently reported a reduction in verbal fluency and improvements in self-reported symptoms of depression after STN DBS. However, in the present study, Beck depression inventory (B.D.I.) was not significantly changed. Other tests, namely, MMSE, TMT, K-BNT, Grooved pegboard test, and the WCST also failed to show significant changes. Of the baseline characteristics, age at onset, number of years in full-time education, and l-dopa equivalent dosage were found to be correlated with a postoperative decline in neuropsychological test results. The correlation of motor improvement and cognitive deterioration was not significant, which suggests that the stimulation effect is rather confined to the motor-related part in the STN. In conclusion, bilateral STN DBS in Parkinson's disease did not lead to a significant global deterioration in cognitive function. However, our findings suggest that it has minor detrimental long-term impacts on memory and frontal lobe function.