1
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Mai AS, Lee YS, Yong JH, Teo DCYJ, Wan YM, Tan EK. Treatment of apathy in Parkinson's disease: A bayesian network meta-analysis of randomised controlled trials. Heliyon 2024; 10:e26107. [PMID: 38440294 PMCID: PMC10909723 DOI: 10.1016/j.heliyon.2024.e26107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 01/12/2024] [Accepted: 02/07/2024] [Indexed: 03/06/2024] Open
Abstract
Background Apathy is an important but unrecognised aspect of Parkinson's disease (PD). The optimal therapeutic options for apathy remain unclear. Early recognition and treatment of apathy can reduce the significant burden of disease for patients and their caregivers. Here we conducted a meta-analysis to evaluate the comparative efficacy of different treatment modalities of apathy in PD (CRD42021292099). Methods We screened Medline, Embase, and PsycINFO databases for articles on therapies for apathy in PD. The outcome of interest is the reduction in apathy scores post-intervention and is measured by standardised mean differences (SMD) with 95% credible intervals (CrI). We included only randomised controlled trials examining interventions targeted at reducing apathy. Results Nineteen studies involving 2372 patients were included in the quantitative analysis. The network meta-analysis found pharmacotherapy to be the most efficacious treatment, significantly better than brain stimulation (SMD -0.43, 95% CrI -0.78 to -0.07), exercise-based interventions (SMD -0.66, 95% CrI -1.25 to -0.08), supplements (SMD -0.33, 95% CrI -0.67 to 0), and placebo (SMD -0.38, 95% CrI -0.56 to -0.23). Subgroup analysis of pharmacotherapy versus placebo found similar efficacy of dopamine agonists (SMD -0.36, 95% CI -0.59 to -0.12, P = 0.003) and alternative medications (SMD -0.42, 95% CI -0.61 to -0.23, P < 0.001). The remaining comparisons and subgroup analyses did not demonstrate any significant treatment effects. Conclusion Our meta-analysis of randomised controlled trials showed that pharmacotherapy is the most efficacious treatment option, with dopamine agonists having similar efficacy as other medications. Further research is needed to determine the optimal management strategy.
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Affiliation(s)
- Aaron Shengting Mai
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yi Siang Lee
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jung Hahn Yong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Yi-Min Wan
- Department of Psychiatry, Ng Teng Fong General Hospital, Singapore
| | - Eng-King Tan
- Department of Neurology, Singapore General Hospital Campus, National Neuroscience Institute, Singapore
- Neuroscience and Behavioural Programme, Duke-NUS Medical School, Singapore
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2
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Merello M, Hariz M. Radiofrequency Ablation: How to Ensure Worldwide Availability of Surgery for Parkinson's Disease. Mov Disord Clin Pract 2024; 11:114-118. [PMID: 38229231 PMCID: PMC10883407 DOI: 10.1002/mdc3.13945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 10/16/2023] [Accepted: 11/15/2023] [Indexed: 01/18/2024] Open
Affiliation(s)
- Marcelo Merello
- Servicio de Movimientos Anormales, Departamento de Neurociencias, Fleni, Buenos Aires, Argentina
- Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET), Buenos Aires, Argentina
| | - Marwan Hariz
- Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
- UCL Institute of Neurology, Queen Square, London, United Kingdom
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3
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Hariz M. Pros and Cons of Ablation for Functional Neurosurgery in the Neurostimulation Age. Neurosurg Clin N Am 2023; 34:291-299. [PMID: 36906335 DOI: 10.1016/j.nec.2022.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Should one recommend stereotactic ablation for Parkinson disease, tremor, dystonia, and obsessive compulsive disorder, in this era of DBS? The answer depends on several variables such as the symptoms to treat, the patient's preferences and expectations, the surgeons' competence and preference, the availability of financial means (by government health care, by private insurance), the geographical issues, and not least the current and dominating fashion at that particular time. Both ablation and stimulation can be either used alone or even combined (provided expertise in both of them) to treat various symptoms of movement and mind disorders.
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Affiliation(s)
- Marwan Hariz
- Department of Clinical Neuroscience, University Hospital, Umeå 90185, Sweden.
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4
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Rajan R, Garg K, Srivastava AK, Singh M. Device-Assisted and Neuromodulatory Therapies for Parkinson's Disease: A Network Meta-Analysis. Mov Disord 2022; 37:1785-1797. [PMID: 35866929 DOI: 10.1002/mds.29160] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/28/2022] [Accepted: 06/28/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Device-assisted and neuromodulatory therapies are the standard of care for Parkinson's disease (PD) with disabling motor complications. We aimed to compare and rank the currently available advanced therapies for PD on patient relevant outcomes. METHODS We searched various databases for randomized controlled trials that studied subthalamic nucleus deep brain stimulation (STN-DBS), globus pallidus interna (GPi) DBS, pallidotomy, subthalamotomy, continuous subcutaneous apomorphine infusion (CSAI), or intrajejunal levodopa infusion (IJLI), in patients with PD and motor complications. Primary outcome was the quality of life (QOL) at 6 months. Secondary outcomes included Unified Parkinson's Disease Rating Scale III and II, ON time, OFF time, levodopa equivalent daily doses, and adverse events (AE). Data were pooled using a Bayesian network meta-analysis, summarized as mean difference (MD) with 95% credibility intervals (CrI) and visualized in forest plots/league tables. Surface under the cumulative ranking curve plots determined the ranking probability. RESULTS We identified 6745 citations and included 26 trials. STN-DBS (MD, -8.0; 95% CrI, -11, -5.8), GPi-DBS (MD, -7.1; 95% CrI, -11, -2.9), and IJLI (MD, -7.0; 95% CrI, -12, -1.8) led to better QOL than medical therapy alone, without significant differences among them. STN-DBS had the highest probability of being ranked the best treatment for QOL (79.6%), followed by IJLI (63.5%) and GPi-DBS (62.8%). CONCLUSIONS In advanced PD, STN-DBS alleviates more patient and clinician relevant outcomes, followed by GPi-DBS and IJLI. In resource limited settings, unilateral pallidotomy may improve motor symptoms and activities of daily living, although overall QOL may not be improved. © 2022 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Roopa Rajan
- Departments of Neurology, CN Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Kanwaljeet Garg
- Department of Neurosurgery, CN Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Achal K Srivastava
- Departments of Neurology, CN Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Manmohan Singh
- Department of Neurosurgery, CN Centre, All India Institute of Medical Sciences, New Delhi, India
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5
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Permezel F. Brain MRI-guided focused ultrasound conceptualised as a tool for brain network intervention. J Clin Neurosci 2021; 90:370-379. [PMID: 34275578 DOI: 10.1016/j.jocn.2021.05.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 05/02/2021] [Accepted: 05/27/2021] [Indexed: 11/25/2022]
Abstract
Magnetic resonance imaging guided high intensity focused ultrasound (HIFU) has emerged as a tool offering incisionless intervention on brain tissue. The low risk and rapid recovery from this procedure, in addition to the ability to assess for clinical benefit and adverse events intraprocedurally, makes it an ideal tool for intervention upon brain networks both for clinical and research applications. This review article proposes that conceptualising brain focused ultrasound as a tool for brain network intervention and adoption of methodology to complement this approach may result in better clinical outcomes, fewer adverse events and may unveil or allow treatment opportunities not otherwise possible. A brief introduction to network neuroscience is discussed before a description of pathological brain networks is provided for a number of conditions for which MRI-guided brain HIFU intervention has been implemented. Essential Tremor is discussed as the most advanced example of MRI-guided brain HIFU intervention adoption along with the issues that present with this treatment modality compared to alternatives. The brain network intervention paradigm is proposed to overcome these issues and a number of examples of implementation of this are discussed. The ability of low intensity MRI guided focussed ultrasound to neuromoduate brain tissue without lesioning is introduced. This tool is discussed with regards to its potential clinical application as well as its potential to further our understanding of network neuroscience via its ability to interrogate brain networks without damaging tissue. Finally, a number of current clinical trials utilising brain focused ultrasound are discussed, along with the additional applications available from the utilisation of low intensity focused ultrasound.
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Affiliation(s)
- Fiona Permezel
- Austin Hospital, Heidelberg, Victoria, Australia; The University of Melbourne, Parkville, Victoria, Australia; The Florey Institute of Neuroscience and Mental Health, Austin Hospital, Victoria, Australia.
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6
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Máñez-Miró JU, Rodríguez-Rojas R, Del Álamo M, Martínez-Fernández R, Obeso JA. Present and future of subthalamotomy in the management of Parkinson´s disease: a systematic review. Expert Rev Neurother 2021; 21:533-545. [PMID: 33788645 DOI: 10.1080/14737175.2021.1911649] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: The subthalamic nucleus (STN) is known to be involved in the pathophysiology of Parkinson´s disease and by reducing its abnormal activity, normal output of basal ganglia can be restored along with improvement in PD cardinal motor features. Deep brain stimulation of the STN is currently the main surgical procedure for PD with motor complications, but lesioning can be an alternative.Areas covered: Here, the authors systematically review the current evidence regarding subthalamotomy both with radiofrequency and, more recently, with focused ultrasound (FUS) for the treatment of PD.Expert opinion: Unilateral subthalamotomy for the treatment of PD motor features can be considered a viable option in asymmetric patients, particularly with FUS which allows a minimally invasive safe and effective ablation of the STN. Risk of inducing dyskinesia (i.e., hemichorea/ballism) may be strikingly reduced when lesions enlarge dorsally to impinge on pallidothalamic fibers.
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Affiliation(s)
- Jorge U Máñez-Miró
- HM CINAC (Centro Integral De Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, Madrid, Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases (CIBERNED), Instituto De Salud Carlos III, Madrid, Spain
| | - Rafael Rodríguez-Rojas
- HM CINAC (Centro Integral De Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, Madrid, Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases (CIBERNED), Instituto De Salud Carlos III, Madrid, Spain
| | - Marta Del Álamo
- HM CINAC (Centro Integral De Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, Madrid, Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases (CIBERNED), Instituto De Salud Carlos III, Madrid, Spain
| | - R Martínez-Fernández
- HM CINAC (Centro Integral De Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, Madrid, Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases (CIBERNED), Instituto De Salud Carlos III, Madrid, Spain
| | - José A Obeso
- HM CINAC (Centro Integral De Neurociencias Abarca Campal), Hospital Universitario HM Puerta Del Sur, Madrid, Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases (CIBERNED), Instituto De Salud Carlos III, Madrid, Spain.,CEU-San Pablo University, Móstoles, Madrid, Spain
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7
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Martínez-Fernández R, Matarazzo M, Máñez-Miró JU, Obeso JA. The Role of Focused Ultrasound in the Management of Movement Disorders: Insights after 5 Years of Experience. Mov Disord Clin Pract 2021; 8:681-687. [PMID: 34307739 DOI: 10.1002/mdc3.13223] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/26/2021] [Accepted: 04/07/2021] [Indexed: 11/07/2022] Open
Affiliation(s)
- Raúl Martínez-Fernández
- HM CINAC (Centro Integral de Neurociencias Abarca Campal) Hospital Universitario HM Puerta del Sur, HM Hospitales Madrid Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases Carlos III Institute Madrid Spain
| | - Michele Matarazzo
- HM CINAC (Centro Integral de Neurociencias Abarca Campal) Hospital Universitario HM Puerta del Sur, HM Hospitales Madrid Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases Carlos III Institute Madrid Spain
| | - Jorge U Máñez-Miró
- HM CINAC (Centro Integral de Neurociencias Abarca Campal) Hospital Universitario HM Puerta del Sur, HM Hospitales Madrid Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases Carlos III Institute Madrid Spain
| | - Jose A Obeso
- HM CINAC (Centro Integral de Neurociencias Abarca Campal) Hospital Universitario HM Puerta del Sur, HM Hospitales Madrid Spain.,Network Center for Biomedical Research on Neurodegenerative Diseases Carlos III Institute Madrid Spain
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8
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Affiliation(s)
| | - Mwiza Ushe
- From the Washington University School of Medicine, St. Louis
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9
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Radiofrequency Ablation Through Previously Effective Deep Brain Stimulation Leads for Parkinson Disease: A Retrospective Series. World Neurosurg 2020; 144:e750-e765. [PMID: 32949803 DOI: 10.1016/j.wneu.2020.09.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/11/2020] [Accepted: 09/12/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Although deep brain stimulation (DBS) of the subthalamic nucleus (STN) or globus pallidus internus (GPi) is the surgical method of choice to treat the canonical symptoms of Parkinson disease, occasionally surgical sites become infected or the hardware erodes, necessitating explantation. Usual practice is to remove and reimplant replacement leads after tissue healing, leaving patients without the clinical benefits of DBS for several months, and at risk for DBS withdrawal in some, and some patients are no longer good surgical candidates for reimplantation. Radiofrequency ablation through the DBS lead is an option for these patients. METHODS We performed a retrospective chart review of all patients who underwent radiofrequency ablation of the STN or GPi through indwelling DBS leads performed before hardware removal at our institution. We generated patient-specific anatomic models to determine lesion locations and volumes. RESULTS Six patients underwent radiofrequency ablation of the STN (n = 4) and GPi (n = 2) through indwelling DBS leads. All 6 of these patients initially showed comparable motor symptom relief to that experienced with DBS before lesioning, with 4 patients sustaining meaningful long-term (≥2 years) improvement. Better outcomes were achieved in those patients with a higher percentage of the planned target lesioned. CONCLUSIONS Radiofrequency ablation through indwelling DBS leads before explantation could be considered a viable alternative to subsequent reimplantation or stereotactic lesion in patients with Parkinson disease in whom hardware explantation is necessary, if the patient achieved substantive symptom relief with DBS. This approach avoids symptom exacerbation while awaiting revision surgery.
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10
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Franzini A, Moosa S, Servello D, Small I, DiMeco F, Xu Z, Elias WJ, Franzini A, Prada F. Ablative brain surgery: an overview. Int J Hyperthermia 2020; 36:64-80. [PMID: 31537157 DOI: 10.1080/02656736.2019.1616833] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Background: Ablative therapies have been used for the treatment of neurological disorders for many years. They have been used both for creating therapeutic lesions within dysfunctional brain circuits and to destroy intracranial tumors and space-occupying masses. Despite the introduction of new effective drugs and neuromodulative techniques, which became more popular and subsequently caused brain ablation techniques to fall out favor, recent technological advances have led to the resurgence of lesioning with an improved safety profile. Currently, the four main ablative techniques that are used for ablative brain surgery are radiofrequency thermoablation, stereotactic radiosurgery, laser interstitial thermal therapy and magnetic resonance-guided focused ultrasound thermal ablation. Object: To review the physical principles underlying brain ablative therapies and to describe their use for neurological disorders. Methods: The literature regarding the neurosurgical applications of brain ablative therapies has been reviewed. Results: Ablative treatments have been used for several neurological disorders, including movement disorders, psychiatric disorders, chronic pain, drug-resistant epilepsy and brain tumors. Conclusions: There are several ongoing efforts to use novel ablative therapies directed towards the brain. The recent development of techniques that allow for precise targeting, accurate delivery of thermal doses and real-time visualization of induced tissue damage during the procedure have resulted in novel techniques for cerebral ablation such as magnetic resonance-guided focused ultrasound or laser interstitial thermal therapy. However, older techniques such as radiofrequency thermal ablation or stereotactic radiosurgery still have a pivotal role in the management of a variety of neurological disorders.
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Affiliation(s)
- Andrea Franzini
- Department of Neurological Surgery, University of Virginia Health System , Charlottesville , VA , USA.,Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta , Milan , Italy
| | - Shayan Moosa
- Department of Neurological Surgery, University of Virginia Health System , Charlottesville , VA , USA
| | - Domenico Servello
- Department of Neurosurgery, Galeazzi Research and Clinical Hospital , Milan , Italy
| | - Isabella Small
- Focused Ultrasound Foundation , Charlottesville , VA , USA
| | - Francesco DiMeco
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta , Milan , Italy.,Department of Pathophysiology and Transplantation, University of Milan , Milan , Italy.,Department of Neurological Surgery, Johns Hopkins Medical School , Baltimore , MD , USA
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System , Charlottesville , VA , USA
| | - William Jeffrey Elias
- Department of Neurological Surgery, University of Virginia Health System , Charlottesville , VA , USA
| | - Angelo Franzini
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta , Milan , Italy
| | - Francesco Prada
- Department of Neurological Surgery, University of Virginia Health System , Charlottesville , VA , USA.,Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta , Milan , Italy.,Focused Ultrasound Foundation , Charlottesville , VA , USA
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11
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Drummond PS, Pourfar MH, Hill TC, Mogilner AY, Kondziolka DS. Subthalamic Gamma Knife Radiosurgery in Parkinson's Disease: A Cautionary Tale. Stereotact Funct Neurosurg 2020; 98:110-117. [PMID: 32101861 DOI: 10.1159/000505709] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 12/30/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Deep brain stimulation (DBS) targeting the subthalamic nucleus (STN) has been shown to reliably improve several symptoms of Parkinson's disease (PD) in appropriately selected patients. Various factors may preclude patients from undergoing DBS and for them, non-invasive lesion-based therapies such as focused ultrasound and Gamma Knife (GK) radiosurgery may present a safer alternative. MATERIALS AND METHODS Based on preliminary positive reports of STN GK for PD, we conducted a prospective, open-label, single-center, pilot study in PD patients deemed potential candidates for unilateral DBS based on their disease characteristics, but contraindicated due to age >74, an irreversible bleeding diathesis, or significant comorbid medical disease. Stereotactic MRI-guided GK radiosurgery was performed using a single 110- or 120-Gy dose targeting the STN contralateral to the more symptomatic extremity. Clinical follow-up and imaging assessed the safety and efficacy of the procedure over a 12-month period. RESULTS Four PD patients with medication-refractory tremors and disabling dyskinesias underwent unilateral STN GK radiosurgery. Contraindications to DBS included high-risk comorbid cardiovas-cular disease in 3 patients and an irreversible bleeding diathesis in 1. There were no immediate post-procedural adverse events. One patient who underwent left STN GK radiosurgery developed right hemiparesis and dysarthria 7 months post-procedure followed by hospitalization at 9 months for bacterial endocarditis and liver failure from which he died. The remaining 3 patients were free of adverse events up to 12 months post-procedure and experienced a reduction in contralateral rigidity, bradykinesia, and tremor. Upon extended follow-up, 2 patients developed subacute worsening of gait. One died at 16 months due to complications of a fall whereas the other saw no change in gait up to 42 months post-procedure. All 3 patients with adverse events demonstrated a hyper-response in the targeted area on follow-up neuroimaging. DISCUSSION/CONCLUSION Despite the potential for clinical improvement, our results suggest that unilateral STN GK radiosurgery should be approached cautiously in medically frail PD patients who may be at higher risk of GK hyper-response and neurologic complications.
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Affiliation(s)
| | - Michael H Pourfar
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Travis C Hill
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Alon Y Mogilner
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
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12
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Walters H, Shah BB. Focused Ultrasound and Other Lesioning Therapies in Movement Disorders. Curr Neurol Neurosci Rep 2019; 19:66. [DOI: 10.1007/s11910-019-0975-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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13
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Altinel Y, Alkhalfan F, Qiao N, Velimirovic M. Outcomes in Lesion Surgery versus Deep Brain Stimulation in Patients with Tremor: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 123:443-452.e8. [DOI: 10.1016/j.wneu.2018.11.175] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 12/21/2022]
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14
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Schreglmann SR, Krauss JK, Chang JW, Bhatia KP, Kägi G. Functional lesional neurosurgery for tremor: a systematic review and meta-analysis. J Neurol Neurosurg Psychiatry 2018; 89:717-726. [PMID: 29326290 DOI: 10.1136/jnnp-2017-316302] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/20/2017] [Accepted: 11/20/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND This work evaluates the consistency, effect size and incidence of persistent side effects of lesional neurosurgical interventions in the treatment of tremor due to Parkinson's disease (PD), essential tremor (ET), multiple sclerosis (MS) and midbrain lesions. METHODS Systematic review and meta-analysis according to PRISMA-P guidelines. Random effects meta-analysis of standardised mean difference based on a peer-reviewed protocol (PROSPERO no. CRD42016048049). RESULTS From 1249 abstracts screened, 86 peer-reviewed studies reporting 102 cohorts homogeneous for tremor aetiology, surgical target and technique were included.Effect on PD tremor was better when targeted at the ventral intermediate nucleus (V.im.) by radiofrequency ablation (RF) (Hedge's g: -4.15;) over V.im. by Gamma Knife (GK) (-2.2), subthalamic nucleus (STN) by RF (-1.12) and globus pallidus internus (GPi) by RF (-0.89). For ET MRI-guided focused ultrasound (MRIgFUS) ablation of the cerebellothalamic tract (CTT) (-2.35) and V.im. (-2.08) showed similar mean tremor reductions to V.im. ablation by RF (-2.42) or GK (-2.13). In MS V.im. ablation by GK (-1.96) and RF (-1.63) were similarly effective.Mean rates of persistent side effects after unilateral lesions in PD were 12.8% (RF V.im.), 13.6% (RF STN), 9.2% (RF GPi), 0.7% (GK V.im.) and 7.0% (MRIgFUS V.im.). For ET, rates were 9.3% (RF V.im.), 1.8% (GK V.im.), 18.7% (MRIgFUS V.im.) and 0.0% (MRIgFUS CTT), for MS 37.7% (RF V.im.) and for rubral tremor 30.3% (RF V.im.). CONCLUSION This meta-analysis quantifies safety, consistency and efficacy of lesional neurosurgical interventions for tremor by target, technique and aetiology.
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Affiliation(s)
- Sebastian R Schreglmann
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, London, UK
| | - Joachim K Krauss
- Department of Neurosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, London, UK
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
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15
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Schreglmann SR, Krauss JK, Chang JW, Martin E, Werner B, Bauer R, Hägele-Link S, Bhatia KP, Kägi G. Functional lesional neurosurgery for tremor: back to the future? J Neurol Neurosurg Psychiatry 2018; 89:727-735. [PMID: 29269505 DOI: 10.1136/jnnp-2017-316301] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 09/18/2017] [Accepted: 11/20/2017] [Indexed: 11/03/2022]
Abstract
For nearly a century, functional neurosurgery has been applied in the treatment of tremor. While deep brain stimulation has been in the focus of academic interest in recent years, the establishment of incisionless technology, such as MRI-guided high-intensity focused ultrasound, has again stirred interest in lesional approaches.In this article, we will discuss the historical development of surgical technique and targets, as well as the technological state-of-the-art of conventional and incisionless interventions for tremor due to Parkinson's disease, essential and dystonic tremor and tremor related to multiple sclerosis (MS) and midbrain lesions. We will also summarise technique-inherent advantages of each technology and compare their lesion characteristics. From this, we identify gaps in the current literature and derive future directions for functional lesional neurosurgery, in particularly potential trial designs, alternative targets and the unsolved problem of bilateral lesional treatment. The results of a systematic review and meta-analysis of the consistency, efficacy and side effect rate of lesional treatments for tremor are presented separately alongside this article.
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Affiliation(s)
- Sebastian R Schreglmann
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland.,Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, UCL, London, UK
| | - Joachim K Krauss
- Department of Neurosurgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Jin Woo Chang
- Department of Neurosurgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ernst Martin
- Center for Focused Ultrasound, University of Zurich, Children's Hospital Zurich, Zurich, Switzerland
| | - Beat Werner
- Center for Focused Ultrasound, University of Zurich, Children's Hospital Zurich, Zurich, Switzerland
| | - Ronald Bauer
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Stefan Hägele-Link
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, UCL, London, UK
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
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16
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Rodriguez-Rojas R, Carballo-Barreda M, Alvarez L, Guridi J, Pavon N, Garcia-Maeso I, Mací As R, Rodriguez-Oroz MC, Obeso JA. Subthalamotomy for Parkinson's disease: clinical outcome and topography of lesions. J Neurol Neurosurg Psychiatry 2018; 89:572-578. [PMID: 29222224 DOI: 10.1136/jnnp-2017-316241] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 09/18/2017] [Accepted: 11/20/2017] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Subthalamotomy is an effective alternative for the treatment of Parkinson's disease (PD). However, uncertainty about the optimal target location and the possibility of inducing haemichorea-ballism have limited its application. We assessed the correlation between the topography of radiofrequency-based lesions of the subthalamic nucleus (STN) with motor improvement and the emergence of haemichorea-ballism. METHODS Sixty-four patients with PD treated with subthalamotomy were evaluated preoperatively and postoperatively using the Unified Parkinson's Disease Rating Scale motor score (UPDRSm), MRI and tractography. Patients were classified according to the degree of clinical motor improvement and dyskinesia scale. Lesions were segmented on MRI and averaged in a standard space. We examined the relationship between the extent of lesion-induced disruption of fibres surrounding the STN and the development of haemichorea-ballism. RESULTS Maximum antiparkinsonian effect was obtained with lesions located within the dorsolateral motor region of the STN as compared with those centre-placed in the dorsal border of the STN and the zona incerta (71.3%, 53.5% and 20.8% UPDRSm reduction, respectively). However, lesions that extended dorsally beyond the STN showed lower probability of causing haemichorea-ballism than those placed entirely within the nucleus. Tractography findings indicate that interruption of pallidothalamic fibres probably determines a low probability of haemichorea-ballism postoperatively. CONCLUSIONS The topography of the lesion is a major factor in the antiparkinsonian effect of subthalamotomy in patients with PD. Lesions involving the motor STN and pallidothalamic fibres induced significant motor improvement and were associated with a low incidence of haemichorea-ballism.
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Affiliation(s)
- Rafael Rodriguez-Rojas
- HM CINAC, Hospital Universitario HM Puerta del Sur, CEU-San Pablo University, Madrid, Spain.,CIBERNED, Institute Carlos III, Madrid, Spain
| | - Maylen Carballo-Barreda
- Brain Images Processing Group and Movement Disorder Unit, International Center for Neurological Restoration, Havana, Cuba
| | - Lazaro Alvarez
- Brain Images Processing Group and Movement Disorder Unit, International Center for Neurological Restoration, Havana, Cuba
| | - Jorge Guridi
- Service of Neurosurgery, Clinica Universidad de Navarra, Pamplona, Spain
| | - Nancy Pavon
- Brain Images Processing Group and Movement Disorder Unit, International Center for Neurological Restoration, Havana, Cuba
| | - Ivan Garcia-Maeso
- Brain Images Processing Group and Movement Disorder Unit, International Center for Neurological Restoration, Havana, Cuba
| | - Raul Mací As
- Brain Images Processing Group and Movement Disorder Unit, International Center for Neurological Restoration, Havana, Cuba
| | - Maria C Rodriguez-Oroz
- CIBERNED, Institute Carlos III, Madrid, Spain.,BioDonostia Health Research Institute, Basque Center on Cognition Brain and Language, San Sebastian, Guipuzcoa, Spain
| | - Jose Angel Obeso
- HM CINAC, Hospital Universitario HM Puerta del Sur, CEU-San Pablo University, Madrid, Spain.,CIBERNED, Institute Carlos III, Madrid, Spain
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17
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Rossi M, Bruno V, Arena J, Cammarota Á, Merello M. Challenges in PD Patient Management After DBS: A Pragmatic Review. Mov Disord Clin Pract 2018; 5:246-254. [PMID: 30363375 PMCID: PMC6174419 DOI: 10.1002/mdc3.12592] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 01/01/2018] [Accepted: 01/15/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus (STN) or internal globus pallidus (GPi) represents an effective and universally applied therapy for Parkinson's disease (PD) motor complications. However, certain procedure-related problems and unrealistic patient expectations may detract specialists from indicating DBS more widely despite significant clinical effects. METHODS This review provides a pragmatic educational summary of the most conflicting postoperative management issues in patients undergoing DBS for PD. RESULTS DBS in PD has been associated with certain complications and post-procedural management issues, which can complicate surgical outcome interpretation. Many PD patients consider DBS outcomes negative due to unfulfilled expectations, even when significant motor symptom improvement is achieved. Speech, gait, postural stability, and cognition may worsen after DBS and body weight may increase. Although DBS may induce impulse control disorders in some cases, in others, it may actually improve them when dopamine agonist dosage is reduced after surgery. However, apathy may also arise, especially when dopaminergic medication tapering is rapid. Gradual loss of response with time suggests disease progression, rather than the wearing off of DBS effects. Furthermore, implantable pulse generator expiration is considered a movement disorder emergency, as it may worsen parkinsonian symptoms or cause life-threatening akinetic crises due to malignant DBS withdrawal syndrome. CONCLUSION Major unsolved issues occurring after DBS therapy preclude complete patient satisfaction. Multidisciplinary management at experienced centers, as well as careful and comprehensive delivery of information to patients, should contribute to make DBS outcome expectations more realistic and allow post procedural complications to be better accepted.
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Affiliation(s)
- Malco Rossi
- Movement Disorders Section, Neuroscience DepartmentRaul Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
| | - Verónica Bruno
- Movement Disorders Section, Neuroscience DepartmentRaul Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
- Argentine National Scientific and Technological Research Council (CONICET)Buenos AiresArgentina
| | - Julieta Arena
- Movement Disorders Section, Neuroscience DepartmentRaul Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
| | - Ángel Cammarota
- Movement Disorders Section, Neuroscience DepartmentRaul Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
| | - Marcelo Merello
- Movement Disorders Section, Neuroscience DepartmentRaul Carrea Institute for Neurological Research (FLENI)Buenos AiresArgentina
- Argentine National Scientific and Technological Research Council (CONICET)Buenos AiresArgentina
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18
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Krack P, Martinez-Fernandez R, del Alamo M, Obeso JA. Current applications and limitations of surgical treatments for movement disorders. Mov Disord 2017; 32:36-52. [DOI: 10.1002/mds.26890] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 11/10/2016] [Accepted: 11/13/2016] [Indexed: 12/11/2022] Open
Affiliation(s)
- Paul Krack
- Neurology Division, Department of Clinical Neurosciences; University Hospital of Geneva; Geneva Switzerland
| | | | - Marta del Alamo
- CINAC-Hospital Universitario HM Puerta del Sur; CEU-San Pablo University; Madrid Spain
- Neurosurgery Department; Hospital Universitario Ramon y Cajal; Madrid Spain
| | - Jose A. Obeso
- CINAC-Hospital Universitario HM Puerta del Sur; CEU-San Pablo University; Madrid Spain
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas; Madrid Spain
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19
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Neuroprotective and Therapeutic Strategies against Parkinson's Disease: Recent Perspectives. Int J Mol Sci 2016; 17:ijms17060904. [PMID: 27338353 PMCID: PMC4926438 DOI: 10.3390/ijms17060904] [Citation(s) in RCA: 115] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 05/27/2016] [Accepted: 05/30/2016] [Indexed: 12/18/2022] Open
Abstract
Parkinsonism is a progressive motor disease that affects 1.5 million Americans and is the second most common neurodegenerative disease after Alzheimer’s. Typical neuropathological features of Parkinson’s disease (PD) include degeneration of dopaminergic neurons located in the pars compacta of the substantia nigra that project to the striatum (nigro-striatal pathway) and depositions of cytoplasmic fibrillary inclusions (Lewy bodies) which contain ubiquitin and α-synuclein. The cardinal motor signs of PD are tremors, rigidity, slow movement (bradykinesia), poor balance, and difficulty in walking (Parkinsonian gait). In addition to motor symptoms, non-motor symptoms that include autonomic and psychiatric as well as cognitive impairments are pressing issues that need to be addressed. Several different mechanisms play an important role in generation of Lewy bodies; endoplasmic reticulum (ER) stress induced unfolded proteins, neuroinflammation and eventual loss of dopaminergic neurons in the substantia nigra of mid brain in PD. Moreover, these diverse processes that result in PD make modeling of the disease and evaluation of therapeutics against this devastating disease difficult. Here, we will discuss diverse mechanisms that are involved in PD, neuroprotective and therapeutic strategies currently in clinical trial or in preclinical stages, and impart views about strategies that are promising to mitigate PD pathology.
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20
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Falowski SM, Bakay RAE. Revision Surgery of Deep Brain Stimulation Leads. Neuromodulation 2016; 19:443-50. [PMID: 26899800 DOI: 10.1111/ner.12404] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Accepted: 12/17/2015] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Deep brain stimulation (DBS) is widely used for various movement disorders. DBS lead revisions are becoming more common as the indications and number of cases increases. METHODS Patients undergoing DBS lead revisions at a single institution were retrospectively analyzed based on diagnosis, reason for revision, where the lead was relocated, and surgical technique. RESULTS We reviewed 497 consecutive DBS lead placements and found that there was need for 25 DBS lead revisions with at least six months of follow-up. Loss of efficacy and development of adverse effects over time were the most common reasons for lead revision across all diagnosis. Lead malfunction was the least common. Ten patients requiring 19 DBS lead revisions that underwent their original surgery at another institution were also analyzed. Surgical technique dictated replacing with a new lead while maintaining brain position and tract with the old lead until final placement. Methods to seal exposed wire were developed. CONCLUSION Surgical technique, as well as variable options are important in lead revision and can be dictated based on reason for revision. Over time patients who have had adequate relief with DBS placement may experience loss of efficacy and development of adverse effects requiring revision of the DBS lead to maintain its effects.
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Affiliation(s)
- Steven M Falowski
- Department of Neurosurgery, St. Lukes University Health Network, Bethlehem, PA, USA
| | - Roy A E Bakay
- Department of Neurosurgery, Rush University Medical College, Chicago, IL, USA
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21
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Duval C, Daneault JF, Hutchison WD, Sadikot AF. A brain network model explaining tremor in Parkinson's disease. Neurobiol Dis 2016; 85:49-59. [DOI: 10.1016/j.nbd.2015.10.009] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 10/01/2015] [Accepted: 10/08/2015] [Indexed: 11/29/2022] Open
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22
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Zimnik AJ, Nora GJ, Desmurget M, Turner RS. Movement-related discharge in the macaque globus pallidus during high-frequency stimulation of the subthalamic nucleus. J Neurosci 2015; 35:3978-89. [PMID: 25740526 PMCID: PMC4348192 DOI: 10.1523/jneurosci.4899-14.2015] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/21/2015] [Accepted: 01/23/2015] [Indexed: 12/21/2022] Open
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus (STN-DBS) has largely replaced ablative therapies for Parkinson's disease. Because of the similar efficacies of the two treatments, it has been proposed that DBS acts by creating an "informational lesion," whereby pathologic neuronal firing patterns are replaced by low-entropy, stimulus-entrained firing patterns. The informational lesion hypothesis, in its current form, states that DBS blocks the transmission of all information from the basal ganglia, including both pathologic firing patterns and normal, task-related modulations in activity. We tested this prediction in two healthy rhesus macaques by recording single-unit spiking activity from the globus pallidus (232 neurons) while the animals completed choice reaction time reaching movements with and without STN-DBS. Despite strong effects of DBS on the activity of most pallidal cells, reach-related modulations in firing rate were equally prevalent in the DBS-on and DBS-off states. This remained true even when the analysis was restricted to cells affected significantly by DBS. In addition, the overall form and timing of perimovement modulations in firing rate were preserved between DBS-on and DBS-off states in the majority of neurons (66%). Active movement and DBS had largely additive effects on the firing rate of most neurons, indicating an orthogonal relationship in which both inputs contribute independently to the overall firing rate of pallidal neurons. These findings suggest that STN-DBS does not act as an indiscriminate informational lesion but rather as a filter that permits task-related modulations in activity while, presumably, eliminating the pathological firing associated with parkinsonism.
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Affiliation(s)
- Andrew J Zimnik
- Department of Neurobiology, Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, and
| | - Gerald J Nora
- Department of Neurobiology, Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, and
| | - Michel Desmurget
- Centre for Cognitive Neuroscience, UMR5229, CNRS, 67 Boulevard Pinel 69500 Bron, France
| | - Robert S Turner
- Department of Neurobiology, Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, and
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23
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Machado FA, Reppold CT. The effect of deep brain stimulation on motor and cognitive symptoms of Parkinson's disease: A literature review. Dement Neuropsychol 2015; 9:24-31. [PMID: 29213938 PMCID: PMC5618988 DOI: 10.1590/s1980-57642015dn91000005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Deep brain stimulator (DBS) implant surgery is considered a breakthrough in the
treatment of Parkinson's disease, especially in cases where motor symptoms
cannot be controlled through conventional drug treatment. Its benefits have been
studied extensively in the literature, particularly in relation to motor
symptoms. However, the disease's cognitive aspects have been studied to a lesser
extent.
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Affiliation(s)
- Flavia Amaral Machado
- Physiotherapist, Master's Student of Master's Program of Rehabilitation Sciences - Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil
| | - Caroline Tozzi Reppold
- PhD, Psychologist, Neuropsychological Assessment Unit, Master's Program of Rehabilitation Sciences and Health Sciences. Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Brazil
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24
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Gökbayrak NS, Piryatinsky I, Gavett RA, Ahmed OJ. Mixed effects of deep brain stimulation on depressive symptomatology in Parkinson's disease: a review of randomized clinical trials. Front Neurol 2014; 5:154. [PMID: 25157240 PMCID: PMC4127672 DOI: 10.3389/fneur.2014.00154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/28/2014] [Indexed: 11/21/2022] Open
Abstract
Although ~50% of patients with Parkinson’s disease (PD) experience depression, treatment for this important and debilitating comorbidity is relatively understudied. Deep brain stimulation (DBS) has been increasingly utilized for the management of tremors in progressive PD. Several preliminary studies have shown the potential benefit of DBS for non-motor PD symptoms such as depression. Here, we critically evaluate seven recent randomized clinical trials of the effectiveness of DBS in reducing depressive symptomatology among individuals with PD. Findings are mixed for the effectiveness of DBS as a treatment for depression in PD. Our review suggests that this is due, in large part, to the anatomical and methodological variation across the DBS studies. We provide a comprehensive discussion of these variations and highlight the need to conduct larger, more controlled studies aimed specifically at evaluating the treatment of depression in PD patients.
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Affiliation(s)
- N Simay Gökbayrak
- Department of Psychology, University of Rhode Island , Kingston, RI , USA
| | - Irene Piryatinsky
- Memory and Aging Program, Butler Hospital, The Warren Alpert Medical School of Brown University , Providence, RI , USA
| | - Rebecca A Gavett
- Memory and Aging Program, Butler Hospital, The Warren Alpert Medical School of Brown University , Providence, RI , USA
| | - Omar J Ahmed
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School , Boston, MA , USA
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25
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Modeling dyskinesia in animal models of Parkinson disease. Exp Neurol 2014; 256:105-16. [DOI: 10.1016/j.expneurol.2013.01.024] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Revised: 01/12/2013] [Accepted: 01/21/2013] [Indexed: 01/23/2023]
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26
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Jourdain VA, Schechtmann G, Di Paolo T. Subthalamotomy in the treatment of Parkinson's disease: clinical aspects and mechanisms of action. J Neurosurg 2014; 120:140-51. [DOI: 10.3171/2013.10.jns13332] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Parkinson's disease (PD) is a neurodegenerative condition that can be pharmacologically treated with levodopa. However, important motor and nonmotor symptoms appear with its long-term use. The subthalamic nucleus (STN) is known to be involved in the pathophysiology of PD and to contribute to levodopa-induced complications. Surgery is considered in patients who have advanced PD that is refractory to pharmacotherapy and who display disabling dyskinesia. Deep brain stimulation of the STN is currently the main surgical procedure for PD, but lesioning is still performed. This review covers the clinical aspects and complications of subthalamotomy as one of the lesion-based options for PD patients with levodopa-induced dyskinesias. Moreover, the authors discuss the possible effects of subthalamic lesioning.
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Affiliation(s)
- Vincent A. Jourdain
- 1Neurosciences Research Center, Centre de Recherche du CHU de Québec
- 2Faculty of Pharmacy, Laval University, Quebec City, Quebec, Canada, and
| | - Gastón Schechtmann
- 3Department of Neurosurgery and Clinical Neuroscience, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Thérèse Di Paolo
- 1Neurosciences Research Center, Centre de Recherche du CHU de Québec
- 2Faculty of Pharmacy, Laval University, Quebec City, Quebec, Canada, and
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27
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Daneault JF, Carignan B, Sadikot AF, Panisset M, Duval C. Drug-induced dyskinesia in Parkinson's disease. Should success in clinical management be a function of improvement of motor repertoire rather than amplitude of dyskinesia? BMC Med 2013; 11:76. [PMID: 23514355 PMCID: PMC3751666 DOI: 10.1186/1741-7015-11-76] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 03/20/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Dyskinesia, a major complication in the treatment of Parkinson's disease (PD), can require prolonged monitoring and complex medical management. DISCUSSION The current paper proposes a new way to view the management of dyskinesia in an integrated fashion. We suggest that dyskinesia be considered as a factor in a signal-to-noise ratio (SNR) equation where the signal is the voluntary movement and the noise is PD symptomatology, including dyskinesia. The goal of clinicians should be to ensure a high SNR in order to maintain or enhance the motor repertoire of patients. To understand why such an approach would be beneficial, we first review mechanisms of dyskinesia, as well as their impact on the quality of life of patients and on the health-care system. Theoretical and practical bases for the SNR approach are then discussed. SUMMARY Clinicians should not only consider the level of motor symptomatology when assessing the efficacy of their treatment strategy, but also breadth of the motor repertoire available to patients.
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Affiliation(s)
- Jean-François Daneault
- Department of Neurology and Neurosurgery, Montreal Neurological Institute, McGill University, 3801 University Street, Montreal, Quebec H3A 2B4, Canada
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28
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Niu L, Ji LY, Li JM, Zhao DS, Huang G, Liu WP, Qu Y, Ma LT, Ji XT. Effect of bilateral deep brain stimulation of the subthalamic nucleus on freezing of gait in Parkinson's disease. J Int Med Res 2013; 40:1108-13. [PMID: 22906284 DOI: 10.1177/147323001204000330] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE A prospective cohort study to evaluate the efficacy of bilateral subthalamic nucleus deep brain stimulation (STN-DBS) on freezing of gait (FOG) in patients with advanced Parkinson's disease. METHODS Patients (n = 10) with advanced Parkinson's disease were surgically implanted with microelectrodes to facilitate STN-DBS. Evaluations of FOG, motor function, activities of daily living and neuropsychological function were carried out in on-medication and off-medication states (with and without levodopa treatment), before surgery and at 6 and 12 months postoperatively. RESULTS STN-DBS was associated with significant improvement in FOG score and neuropsychological function at both 6 and 12 months postoperatively, compared with preoperatively. Significant postoperative improvements were also observed in motor function and activities of daily living. Daily levodopa dosage was significantly lower at both 6 and 12 months postoperatively. CONCLUSIONS STN-DBS improved FOG in patients with advanced Parkinson's disease. The significant reduction in levodopa dosage and improvement in neuropsychological function may be the reason for the therapeutic effect seen with STN-DBS.
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Affiliation(s)
- L Niu
- Department of Neurosurgery, Xijing Hospital, The Fourth Military Medical University, Xi'an, China
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29
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Abstract
The renaissance of functional stereotactic neurosurgery was pioneered in the mid 1980s by Laitinen's introduction of Leksell's posteroventral pallidotomy for Parkinson´s disease (PD). This ablative procedure experienced a worldwide spread in the 1990s, owing to its excellent effect on dyskinesias and other symptoms of post-l-dopa PD. Modern deep brain stimulation (DBS), pioneered by Benabid and Pollak in 1987 for the treatment of tremor, first became popular when it was applied to the subthalamic nucleus (STN) in the mid 1990s, where it demonstrated a striking effect on all cardinal symptoms of advanced PD, and permitted reduced dosages of medication. DBS, as a nondestructive, adaptable, and reversible procedure that is proving safe in bilateral surgery on basal ganglia, has great appeal to clinicians and patients alike, despite the fact that it is expensive, laborious, and relies on very strict patient selection criteria, especially for STN DBS. Psychiatric surgery has experienced the same phenomenon, with DBS supplanting completely stereotactic ablative procedures. This chapter discusses the pros and cons of ablation versus stimulation and investigates the reasons why DBS has overshadowed proven efficient ablative procedures such as pallidotomy for PD, and capsulotomy and cingulotomy for obsessive-compulsive disorder and depression.
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Affiliation(s)
- Marwan I Hariz
- Department of Neurosurgery, UCL Institute of Neurology, Queen Square, London, UK
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Vilela-Filho O, Silva DJ, Morais BA, Souza JT, Ragazzo PC. Possible Mechanisms Involved in Subthalamotomy-Induced Dyskinesia in Patients with Parkinson's Disease. Stereotact Funct Neurosurg 2013; 91:323-7. [DOI: 10.1159/000346499] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2012] [Accepted: 11/28/2012] [Indexed: 11/19/2022]
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31
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Jourdain VA, Grégoire L, Morissette M, Morin N, Parent M, Di Paolo T. Potentiation of response to low doses of levodopa in MPTP-injected monkeys by chemical unilateral subthalamotomy. J Neurosurg 2013; 118:180-91. [DOI: 10.3171/2012.9.jns12295] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Subthalamotomy is a stereotactic surgery performed in patients with disabling dyskinesias due to Parkinson disease. The authors set out to model this human condition in MPTP monkeys and determine if subthalamotomy allowed a reduction of levodopa for similar benefit.
Methods
The authors performed unilateral subthalamotomy in 4 parkinsonian dyskinetic monkeys by stereotactic injection of ibotenic acid. An optimal dose, defined as the highest dose of levodopa improving parkinsonian motor symptoms while inducing low or no dyskinesias, was established in these animals. Each monkey was scored for the antiparkinsonian and dyskinetic effects of the optimal dose of levodopa, as well as suboptimal and dyskinesia-inducing doses (60% and 140% of the optimal dose, respectively), and these scores were compared with those obtained at baseline before and after subthalamotomy. Bradykinesia was assessed by a prehension task.
Results
Unilateral subthalamotomy had a positive effect on the antiparkinsonian response for all doses of levodopa as well as the baseline. There were no differences in the antiparkinsonian response between the suboptimal dose postsurgery and the optimal dose presurgery. Dyskinesias were increased at the suboptimal and the optimal doses. After surgery, the duration of response to levodopa increased between 20% and 25% in the suboptimal dose, whereas it remained unchanged with higher doses. Bradykinesia was significantly reduced after surgery only at the suboptimal dose.
Conclusions
Subthalamotomy potentiated the response to suboptimal doses of levodopa. Thus, levodopa can be reduced by 40% after surgery for similar beneficial antiparkinsonian response and less dyskinesia than with an optimal dose before surgery.
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Affiliation(s)
- Vincent A. Jourdain
- 1Molecular Endocrinology and Genomic Research Center, CHUQ Research Center (CHUL)
- 2Faculty of Pharmacy, Laval University; and
| | - Laurent Grégoire
- 1Molecular Endocrinology and Genomic Research Center, CHUQ Research Center (CHUL)
| | - Marc Morissette
- 1Molecular Endocrinology and Genomic Research Center, CHUQ Research Center (CHUL)
| | - Nicolas Morin
- 1Molecular Endocrinology and Genomic Research Center, CHUQ Research Center (CHUL)
- 2Faculty of Pharmacy, Laval University; and
| | - Martin Parent
- 3Centre de recherche de l'Institut universitaire en santé mentale de Québec, Quebec City, Quebec, Canada
| | - Thérèse Di Paolo
- 1Molecular Endocrinology and Genomic Research Center, CHUQ Research Center (CHUL)
- 2Faculty of Pharmacy, Laval University; and
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32
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Hariz M. Twenty-five years of deep brain stimulation: celebrations and apprehensions. Mov Disord 2012; 27:930-3. [PMID: 22674402 DOI: 10.1002/mds.25007] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/22/2012] [Indexed: 11/10/2022] Open
Abstract
The year 2012 marks the 25th anniversary of the birth of modern deep brain stimulation (DBS), which was introduced by Benabid et al in 1987, initially to treat tremor with DBS of the ventral intermediate nucleus of the thalamus. The subsequent extension of DBS to the subthalamic nucleus (STN), demonstrating its efficacy on virtually all symptoms of advanced Parkinson's disease (PD), sparked an era of intense clinical and research activities, eventually transcending PD and movement disorders to encompass mood and mind. Investigations of the role of DBS in a variety of neurological, psychiatric, cognitive, and behavioral conditions is ongoing. Serendipitous discoveries and advances in functional imaging are providing "new" brain targets for an increasing number of pathologies. Toward the end of this quarter of a century of DBS, there have been some indications that the field may be at risk of gliding down a slippery slope, reminiscent of the excesses of the old-era DBS. Although there are many reasons this year to celebrate the achievements of 25 years of modern DBS, there are also reasons to fear the opening of a new Pandora's box.
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Fox SH, Katzenschlager R, Lim SY, Ravina B, Seppi K, Coelho M, Poewe W, Rascol O, Goetz CG, Sampaio C. The Movement Disorder Society Evidence-Based Medicine Review Update: Treatments for the motor symptoms of Parkinson's disease. Mov Disord 2012; 26 Suppl 3:S2-41. [PMID: 22021173 DOI: 10.1002/mds.23829] [Citation(s) in RCA: 385] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The objective was to update previous evidence-based medicine reviews of treatments for motor symptoms of Parkinson's disease published between 2002 and 2005. Level I (randomized, controlled trial) reports of pharmacological, surgical, and nonpharmacological interventions for the motor symptoms of Parkinson's disease between January 2004 (2001 for nonpharmacological) and December 2010 were reviewed. Criteria for inclusion, clinical indications, ranking, efficacy conclusions, safety, and implications for clinical practice followed the original program outline and adhered to evidence-based medicine methodology. Sixty-eight new studies qualified for review. Piribedil, pramipexole, pramipexole extended release, ropinirole, rotigotine, cabergoline, and pergolide were all efficacious as symptomatic monotherapy; ropinirole prolonged release was likely efficacious. All were efficacious as a symptomatic adjunct except pramipexole extended release, for which there is insufficient evidence. For prevention/delay of motor fluctuations, pramipexole and cabergoline were efficacious, and for prevention/delay of dyskinesia, pramipexole, ropinirole, ropinirole prolonged release, and cabergoline were all efficacious, whereas pergolide was likely efficacious. Duodenal infusion of levodopa was likely efficacious in the treatment of motor complications, but the practice implication is investigational. Entacapone was nonefficacious as a symptomatic adjunct to levodopa in nonfluctuating patients and nonefficacious in the prevention/delay of motor complications. Rasagiline conclusions were revised to efficacious as a symptomatic adjunct, and as treatment for motor fluctuations. Clozapine was efficacious in dyskinesia, but because of safety issues, the practice implication is possibly useful. Bilateral subthalamic nucleus deep brain stimulation, bilateral globus pallidus stimulation, and unilateral pallidotomy were updated to efficacious for motor complications. Physical therapy was revised to likely efficacious as symptomatic adjunct therapy. This evidence-based medicine review updates the field and highlights gaps for research.
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Affiliation(s)
- Susan H Fox
- Movement Disorder Clinic, Toronto Western Hospital, Toronto, Ontario, Canada.
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Smith Y, Wichmann T, Factor SA, DeLong MR. Parkinson's disease therapeutics: new developments and challenges since the introduction of levodopa. Neuropsychopharmacology 2012; 37:213-46. [PMID: 21956442 PMCID: PMC3238085 DOI: 10.1038/npp.2011.212] [Citation(s) in RCA: 156] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 07/28/2011] [Accepted: 07/29/2011] [Indexed: 12/13/2022]
Abstract
The demonstration that dopamine loss is the key pathological feature of Parkinson's disease (PD), and the subsequent introduction of levodopa have revolutionalized the field of PD therapeutics. This review will discuss the significant progress that has been made in the development of new pharmacological and surgical tools to treat PD motor symptoms since this major breakthrough in the 1960s. However, we will also highlight some of the challenges the field of PD therapeutics has been struggling with during the past decades. The lack of neuroprotective therapies and the limited treatment strategies for the nonmotor symptoms of the disease (ie, cognitive impairments, autonomic dysfunctions, psychiatric disorders, etc.) are among the most pressing issues to be addressed in the years to come. It appears that the combination of early PD nonmotor symptoms with imaging of the nigrostriatal dopaminergic system offers a promising path toward the identification of PD biomarkers, which, once characterized, will set the stage for efficient use of neuroprotective agents that could slow down and alter the course of the disease.
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Affiliation(s)
- Yoland Smith
- Yerkes National Primate Research Center, Emory University, Atlanta, GA 30322, USA.
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ANDRES DANIELASABRINA, CERQUETTI DANIEL, MERELLO MARCELO. FINITE DIMENSIONAL STRUCTURE OF THE GPI DISCHARGE IN PATIENTS WITH PARKINSON'S DISEASE. Int J Neural Syst 2011; 21:175-86. [PMID: 21656921 DOI: 10.1142/s0129065711002778] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Stochastic systems are infinitely dimensional and deterministic systems are low dimensional, while real systems lie somewhere between these two limit cases. If the calculation of a low (finite) dimension is in fact possible, one could conclude that the system under study is not purely random. In the present work we calculate the maximal Lyapunov exponent from interspike intervals time series recorded from the internal segment of the Globus Pallidusfrom patients with Parkinson's disease. We show the convergence of the maximal Lyapunov exponent at a dimension equal to 7 or 8, which is therefore our estimation of the embedding dimension for the system. For dimensions below 7 the observed behavior is what would be expected from a stochastic system or a complex system projecting onto lower dimensional spaces. The maximal Lyapunov exponent did not show any differences between tremor and akineto-rigid forms of the disease. However, it did decay with the value of motor Unified Parkinson's Disease Rating Scale -OFF scores. Patients with a more severe disease (higher UPDRS-OFF score) showed a lower value of the maximal Lyapunov exponent. Taken together, both indexes (the maximal Lyapunov exponent and the embedding dimension) remark the importance of taking into consideration the system's non-linear properties for a better understanding of the information transmission in the basal ganglia.
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Affiliation(s)
- DANIELA SABRINA ANDRES
- Institute for Neurological Research Raúl Carrea, Movement Disorders Section, Neuroscience Department, FLENI, Montañeses 2325, C1428AQK, Buenos Aires, Argentina
- Department of Physiology, Medicine School, University of Buenos Aires, Conicet, Argentina
| | - DANIEL CERQUETTI
- Institute for Neurological Research Raúl Carrea, Movement Disorders Section, Neuroscience Department, FLENI, Montañeses 2325, C1428AQK, Buenos Aires, Argentina
| | - MARCELO MERELLO
- Institute for Neurological Research Raúl Carrea, Movement Disorders Section, Neuroscience Department, FLENI, Montañeses 2325, C1428AQK, Buenos Aires, Argentina
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Neuronal discharge patterns in the Globus Pallidus pars interna in a patient with Parkinson’s disease and hemiballismus secondary to subthalamotomy. Exp Brain Res 2011; 213:447-55. [DOI: 10.1007/s00221-011-2794-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Accepted: 07/06/2011] [Indexed: 11/29/2022]
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Andres DS, Cerquetti DF, Merello M. Turbulence in Globus pallidum neurons in patients with Parkinson's disease: Exponential decay of the power spectrum. J Neurosci Methods 2011; 197:14-20. [DOI: 10.1016/j.jneumeth.2011.01.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Revised: 12/18/2010] [Accepted: 01/20/2011] [Indexed: 10/18/2022]
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Bickel S, Alvarez L, Macias R, Pavon N, Leon M, Fernandez C, Houghton DJ, Salazar S, Rodríguez-Oroz MC, Juncos J, Guridi J, Delong M, Obeso JA, Litvan I. Cognitive and neuropsychiatric effects of subthalamotomy for Parkinson's disease. Parkinsonism Relat Disord 2010; 16:535-9. [PMID: 20650671 DOI: 10.1016/j.parkreldis.2010.06.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2009] [Revised: 06/09/2010] [Accepted: 06/12/2010] [Indexed: 02/02/2023]
Abstract
Since the advent of deep brain stimulation (DBS) for the treatment of Parkinson's disease (PD), subsequent cognitive and neuropsychiatric effects of this procedure have become well-chronicled. Yet, thermolitic lesion of the subthalamic nucleus (STN) is still a valid option when DBS cannot be applied, and little has been published regarding its impact on cognition and mood. We examined the cognitive and neuropsychiatric functions of 10 consecutive patients with advanced PD undergoing simultaneous bilateral subthalamotomies. With 24 months of follow-up, the patients, three of whom were on anticholinergics prior to surgery, showed no deterioration in cognitive assessments including verbal fluency. Hypoactive behaviors (depression and apathy) showed lasting improvement, while hyperactive behaviors (euphoria and disinhibition) transiently increased after surgery. Improvement in hypoactive behaviors correlated with improvement in hypokinetic movements, and enhanced hyperactive behaviors followed the course of post-operative hyperkinetic movements. Such correlations may support the role of the STN in modulating limbic connections between the basal ganglia and frontal cortex. The results of this proof-of-concept pilot study suggest the need for larger, long-term, randomized controlled studies to assess motor, neuropsychiatric, behavioral and radiologic correlations after subthalamotomies.
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Affiliation(s)
- Scott Bickel
- Division of Movement Disorders, Department of Neurology, University of Louisville School of Medicine, Frazier Rehab Neuroscience Institute, 220 Abraham Flexner Way, Ste 1503, Louisville, KY 40202, USA
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Merello M, Cavanagh S, Perez-Lloret S, Roldan E, Bruno V, Tenca E, Leiguarda R. Irritability, psychomotor agitation and progressive insomnia induced by bilateral stimulation of the area surrounding the dorsal subthalamic nucleus (zona incerta) in Parkinson’s disease patients. J Neurol 2009; 256:2091-3. [DOI: 10.1007/s00415-009-5285-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 07/22/2009] [Accepted: 08/04/2009] [Indexed: 11/24/2022]
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Çoban A, Hanagasi HA, Karamursel S, Barlas O. Comparison of unilateral pallidotomy and subthalamotomy findings in advanced idiopathic Parkinson's disease. Br J Neurosurg 2009; 23:23-9. [DOI: 10.1080/02688690802507775] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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