神经电刺激治疗神经精神疾病的应用进展

应用脑深部电刺激（deepbrain stimulation，DBS）治疗运动障碍疾病以来，神经电刺激的适用范围逐渐增加，最初DBS仅用于对药物治疗效果不佳的帕金森病、肌张力障碍、特发性震颤等患者。自90年代开始，随着对新的临床指证，解剖靶点和手术技术认识的不断深入，     

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]     

脑深部电刺激临床应用的若干问题

脑深部电刺激(deep brain stimulation,DRS)自20世纪80年代末用于治疗特发性震颤,近年来在欧美国家DBS几乎完全替代了立体定向毁损术用于治疗帕金森病等运动障碍病。另外,DBS治疗癫(?),顽固性疼痛,某些精神疾病(如强迫症、抑郁症),摄食障碍等目前也进入临床研究阶段,并已显示出良好疗效。     

脑深部电刺激在神经外科的应用

脑深部电刺激(deep brain stimulation,DBS)是近年来用于治疗脑功能性疾病的一项新技术,其具有可逆性、可调性、非破坏性等特点。脑深部电刺激主要用于治疗帕金森病为代表肌张力障碍和运动障碍疾病,也用于一些非运动障碍性疾病,如癫痫、神经精神疾病、疼痛等。本文综述了脑深部电刺激在神经外科的临床应用情况。     

脑深部电刺激术的现状与未来

脑深部电刺激术(deep brain stimulation,DBS)自1987年发展至今,已成为功能神经外科领域中的重要手术方法之一,其对帕金森病、肌张力障碍、特发性震颤等运动障碍疾病治疗的有效性和长期稳定性已得到世界公认,在癫痫、疼痛、精神障碍等疾病的治疗方面也显示出良好的应用前景.     

脑深部电刺激治疗运动障碍性疾病

随着神经影像学、神经生理学和生物工程的发展，使运动障碍性疾病的外科疗效有明显提高，近几年来脑深部电刺激(deep brain stimulation，DBS)是治疗运动障碍性疾病的有效方法，具有效果明显，手术安全，并发症低等优点，DBS在运动障碍性疾病手术中除合理选择颅内靶点外，手术后的DBS程控调节是治疗帕金森病的重要环节，     

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。     

从头部立体定向框架到神经外科机器人系统辅助脑深部电刺激术

脑深部电刺激术(deep brain stimulation,DBS)又称为脑起搏器植入术,是神经外科针对帕金森病、原发性震颤和肌张力障碍等功能性疾病,在脑内深部核团精准植入带有电触点的电极,通过体外程控设定电刺激参数影响神经核团或神经环路电活动,改善临床症状的一种微创可逆可调节手术技术[1].DBS由法国神经外科医师...     

影响脑深部刺激器寿命的相关因素的研究进展

脑深部电刺激术(deep brain stimulation, DBS)已成为帕金森病、肌张力障碍、特发性震颤等多种顽固性运动障碍疾病公认的外科治疗方法。体内植入部分由脉冲发生器(impulse generator, IPG)等组成。对于传统的不可充电IPG,需要在IPG使用寿命到期之前选择更换。对IPG寿命的可靠估计在临床上具有重要意义。错误估计IPG寿命会带来患者临床症状恶化、致命并发症的发生及治疗成本的增加。本文就影响脑深部电刺激器寿命的相关因素的研究进展做一综述。     

神经外科手术机器人辅助脑深部电刺激手术的中国专家共识

1 概述 脑深部电刺激(deep brain stimulation,DBS)手术是通过立体定向方法进行精确定位,在脑内特定靶点植入刺激电极进行电刺激,从而改变相应核团兴奋性,以达到改善帕金森病及肌张力障碍症状,控制癫痫发作,缓解疼痛、痴呆、精神疾病等的一种神经调控疗法,现已成为治疗神经外科功能性疾病的重要手段之一[1...     

Advances in neurostimulation for movement disorders

In just 12 years since its introduction, deep brain stimulation (DBS) has become well established as a safe and effective therapy in the treatment of medically refractory movement disorders. Ventralis intermedius (Vim) DBS has virtually replaced thalamotomy in the routine clinical treatment of essential tremor, affording relief to thousands of patients who previously would not have undergone surgery, and there is increasing usage of Vim DBS in other tremors of intention (e.g., multiple sclerosis). Subthalamic nucleus (STN) and globus pallidus internus (GPi) DBS have revolutionized the treatment of advanced stage Parkinson's disease, improving all cardinal disease features and increasing 'on' time without dyskinesias. Finally, DBS of various sub-cortical structures is being developed and tested in other less prevalent movement disorders such as dystonia. Future developments in this rapidly advancing area will no doubt include widening indications for this relatively safe surgical procedure, elucidation of the mechanisms of action of electrical stimulation, and technological advancements improving effectiveness and convenience.     

Deep brain stimulation for the treatment of Parkinson's disease.

Deep brain stimulation (DBS) is increasingly accepted as an adjunct therapy for Parkinson's disease (PD). It is considered a surgical treatment alternative for patients with intractable tremor or for those patients who are affected by long-term complications of levodopa therapy such as motor fluctuations and severe dyskinesias. Thalamic stimulation in the ventral intermediate nucleus (Vim) leads to a marked reduction of contralateral tremor but has no beneficial effect on other symptoms of Parkinson's disease. The subthalamic nucleus (STN) and the internal segment of the globus pallidus (GPi) are targeted for the treatment of advanced Parkinson's disease. Several studies have proven the efficacy of STN-DBS and GPi-DBS in alleviating off motor symptoms and dyskinesias. Sub-thalamic nucleus deep brain stimulation is currently considered superior to GPi-DBS because the antiakinetic effect seems to be more pronounced, allows a more marked reduction of antiparkinsonian medication, and requires less stimulation energy. More recently, however, a number of reports on possible psychiatric and behavioral side effects of STN-DBS have been a matter of concern. Given the chronic nature of PD and the noncurative approach of DBS, both targets will need to be reevaluated on the basis of their long-term efficacy and their impact on quality of life. Despite the rapidly increasing numbers of DBS procedures, surprisingly few controlled clinical trials are available that address important clinical issues such as: When should DBS be applied during the course of disease? Which patients should be selected? Which target should be considered? Which guidelines should be followed during postoperative care? Here is summarized the available evidence on DBS as a therapeutic tool for the treatment of Parkinson's disease and the current state of debate on open issues.     

Clinical perspectives of adaptive deep brain stimulation

BackgroundThe application of stimulators implanted directly over deep brain structures (i.e., deep brain stimulation, DBS) was developed in the late 1980s and has since become a mainstream option to treat several neurological conditions. Conventional DBS involves the continuous stimulation of the target structure, which is an approach that cannot adapt to patients’ changing symptoms or functional status in real-time. At the beginning of 2000, a more sophisticated form of stimulation was conceived to overcome these limitations. Adaptive deep brain stimulation (aDBS) employs on-demand, contingency-based stimulation to stimulate only when needed. So far, aDBS has been tested in several pathological conditions in animal and human models.ObjectiveTo review the current findings obtained from application of aDBS to animal and human models that highlights effects on motor, cognitive and psychiatric behaviors.Findingswhile aDBS has shown promising results in the treatment of Parkinson's disease and essential tremor, the possibility of its use in less common DBS indications, such as cognitive and psychiatric disorders (Alzheimer's disease, obsessive-compulsive disorder, post-traumatic stress disorder) is still challenging.ConclusionsWhile aDBS seems to be effective to treat movement disorders (Parkinson's disease and essential tremor), its role in cognitive and psychiatric disorders is to be determined, although neurophysiological assumptions are promising.     

Surgery insight: Deep brain stimulation for movement disorders

Over the past two decades, deep brain stimulation (DBS) has supplanted lesioning techniques for the treatment of movement disorders, and has been shown to be safe and efficacious. The primary therapeutic indications for DBS are essential tremor, dystonia and Parkinson's disease. In the case of Parkinson's disease, DBS is effective for treating the primary symptoms--tremor, bradykinesia and rigidity--as well as the motor complications of drug treatment. Progress has been made in understanding the effects of stimulation at the neuronal level, and this knowledge should eventually improve the effectiveness of this therapy. Preliminary studies also indicate that DBS might be used to treat Tourette's syndrome, obsessive-compulsive disorder, depression and epilepsy. As we will discuss in this review, the success of DBS depends on an appropriate rationale for the procedure, and on collaborations between neurologists and neurosurgeons in defining outcomes.     

Deep brain stimulation in the treatment of movement disorders]

The introduction of deep brain stimulation (DBS) was a historical step forward for the treatment of advanced and medically intractable movement disorders that include Parkinson's disease, dystonias, essential tremor, and Holmes' tremor. DBS is able to modulate the target region electrically in a reversible and adjustable fashion in contrast to an irreversible and destructive lesioning procedure. In the treatment of movement disorders, the potential targets are the thalamic ventral intermediate nucleus (Vim), globus pallidus internus (GPi), subthalamic nucleus (STN), pedunculopontine nucleus (PPN), and thalamic Vo-complex nucleus. With the development of DBS technology and stereotactic neurosurgical techniques, its therapeutic efficacy has been increased while reducing surgical complications. DBS has become an established therapy for disabling movement disorders and is currently being used to treat neuropsychiatric disorders.     

Long-term follow-up of DBS of thalamus for tremor and STN for Parkinson's disease

In 1994 we commenced deep brain stimulation (DBS) of the thalamus for patients with severe tremor. This was done under the guidance of Professor Alim Benabid from Grenoble, France, who pioneered the technique. In the beginning we commenced DBS of the thalamus for patients with severe tremulous Parkinson's disease, essential tremor, and in one case, severe post-traumatic tremor. In all, we had 28 patients for whom the procedure was performed for tremulous Parkinson's disease, six patients with essential tremor and one patient with post-traumatic tremor. In 1997, again under the guidance of Professor Benabid, we commenced bilateral subthalamic nucleus stimulation (STN) for patients with severe Parkinson's disease. We were the second unit in Australia to become established for these procedures. A total of 45 patients have undergone STN DBS and have been followed up on a regular basis by the same neurologist (DOS). The surgical complications and long-term complications, including hardware problems will be reviewed retrospectively, as well as the long-term benefits of these surgical procedures.     

刺激术和毁损术在双侧立体定向手术治疗帕金森病中的比较

目的比较脑深部刺激术和毁损术在双侧立体定向手术治疗帕金森病中的优缺点。方法69例帕金森病病人进行了双侧手术治疗,其中同期双侧丘脑底核(STN)脑深部刺激术(DBS)11例,同期一侧苍白球腹后部毁损术(PVP),另一侧STNDBS3例,分期一侧PVP或腹中间核(Vim)毁损术、另一侧STN或VimDBS9例;分期双侧PVP或Vim毁损术41例,同期双侧PVP5例。平均随访9.3个月。结果UPDRS评分显示刺激术和毁损术均能显著改善对侧肢体震颤、僵硬和运动迟缓症状,双侧刺激术还能改善步态和姿势症状,但双侧毁损术可加重语言、吞咽及流涎等症状,并发症较高。结论双侧DBS是具有双侧症状的帕金森病病人手术治疗的最佳术式,双侧毁损术并发症较高,应严格慎重采用。     

Deep brain stimulation in movement disorders

Deep brain stimulation (DBS) is used for advanced and medically intractable patients with Parkinson's disease (PD), essential tremor (ET), and dystonia who meet strict criteria after a detailed motor, cognitive, and psychiatric evaluation. The potential targets are the ventral intermediate nucleus (VIM) of the thalamus for tremor, the globus pallidus interna (GPI) and the subthalamic nucleus (STN) for PD, and GPI for dystonia. The optimal target for PD has not been determined yet, although STN DBS has been performed more frequently in recent years. The mechanism of DBS effect is believed to be associated with disruption of pathological network activity in the cortico-basal ganglia-thalamic circuits by affecting the firing rates and bursting patterns of neurons and synchronized oscillatory activity of neuronal networks. Good candidates should be free of dementia, major psychiatric disorders, structural brain lesions, and important general medical problems. Although the risk for complications with DBS is less than with lesioning techniques, there is still a small risk for major complications associated with surgery. Bilateral procedures are more likely to cause problems with speech, cognition, and gait.     

How does deep brain stimulation work? Present understanding and future questions.

High-frequency deep brain stimulation (DBS) of the thalamus or basal ganglia represents an effective clinical technique for the treatment of several medically refractory movement disorders (e.g., Parkinson's disease, essential tremor, and dystonia). In addition, new clinical applications of DBS for other neurologic and psychiatric disorders (e.g., epilepsy and obsessive-compulsive disorder) have been vaulted forward. Although DBS has been effective in the treatment of movement disorders and is rapidly being explored for the treatment of other neurologic disorders, the scientific understanding of its mechanisms of action remains unclear and continues to be debated in the scientific community. Optimization of DBS technology for present and future therapeutic applications will depend on identification of the therapeutic mechanism(s) of action. The goal of this review is to address the present knowledge of the effects of high frequency stimulation within the central nervous system and comment on the functional implications of this knowledge for uncovering the mechanism(s) of DBS. Four general hypotheses have been developed to explain the mechanism(s) of DBS: depolarization blockade, synaptic inhibition, synaptic depression, and stimulation-induced modulation of pathologic network activity. Using the results from microdialysis, neural recording, functional imaging, and neural modeling experiments, the authors address the main hypotheses and attempt to reconcile what have been considered conflicting results from different research modalities.     

Treatment of motor and non-motor features of Parkinson's disease with deep brain stimulation

Deep brain stimulation (DBS) is an established procedure for the symptomatic treatment of Parkinson's disease. Several deep brain nuclei have been stimulated, producing a wide range of effects on the motor and non-motor symptoms of Parkinson's disease. Long-term, high-quality evidence is available for stimulation of the subthalamic nucleus and globus pallidus internus, both of which uniformly improve motor features, and for stimulation of the thalamic ventralis intermedius, which improves tremor. Short-term data are available for stimulation of other deep brain targets, such as the pedunculopontine nucleus and the centremedian/parafascicular thalamic complex. Some non-motor symptoms improve after DBS, partly because of motor benefit or reduction of drug treatment, and partly as a direct effect of stimulation. More evidence on the effects of DBS on non-motor symptoms is needed and specifically designed studies are warranted.