脑深部电刺激治疗运动障碍性疾病

脑深部电刺激 (ｄｅｅｐｂｒａｉｎｓｔｉｍｕｌａｔｉｏｎ ,ＤＢＳ)是一种治疗神经系统运动障碍性疾病的方法 ,其通过在脑的深部特定核团埋置微电极 ,脑外刺激器控制、调整刺激的电压、脉宽、频率等参数的方法来进行治疗。在过去的几年中 ,ＤＢＳ技术日渐成熟 ,其在治疗难治性运动障碍性疾病中的安全性和有效性得到公认。ＤＢＳ在治疗多种运动障碍性疾病时所具有的较好效果、独特的优点和较少的不良反应引起人们对ＤＢＳ的极大兴趣。下面就ＤＢＳ在运动障碍性疾病中的应用及研究进展作一介绍。一、ＤＢＳ概述ＤＢＳ最早在 2 0世纪 50年代应…     

脑深部电刺激治疗原发性帕金森病

帕金森病 (Ｐａｒｋｉｎｓｏｎ ｓｄｉｓｅａｓｅ,ＰＤ)是一种以多巴胺能黑质纹状体神经元凋亡为特征的慢性退行性变。 2 0世纪 80年代 ,法国Ｇｒｅｎｏｂｌｅ的Ｂｅｎ ａｂｉｄ及其同事向世人介绍了一种全新的治疗手段———脑深部刺激术 (ｄｅｅｐｂｒｉａｎｓｔｉｍｕｌａｔｉｏｎ ,ＤＢＳ) ,本文就有关内容作一综述。一、可能的机制在帕金森病病人中 ,来自黑质的兴奋性神经元失去了抑制 ,导致苍白球内侧部 (ＧＰｉ)过度兴奋 ,从而增加了丘脑和皮质的兴奋性 ,并进一步导致运动神经元亢进 ,出现临床症状。ＤＢＳ技术是将电极植入深部神经…     

脑深部电刺激术治疗痉挛性斜颈1例

目的 探讨脑深部电刺激术(deep brain stimulation,DBS)治疗痉挛性斜颈的效果和靶点选择.方法 回顾分析1例痉挛性斜颈病例资料,经严格术前评估,采用苍白球内侧部(globus pallidus internus,Gpi)为靶点行DBS治疗.结果 术后病人无并发症,症状较术前明显改善,随访Burke...     

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.     

脑深部电刺激术治疗帕金森病研究进展

脑深部电刺激为中晚期的帕金森病患者提供了一种有效的治疗手段.这项技术已得到了广泛应用并有逐步取代毁损术的趋势.但其作用机制仍不十分清楚.本文综述了脑深部电刺激术治疗帕金森病的作用机制、优缺点、病例选择、靶点选择及并发症,把重点放在作用机制的探讨上,并展望了脑深部电刺激术未来的发展方向.     

脑深部电刺激治疗帕金森病和特发性震颤的近期和远期疗效

自1987年以后,脑深部电刺激(deep brain stimulation,DBS)成为治疗难治性帕金森病和特发性震颤的主要外科手段。刺激的靶点最先为丘脑腹侧中间核(nucleus ventero-intermedius,Vim)。由于Vim DBS只能缓解震颤,而对于帕金森病的其他核心症状以及多巴长期应用后的不良反应,如运动波动和异动症疗效不显著,1990年后治疗PD的靶点转移到丘脑底核(subthalamic nucleus,STN)和苍白球内侧部(interal globus pallidus,GPi),上述问题在这两个靶点得到显著改善。Vim DBS仍然为治疗特发性震颤的位点。本文就这3个靶点的持续电刺激在治疗帕金森病和特发性震颤的近期和远期疗效等进行评述。     

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

脑深部电刺激 (ｄｅｅｐｂｒａｉｎｓｔｉｍｕｌａｔｉｏｎ ,ＤＢＳ)自 90年代后期作为一种理想的手术方法治疗特发性震颤及帕金森病 ,在欧美国家已广泛应用 ,并基本取代了毁损手术。本中心自1999年 11月以来共为 31例患者植入 4 1侧深部电极 ,其中同期双侧丘脑底核 (ＳＴＮ)刺激 10例 ,单侧ＳＴＮ刺激 2 0例 (其中 4例为已作过对侧或同侧Ｖｉｍ毁损术 ) ,单侧苍白球内侧核 (ＧＰｉ )刺激 1例 ,现介绍如下。资料和方法 :(1)观察对象 :31例ＰＤ患者中男性 2 2例 ,女性 9例。年龄 37～ 82岁 ,平均年龄 (6 4 2± 7 5 )岁 ,排除各种原因引起的…     

脑深部电刺激苍白球内侧部和丘脑底核对帕金森病震颤改善的对比性研究

目的探讨苍白球内侧部(GPi)和丘脑底核(STN)作为脑深部电刺激(DBS)治疗帕金森病(PD)的靶点,对震颤改善的差异。方法本院2016年1月—2017年12月行双侧DBS术的56例PD患者,按照手术靶点的不同随机分为STN组和GPi组。其中STN组30例,男20例,女10例,平均年龄(59. 3±10. 7)岁; GPi组26例,男19例,女7例,平均年龄(61. 3±7. 2)岁。采用国际通用的UPDRS评分表中的震颤评分项目对患者术前、术后3个月震颤进行评分。结果 STN和GPi组术后开机未服药状态的震颤评分比术前均有明显改善,差异有统计学意义(P 0. 001,P=0. 001)。而两组间震颤改善率的差异无统计学意义(P 0. 05)。与术前比较,STN组术后开机服药状态的震颤评分改善有统计学意义(P 0. 05);而GPi组与术前开期比较,术后开期服药状态下的震颤评分改善无统计学意义(P 0. 05)。两组术后开机服药状态的震颤改善率比较,差异也无统计学意义(P 0. 05)。结论 DBS是治疗PD震颤症状的有效治疗手段,无论靶点是STN或GPi。STN和GPi作为治疗PD的靶点,在改善震颤程度方面没有明显的差别。     

帕金森病的脑深部电刺激治疗

帕金森病(PD)是神经内、外科治疗的难题。药物治疗效果不好;立体定向损毁疗法有半数病人术后复发,二次损毁副作用大,效果较差;双侧损毁治疗风险更大,且效果不稳定。近年,国外应用脑深部电刺激(DBS)治疗帕金森病,取得了良好疗效。本文综合近年国外文献,对DBS治疗PD的概况作一介绍。     

Effects of ventral intermediate nucleus deep brain stimulation across multiple effectors in essential tremor

ObjectiveEssential tremor (ET) prominently affects the upper-limbs during voluntary movements, but can also affect the lower-limbs, head, and chin. Although deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of thalamus improves both clinical ratings and quantitative measures of tremor, no study has quantified effects of DBS on tremor across multiple body parts. Our objective was to quantify therapeutic effects of DBS across multiple body parts in ET.MethodsWe performed quantitative assessment of tremor in ET patients who had DBS for at least one year. We assessed tremor on and off VIM-stimulation using triaxial accelerometers on the upper-limbs, lower-limbs, head and chin during seated and standing tasks.ResultsVIM-DBS significantly reduced tremor, but there was no statistical difference in degree of tremor reduction across the measured effectors. Compared to healthy controls, ET patients treated with DBS showed significantly greater tremor power (4–8 Hz) across all effectors during seated and standing tasks.ConclusionsVIM-DBS reduced tremor in ET patients. There was no significant difference in the degree of tremor reduction across the measured effectors.SignificanceThis study provides new quantitative evidence that VIM-DBS is effective at reducing tremor across multiple parts of the body.     

Deep brain stimulation for Holmes’ tremor related to a thalamic abscess

BACKGROUND: Medical treatment is usually ineffective for Holmes' tremor, and surgery is the treatment of choice for many patients. Here we report the case of a 14-year-old girl who developed Holmes' tremor related to a thalamic abscess and was successfully treated with thalamic deep brain stimulation. CASE REPORT: The patient presented with left hemiparesis and headache and was hospitalized. Investigation revealed a thalamic abscess in the left cerebral hemisphere. The abscess was drained via stereotactic surgery and a course of antibiotic treatment was completed. Four months after treatment, the patient developed Holmes' tremor in her left upper extremity. When attempts at medical treatment with levodopa, clonazepam, and trihexyphenidyl all failed, an implant was placed and deep brain stimulation of the ventral intermediate nucleus of the thalamus was initiated. During 2.5 years of follow-up, her tremor diminished by 90%. CONCLUSION: This case demonstrates that medically resistant Holmes' tremor related to a thalamic lesion can be successfully treated with thalamic deep brain stimulation.     

Wearable sensor-driven responsive deep brain stimulation for essential tremor

BackgroundDeep brain stimulation (DBS) is an effective surgical therapy for individuals with essential tremor (ET). However, DBS operates continuously, resulting in adverse effects such as postural instability or dysarthria. Continuous DBS (cDBS) also presents important practical issues including limited battery life of the implantable neurostimulator (INS). Collectively, these shortcomings impact optimal therapeutic benefit in ET.ObjectiveThe goal of the study was to establish a physiology-driven responsive DBS (rDBS) system to provide targeted and personalized therapy based on electromyography (EMG) signals.MethodsTen participants with ET underwent rDBS using Nexus-D, a Medtronic telemetry wand that acts as a direct conduit to the INS by modulating stimulation voltage. Two different rDBS paradigms were tested: one driven by one EMG (single-sensor) and another driven by two or more EMGs (multi-sensor). The feature(s) used in the rDBS algorithms was the pow2er in the participant's tremor frequency band derived from the sensors controlling stimulation. Both algorithms were trained on kinetic and postural data collected during DBS off and cDBS states.ResultsUsing established clinical scales and objective measurements of tremor severity, we confirm that both rDBS paradigms deliver equivalent clinical benefit as cDBS. Moreover, both EMG-driven rDBS paradigms delivered less total electrical energy translating to an increase in the battery life of the INS.ConclusionsThe results of this study verify that EMG-driven rDBS provides clinically equivalent tremor suppression compared to cDBS, while delivering less total electrical energy. Controlling stimulation using a dynamic rDBS paradigm can mitigate limitations of traditional cDBS systems.     

Effect of lead trajectory on the response of essential head tremor to deep brain stimulation

BackgroundEssential tremor (ET) is one of the most common movement disorders. Normally ET affects the distal upper extremities, but it can also be accompanied by midline symptoms. Ventralis intermedius (VIM) thalamic deep brain stimulation (DBS) has been shown to be effective in reducing hand tremor, but its effects on head tremor have been inconsistent.MethodsTwenty-nine DBS patients with a diagnosis of ET met inclusion criteria. All implantations targeted VIM. The factors examined included age, gender, disease duration, presence or absence of head tremor, handedness, and the Fahn-Tolosa-Marin rating scale (TRS). This analysis specifically focused on TRS head tremor sub-scores at baseline, 6 months and 12 months post-DBS. Additionally, DBS lead entry angles were examined.ResultsTwenty-three ET patients underwent unilateral DBS and six underwent staged bilateral DBS. At both 6 and 12 months following DBS, stimulation resulted in diminished head tremor (ON vs OFF; p < 0.0001). The most important predictor of head tremor suppression was the entry angle of the DBS lead in the sagittal projection relative to the AC–PC axial plane (AC–PC angle). Head tremor reduction was greater among more vertical AC–PC angles.ConclusionA more vertical AC–PC angle of the DBS lead trajectory was associated with improved head tremor suppression. Further studies will be necessary to confirm this potentially important finding.     

Thalamic stimulation for primary writing tremor

We report a patient with primary writing tremor whose tremor was treated with thalamic stimulation. He had undergone trials of multiple oral medications with no benefit for his tremor. An electrode lead was implanted in the thalamic nucleus ventralis intermedius with nearly complete control of his tremor and no postoperative complications. We conclude that nucleus ventralis intermedius thalamic stimulation is safe and effective for primary writing tremor. Received: 30 March 2000 / Received in revised form: 31 October 2000 / Accepted: 13 November 2000     

Effects of ramped-frequency thalamic deep brain stimulation on tremor and activity of modeled neurons

ObjectiveWe conducted intraoperative measurements of tremor to quantify the effects of temporally patterned ramped-frequency DBS trains on tremor.MethodsSeven patterns of stimulation were tested in nine subjects with thalamic DBS for essential tremor: stimulation ‘off’, three ramped-frequency stimulation (RFS) trains from 130 → 50 Hz, 130 → 60 Hz, and 235 → 90 Hz, and three constant frequency stimulation (CFS) trains at 72, 82, and 130 Hz. The same patterns were applied to a computational model of the thalamic neural network.ResultsTemporally patterned 130 → 60 Hz ramped-frequency trains suppressed tremor relative to stimulation ‘off,’ but 130 → 50 Hz, 130 → 60 Hz, and 235 → 90 Hz ramped-frequency trains were no more effective than constant frequency stimulation with the same mean interpulse interval (IPI). Computational modeling revealed that rhythmic burst-driver inputs to thalamus were masked during DBS, but long IPIs, concurrent with pauses in afferent cerebellar and cortical firing, allowed propagation of bursting activity. The mean firing rate of bursting-type model neurons as well as the firing pattern entropy of model neurons were both strongly correlated with tremor power across stimulation conditions.ConclusionFrequency-ramped DBS produced equivalent tremor suppression as constant frequency thalamic DBS. Tremor-related thalamic burst activity may result from burst-driver input, rather than by an intrinsic rebound mechanism.SignificanceRamping stimulation frequency may exacerbate thalamic burst firing by introducing consecutive pauses of increasing duration to the stimulation pattern.     

Effects of chronic alcohol consumption on long-term outcomes of thalamic deep brain stimulation for essential tremor

The prevalence of essential tremor (ET) is about 4% above 40 years of age. Chronic alcohol consumption is present in around 20% of patients with ET. Our objective was to identify whether chronic alcohol consumption was associated with a negative effect on tremor outcome after thalamic deep brain stimulation (DBS) in ET patients. We conducted a retrospective chart review, from January 2005 to December 2012, from which 23 patients who had ventral intermediate nucleus (Vim)-DBS surgery for ET were identified. Seven patients had a positive history of chronic alcohol consumption. We defined as chronic alcohol users those patients with a habit of drinking alcohol every day in order to suppress tremor. In the overall group of 23 patients, there was a reduction in the median tremor score from 8 pre-operatively, to 1 post-operatively (p < 0.0001). The alcohol consumers group experienced a reduction in the median tremor score from 6 pre-operatively to 0 post-operatively (p = 0.03). The non-alcohol consumers group had a reduction in the median tremor score from 8 pre-operatively to 1.7 post-operatively (p < 0.0001). Both groups of patients experienced significant benefit from thalamic DBS. A larger study may reveal statistically significant differences between subgroups.     

Use of efficacy probability maps for the post-operative programming of deep brain stimulation in essential tremor

IntroductionPost-operative programming of deep brain stimulation for movement disorders can be both time consuming and difficult, which can delay the optimal symptom control for the patient. Probabilistic maps of stimulation response could improve programming efficiency and optimization.MethodsThe clinically selected contacts of patients who had undergone ventral intermediate nucleus deep brain stimulation for the treatment of essential tremor at our institution were compared against contacts selected based on a probability map of symptom reduction built by populating data from a number of patients using non-rigid image registration. A subgroup of patients whose clinical contacts did not match the map-based selections prospectively underwent a tremor rating scale evaluation to compare the symptom relief achieved by the two options. Both the patient and video reviewer were blinded to the selection.Results54% of the map-based and clinical contacts were an exact match retrospectively and were within one contact 83% of the time. In 5 of the 8 mismatched leads that were evaluated prospectively in a double blind fashion, the map-based contact showed equivalent or better tremor improvement than the clinically active contact.ConclusionsThis study suggests that probability maps of stimulation responses can assist in selecting the clinically optimal contact and increase the efficiency of programming.