1
|
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.
Collapse
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
| |
Collapse
|
2
|
Beu ND, Burns NR, Baetu I. Polymorphisms in dopaminergic genes predict proactive processes of response inhibition. Eur J Neurosci 2019; 49:1127-1148. [DOI: 10.1111/ejn.14323] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 11/28/2018] [Accepted: 12/12/2018] [Indexed: 01/11/2023]
Affiliation(s)
- Nathan D. Beu
- The School of Psychology University of Adelaide Adelaide South Australia Australia
| | - Nicholas R. Burns
- The School of Psychology University of Adelaide Adelaide South Australia Australia
| | - Irina Baetu
- The School of Psychology University of Adelaide Adelaide South Australia Australia
| |
Collapse
|
3
|
Guridi J, Rodriguez-Rojas R, Carmona-Abellán M, Parras O, Becerra V, Lanciego JL. History and future challenges of the subthalamic nucleus as surgical target: Review article. Mov Disord 2018; 33:1540-1550. [DOI: 10.1002/mds.92] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 01/22/2023] Open
Affiliation(s)
- Jorge Guridi
- Department of Neurosurgery, Neurology and Neurosciences; Clínica Universidad de Navarra, University of Navarra; Pamplona Spain
- Instituto de Investigación Sanitaria Navarra; Pamplona Spain
| | - Rafael Rodriguez-Rojas
- Centro Integral de Neurociencias; University Hospital HM Puerta del Sur; Móstoles Madrid Spain
| | - Mar Carmona-Abellán
- Department of Neurosurgery, Neurology and Neurosciences; Clínica Universidad de Navarra, University of Navarra; Pamplona Spain
- Instituto de Investigación Sanitaria Navarra; Pamplona Spain
| | - Olga Parras
- Department of Neurosurgery, Neurology and Neurosciences; Clínica Universidad de Navarra, University of Navarra; Pamplona Spain
- Instituto de Investigación Sanitaria Navarra; Pamplona Spain
| | - Victoria Becerra
- Department of Neurosurgery, Neurology and Neurosciences; Clínica Universidad de Navarra, University of Navarra; Pamplona Spain
- Instituto de Investigación Sanitaria Navarra; Pamplona Spain
| | - Jose Luis Lanciego
- Department of Neurosurgery, Neurology and Neurosciences; Clínica Universidad de Navarra, University of Navarra; Pamplona Spain
- Instituto de Investigación Sanitaria Navarra; Pamplona Spain
- Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas; Pamplona Spain
| |
Collapse
|
4
|
Obeso I, Casabona E, Rodríguez-Rojas R, Bringas ML, Macías R, Pavón N, Obeso JA, Jahanshahi M. Unilateral subthalamotomy in Parkinson's disease: Cognitive, psychiatric and neuroimaging changes. Cortex 2017; 94:39-48. [DOI: 10.1016/j.cortex.2017.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 05/18/2017] [Accepted: 06/08/2017] [Indexed: 12/28/2022]
|
5
|
Foki T, Hitzl D, Pirker W, Novak K, Pusswald G, Auff E, Lehrner J. Assessment of individual cognitive changes after deep brain stimulation surgery in Parkinson's disease using the Neuropsychological Test Battery Vienna short version. Wien Klin Wochenschr 2017; 129:564-571. [PMID: 28176003 PMCID: PMC5552840 DOI: 10.1007/s00508-017-1169-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 01/18/2017] [Indexed: 12/16/2022]
Abstract
Long-term therapy of Parkinson’s disease with L‑DOPA is associated with a high risk of developing motor fluctuations and dyskinesia. Deep brain stimulation (DBS) of the subthalamic nucleus (STN) can improve these motor complications. Although the positive effect on motor symptoms has been proven, postoperative cognitive decline has been documented. To tackle the impact of DBS on cognition, 18 DBS patients were compared to 25 best medically treated Parkinson’s patients, 24 patients with mild cognitive impairment (MCI) and 12 healthy controls using the Neuropsychological Test Battery Vienna short version (NTBV-short) for cognitive outcome 12 months after the first examination. Reliable change index methodology was used. Roughly 10% of DBS patients showed cognitive decline mainly affecting the domains attention and executive functioning (phonemic fluency). Further research is needed to identify the mechanisms that lead to improvement or deterioration of cognitive functions in individual cases.
Collapse
Affiliation(s)
- Thomas Foki
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1097, Vienna, Austria
| | - Daniela Hitzl
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1097, Vienna, Austria
| | - Walter Pirker
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1097, Vienna, Austria
- Department of Neurology, Wilhelminenspital Wien, Vienna, Austria
| | - Klaus Novak
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gisela Pusswald
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1097, Vienna, Austria
| | - Eduard Auff
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1097, Vienna, Austria
| | - Johann Lehrner
- Department of Neurology, Medical University of Vienna, Währinger Gürtel 18-20, 1097, Vienna, Austria.
| |
Collapse
|
6
|
Tremblay C, Macoir J, Langlois M, Cantin L, Prud'homme M, Monetta L. The effects of subthalamic deep brain stimulation on metaphor comprehension and language abilities in Parkinson's disease. BRAIN AND LANGUAGE 2015; 141:103-109. [PMID: 25577507 DOI: 10.1016/j.bandl.2014.12.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Revised: 10/20/2014] [Accepted: 12/15/2014] [Indexed: 06/04/2023]
Abstract
The effects of subthalamic nucleus (STN) deep brain stimulation (DBS) in Parkinson's disease (PD) on different language abilities are still controversial and its impact on high-level language abilities such as metaphor comprehension has been overlooked. The aim of this study was to determine the effects of STN electrical stimulation on metaphor comprehension and language abilities such as lexical and semantic capacities. Eight PD individuals with bilateral STN-DBS were first evaluated OFF-DBS and, at least seven weeks later, ON-DBS. Performance on metaphor comprehension, lexical decision, word association and verbal fluency tasks were compared ON and OFF-DBS in addition to motor symptoms evaluation. STN stimulation had a significant beneficial effect on motor symptoms in PD. However, this stimulation did not have any effect on metaphor comprehension or any other cognitive ability evaluated in this study. These outcomes suggest that STN stimulation may have dissociable effects on motor and language functions.
Collapse
Affiliation(s)
- Christina Tremblay
- Faculté de médecine, Département de réadaptation, Université Laval, 1050, ave de la Médecine, Québec, QC G1V 0A6, Canada; Institut Universitaire en Santé Mentale de Québec, 2601, rue de la Canardière, Québec, QC G1J 2G3, Canada.
| | - Joël Macoir
- Faculté de médecine, Département de réadaptation, Université Laval, 1050, ave de la Médecine, Québec, QC G1V 0A6, Canada; Institut Universitaire en Santé Mentale de Québec, 2601, rue de la Canardière, Québec, QC G1J 2G3, Canada.
| | - Mélanie Langlois
- Clinique des troubles du mouvement, Hôpital de l'Enfant-Jésus, 1401, 18(e) rue, Québec, QC G1J 1Z4, Canada.
| | - Léo Cantin
- Clinique des troubles du mouvement, Hôpital de l'Enfant-Jésus, 1401, 18(e) rue, Québec, QC G1J 1Z4, Canada.
| | - Michel Prud'homme
- Clinique des troubles du mouvement, Hôpital de l'Enfant-Jésus, 1401, 18(e) rue, Québec, QC G1J 1Z4, Canada.
| | - Laura Monetta
- Faculté de médecine, Département de réadaptation, Université Laval, 1050, ave de la Médecine, Québec, QC G1V 0A6, Canada; Institut Universitaire en Santé Mentale de Québec, 2601, rue de la Canardière, Québec, QC G1J 2G3, Canada.
| |
Collapse
|
7
|
Jahanshahi M, Obeso I, Baunez C, Alegre M, Krack P. Parkinson's Disease, the Subthalamic Nucleus, Inhibition, and Impulsivity. Mov Disord 2014; 30:128-40. [DOI: 10.1002/mds.26049] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 08/21/2014] [Accepted: 09/07/2014] [Indexed: 12/14/2022] Open
Affiliation(s)
- Marjan Jahanshahi
- Cognitive Motor Neuroscience Group and Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology; London United Kingdom
| | - Ignacio Obeso
- CINAC, HM-Puerta del Sur, Hospitales de Madrid; CEU-San Pablo University, Móstoles; Madrid Spain
| | - Christelle Baunez
- Basal Ganglia, Motivation and Reward' (BAGAMORE), Institut de Neurosciences de la Timone, UMR7289 CNRS and AMU (Aix Marseille Universite); Marseille France
| | - Manuel Alegre
- Neurophysiology Laboratory, Neuroscience Area, CIMA, University of Navarra; Pamplona Spain
| | - Paul Krack
- INSERM U836, F-38000 Grenoble, France; University Grenoble Alpes, GIN, Grenoble, France, and CHU de Grenoble, Movement Disorder Unit; Grenoble France
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
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.
Collapse
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
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Mount DL, Lambert MC. Mental ability performance among adults with type 2 diabetes in primary care. MENTAL HEALTH IN FAMILY MEDICINE 2009; 6:99-106. [PMID: 22477898 PMCID: PMC2777606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 07/21/2009] [Indexed: 05/31/2023]
Abstract
Aim and method The present university-based outpatient clinic, cross-sectional study assessed cognitive performance in a sample of 137 adults, with the primary objective of determining differences in cognitive performance as a function of gender and hypertension status in a type 2 diabetes cohort.Results Approximately 64% of the sample was 65 years old and younger, and 50 subjects had > 13 years of education. Global mental ability scores were relatively similar by age grouping, and higher-ordered cognitive functioning and reading literacy were strongly correlated, r (98) = 0.62, P < 0.01. Approximately 30% of the sample posted global mental ability scores in the slow learner range on tasks measuring attention, immediate memory and verbal reasoning. Males achieved higher cognitive functioning scores compared to females on multiple mental ability tasks. The presence of hypertension was associated with significantly worse cognitive performance compared to those subjects without hypertension, t = 2.11, P = 0.03. Approximately 57% of the hypertension group was classified as mild cognitive impaired.Conclusion While approximately half of the general population can be expected to demonstrate an average range of performance on cognitive ability measures, such an expectation could be inappropriately generalised to persons diagnosed with type 2 diabetes, even among those who were high school educated.
Collapse
Affiliation(s)
- David L Mount
- Assistant Professor, Department of Internal Medicine, Section of General Internal Medicine and Director of the Maya Angelou Research Center for Health Equity, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | |
Collapse
|
11
|
Halpern CH, Rick JH, Danish SF, Grossman M, Baltuch GH. Cognition following bilateral deep brain stimulation surgery of the subthalamic nucleus for Parkinson's disease. Int J Geriatr Psychiatry 2009; 24:443-51. [PMID: 19016252 DOI: 10.1002/gps.2149] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Parkinson's disease (PD) is a neurodegenerative disorder characterized by significant motor dysfunction and various non-motor disturbances, including cognitive alterations. Deep brain stimulation (DBS) is an increasingly utilized therapeutic option for patients with PD that yields remarkable success in alleviating disabling motor symptoms. DBS has additionally been associated with changes in cognition, yet the evidence is not consistent across studies. The following review sought to provide a clearer understanding of the various cognitive sequelae of bilateral subthalamic nucleus (STN) DBS while taking into account corresponding neuroanatomy and potential confounding variables. DESIGN A literature search was performed using the following inclusion criteria: (1) at least five subjects followed for a mean of at least 3 months after surgery; (2) pre- and postoperative cognitive data using at least one standardized measure; (3) adequate report of study results using means and standard deviations. RESULTS Two recent meta-analyses found mild post-operative impairments in verbal learning and executive function in patients who underwent DBS surgery. However, studies have revealed improved working memory and psychomotor speed in the 'on' vs 'off' stimulation state. A deficit in language may be a consequence of the surgical procedure. CONCLUSIONS While cognitive decline has been observed in some domains, our review of the data suggests that STN DBS is a worthwhile and safe method to treat PD.
Collapse
Affiliation(s)
- Casey H Halpern
- Department of Neurosurgery, Neurology and Psychiatry, University of Pennsylvania, Philadelphia, PA, USA
| | | | | | | | | |
Collapse
|
12
|
Lueken U, Schwarz M, Hertel F, Schweiger E, Wittling W. Impaired performance on the Wisconsin Card Sorting Test under left- when compared to right-sided deep brain stimulation of the subthalamic nucleus in patients with Parkinson’s disease. J Neurol 2009; 255:1940-8. [DOI: 10.1007/s00415-009-0040-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2007] [Revised: 11/27/2007] [Accepted: 06/27/2008] [Indexed: 11/25/2022]
|
13
|
Heo JH, Lee KM, Paek SH, Kim MJ, Lee JY, Kim JY, Cho SY, Lim YH, Kim MR, Jeong SY, Jeon BS. The effects of bilateral Subthalamic Nucleus Deep Brain Stimulation (STN DBS) on cognition in Parkinson disease. J Neurol Sci 2008; 273:19-24. [DOI: 10.1016/j.jns.2008.06.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 05/29/2008] [Accepted: 06/05/2008] [Indexed: 10/21/2022]
|
14
|
Zahodne LB, Okun MS, Foote KD, Fernandez HH, Rodriguez RL, Kirsch-Darrow L, Bowers D. Cognitive declines one year after unilateral deep brain stimulation surgery in Parkinson's disease: a controlled study using reliable change. Clin Neuropsychol 2008; 23:385-405. [PMID: 18821180 DOI: 10.1080/13854040802360582] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Conflicting research suggests that deep brain stimulation surgery, an effective treatment for medication-refractory Parkinson's disease (PD), may lead to selective cognitive declines. We compared cognitive performance of 22 PD patients who underwent unilateral DBS to the GPi or STN to that of 19 PD controls at baseline and 12 months. We hypothesized that compared to PD controls, DBS patients would decline on tasks involving dorsolateral prefrontal cortex circuitry (letter fluency, semantic fluency, and Digit Span Backward) but not on other tasks (Vocabulary, Boston Naming Test), and that a greater proportion of DBS patients would fall below Reliable Change Indexes (RCIs). Compared to controls, DBS patients declined only on the fluency tasks. Analyses classified 50% of DBS patients as decliners, compared to 11% of controls. Decliners experienced less motor improvement than non-decliners. The present study adds to the literature through its hypothesis-driven method of task selection, inclusion of a disease control group, longer-term follow-up and use of Reliable Change. Our findings provide evidence that unilateral DBS surgery is associated with verbal fluency declines and indicate that while these changes may not be systematically related to age, cognitive or depression status at baseline, semantic fluency declines may be more common after left-sided surgery. Finally, use of Reliable Change highlights the impact of individual variability and indicates that fluency declines likely reflect significant changes in a subset of patients who demonstrate a poorer surgical outcome overall.
Collapse
Affiliation(s)
- Laura B Zahodne
- Clinical and Health Psychology, University of Florida, Gainesville, FL 32610-0165, USA.
| | | | | | | | | | | | | |
Collapse
|
15
|
Wojtecki L, Timmermann L, Jörgens S, Südmeyer M, Maarouf M, Treuer H, Gross J, Lehrke R, Koulousakis A, Voges J, Sturm V, Schnitzler A. Frequency-dependent reciprocal modulation of verbal fluency and motor functions in subthalamic deep brain stimulation. ACTA ACUST UNITED AC 2006; 63:1273-6. [PMID: 16966504 DOI: 10.1001/archneur.63.9.1273] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND High-frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves motor functions in those with Parkinson disease but may worsen frontal functions such as verbal fluency (VF). In contrast, low-frequency DBS leads to deterioration of motor functions. It is not known whether low-frequency STN DBS also has an effect on frontal functions. OBJECTIVE To examine whether low-frequency STN DBS in contrast to high-frequency STN DBS has a positive effect on frontal functions on the basis of VF test results. DESIGN A double-blind randomized crossover experiment to compare performance in 4 VF subtests and motor performance at 10 Hz, 130 Hz, and no stimulation. SETTING University hospitals in Düsseldorf and Cologne, Germany. PATIENTS Twelve patients with Parkinson disease 3 months or more after bilateral electrode implantation into the STN. MAIN OUTCOME MEASURE Mean number of words in VF at different stimulation frequencies. RESULTS The VF was significantly better at 10 Hz (48.3 words) compared with 130 Hz and showed a nonsignificant trend toward worsening at 130 Hz (42.3 words) compared with no stimulation (43.8 words). These results were consistent across all subtests. CONCLUSIONS The study provides evidence of a beneficial effect of low-frequency (10 Hz) STN DBS on VF, which may be caused by activating neural pathways projecting to the frontal cortex. In addition, the study reproduces the negative effect of therapeutic high-frequency STN DBS on VF. The study results provide evidence for a frequency-dependent modulation of cognitive circuits involving the STN.
Collapse
Affiliation(s)
- Lars Wojtecki
- Department of Neurology, Heinrich Heine University, Moorenstrasse 5, 40225 Düsseldorf, Germany
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Abdullah MS, Al-Waili NS, Baban NK, Butler GJ, Sultan L. Postsurgical psychosis: case report and review of literature. Adv Ther 2006; 23:325-31. [PMID: 16751164 DOI: 10.1007/bf02850137] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A wide range of behavioral symptoms may occur following surgery, including depression, hallucinations, true psychosis, mania, and impulsivity. Psychoses, including those that occur postoperatively, are among the most frequent indications for hospitalization in the United States and are associated with a substantially increased rate of morbidity. The exact cause of postoperative psychosis has not been identified. A 59-year-old woman who developed acute psychosis after cholecystectomy is described here. The patient was brought to Mount Vernon Hospital in New York because she exhibited acute disruptive behavior following endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy performed on 2 consecutive days. The patient was psychotic and was unable to be managed; she was disorganized, confused, and perplexed. Findings of computed tomography of the head, electroencephalography, and chemical and hematologic tests were normal. The patient was treated with lorazepam 1 mg every 6 h, olanzapine 5 mg at bedtime, and clonazepam 1 mg at bedtime. She experienced a mixture of auditory and visual hallucinations with a paranoid perspective and was then treated with haloperidol 5 mg, diphenhydramine chloride 25 mg, and divalproex sodium 500 mg. After 1 wk, the patient was described as acutely psychotic; antipsychotic medication dosages were readjusted and the patient's condition stabilized. The association between surgical procedures and psychosis is thoroughly reviewed here. Awareness, ability to diagnose, and an understanding of the cause of psychotic symptoms that emerge following surgery must be established if physicians are to provide better care and more effective treatment.
Collapse
Affiliation(s)
- Mahdi S Abdullah
- Methodist Medical Center, The Mount Vernon Hospital, Life Support Technology Groups, Mount Vernon, New York 10550, USA
| | | | | | | | | |
Collapse
|
17
|
Whelan BM, Murdoch BE, Theodoros DG, Silburn P, Hall B. Beyond verbal fluency: investigating the long-term effects of bilateral subthalamic (STN) deep brain stimulation (DBS) on language function in two cases. Neurocase 2005; 11:93-102. [PMID: 16036464 DOI: 10.1080/13554790590925501] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Cognitive functioning has been described as largely impervious to chronic STN-DBS administered over 12-month periods. In relation to the domain of language, however, the effects of STN-DBS are yet to be thoroughly delineated. Verbal fluency tasks represent an almost exclusively applied index of linguistic proficiency relative to neuropsychological research within this population. Comprehensive investigations of the impact of STN-DBS on language function, however, have never been undertaken. The more precise elucidation of the role of the STN in the mediation of language processes, by way of assessments which probe language comprehension and production mechanisms, served as the primary focus of this research. Longitudinal analysis also afforded consideration of the way in which cognitive-linguistic circuits respond to STN-DBS over time. Bilateral STN-DBS primarily effected clinically reliable fluctuations (i.e., both improvements and declines) in performance in both subjects on tasks demanding cognitive-linguistic flexibility in the formulation and comprehension of complex language. Of particular note, both subjects demonstrated a cumulative increase in the proportion of reliable post-operative improvements achieved over time. The findings of this research lend support to models of subcortical participation in language which endorse a role for the STN, and suggest that bilateral STN-DBS may serve to enhance the proficiency of basal ganglia-thalamocortical linguistic circuits over time.
Collapse
Affiliation(s)
- Brooke-Mai Whelan
- Motor Speech Research Unit, Department of Speech Pathology and Audiology, University of Queensland, Brisbane, Australia.
| | | | | | | | | |
Collapse
|
18
|
Patel NK, Bunnage M, Plaha P, Svendsen CN, Heywood P, Gill SS. Intraputamenal infusion of glial cell line-derived neurotrophic factor in PD: A two-year outcome study. Ann Neurol 2005; 57:298-302. [PMID: 15668979 DOI: 10.1002/ana.20374] [Citation(s) in RCA: 293] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
We have shown previously that intraparenchymal infusion of glial cell line-derived neurotrophic factor (GDNF) continuously into the posterior putamen in five Parkinson's disease patients is safe and may represent a new treatment option. Here, we report a continuation of this phase I study. After 2 years of continual GDNF infusion, there were no serious clinical side effects and no significant detrimental effects on cognition. Patients showed a 57% and 63% improvement in their off-medication motor and activities of daily living subscores of the Unified Parkinson's Disease Rating Scale, respectively, and health-related quality-of-life measures (Parkinson's Disease Questionnaire-39 and Short Form-36) showed general improvement over time.
Collapse
Affiliation(s)
- Nikunj K Patel
- Frenchay Hospital, Institute of Neurosciences, Bristol, United Kingdom
| | | | | | | | | | | |
Collapse
|
19
|
Whelan BM, Murdoch BE, Theodoros D, Silburn P, Hall B. Re-appraising contemporary theories of subcortical participation in language: proposing an interhemispheric regulatory function for the subthalamic nucleus (STN) in the mediation of high-level linguistic processes. Neurocase 2004; 10:345-52. [PMID: 15788272 DOI: 10.1080/13554790490893742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Apropos the basal ganglia, the dominant striatum and globus pallidus internus (GPi) have been hypothesized to represent integral components of subcortical language circuitry. Working subcortical language theories, however, have failed thus far to consider a role for the STN in the mediation of linguistic processes, a structure recently defined as the driving force of basal ganglia output. The aim of this research was to investigate the impact of surgically induced functional inhibition of the STN upon linguistic abilities, within the context of established models of basal ganglia participation in language. Two males with surgically induced'lesions'of the dominant and non-dominant dorsolateral STN, aimed at relieving Parkinsonian motor symptoms, served as experimental subjects. General and high-level language profiles were compiled for each subject up to 1 month prior to and 3 months following neurosurgery, within the drug-on state (i.e., when optimally medicated). Comparable post-operative alterations in linguistic performance were observed subsequent to surgically induced functional inhibition of the left and right STN. More specifically, higher proportions of reliable decline as opposed to improvement in post-operative performance were demonstrated by both subjects on complex language tasks, hypothesised to entail the interplay of cognitive-linguistic processes. The outcomes of the current research challenge unilateralised models of functional basal ganglia organisation with the proposal of a potential interhemispheric regulatory function for the STN in the mediation of high-level linguistic processes.
Collapse
Affiliation(s)
- Brooke-Mai Whelan
- Motor Speech/ Neurogenic Language Research Centre, School of Health and Rehabilitation Sciences, Division of Speech Pathology, University of Queensland, Brisbane, Australia.
| | | | | | | | | |
Collapse
|
20
|
Hälbig TD, Gruber D, Kopp UA, Scherer P, Schneider GH, Trottenberg T, Arnold G, Kupsch A. Subthalamic stimulation differentially modulates declarative and nondeclarative memory. Neuroreport 2004; 15:539-43. [PMID: 15094519 DOI: 10.1097/00001756-200403010-00031] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Declarative memory has been reported to rely on the medial temporal lobe system, whereas non-declarative memory depends on basal ganglia structures. We investigated the functional role of the subthalamic nucleus (STN), a structure closely connected with the basal ganglia for both types of memory. Via deep brain high frequency stimulation (DBS) we manipulated neural activity of the STN in humans. We found that DBS-STN differentially modulated memory performance: declarative memory was impaired, whereas non-declarative memory was improved in the presence of STN-DBS indicating a specific role of the STN in the activation of memory systems.
Collapse
Affiliation(s)
- Thomas D Hälbig
- Department of Neurology, Charité-University Medicine Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, D-13353 Berlin, Germany.
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Whelan BM, Murdoch BE, Theodoros DG, Darnell R, Silburn P, Hall B. Redefining functional models of basal ganglia organization: Role for the posteroventral pallidum in linguistic processing? Mov Disord 2004; 19:1267-78. [PMID: 15390054 DOI: 10.1002/mds.20252] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Traditionally the basal ganglia have been implicated in motor behavior, as they are involved in both the execution of automatic actions and the modification of ongoing actions in novel contexts. Corresponding to cognition, the role of the basal ganglia has not been defined as explicitly. Relative to linguistic processes, contemporary theories of subcortical participation in language have endorsed a role for the globus pallidus internus (GPi) in the control of lexical-semantic operations. However, attempts to empirically validate these postulates have been largely limited to neuropsychological investigations of verbal fluency abilities subsequent to pallidotomy. We evaluated the impact of bilateral posteroventral pallidotomy (BPVP) on language function across a range of general and high-level linguistic abilities, and validated/extended working theories of pallidal participation in language. Comprehensive linguistic profiles were compiled up to 1 month before and 3 months after BPVP in 6 subjects with Parkinson's disease (PD). Commensurate linguistic profiles were also gathered over a 3-month period for a nonsurgical control cohort of 16 subjects with PD and a group of 16 non-neurologically impaired controls (NC). Nonparametric between-groups comparisons were conducted and reliable change indices calculated, relative to baseline/3-month follow-up difference scores. Group-wise statistical comparisons between the three groups failed to reveal significant postoperative changes in language performance. Case-by-case data analysis relative to clinically consequential change indices revealed reliable alterations in performance across several language variables as a consequence of BPVP. These findings lend support to models of subcortical participation in language, which promote a role for the GPi in lexical-semantic manipulation mechanisms. Concomitant improvements and decrements in postoperative performance were interpreted within the context of additive and subtractive postlesional effects. Relative to parkinsonian cohorts, clinically reliable versus statistically significant changes on a case by case basis may provide the most accurate method of characterizing the way in which pathophysiologically divergent basal ganglia linguistic circuits respond to BPVP.
Collapse
Affiliation(s)
- Brooke-Mai Whelan
- School of Health and Rehabilitation Sciences, Division of Speech Pathology, Motor Speech Research Unit, University of Queensland, Brisbane, Australia.
| | | | | | | | | | | |
Collapse
|
22
|
Patel NK, Plaha P, O'Sullivan K, McCarter R, Heywood P, Gill SS. MRI directed bilateral stimulation of the subthalamic nucleus in patients with Parkinson's disease. J Neurol Neurosurg Psychiatry 2003; 74:1631-7. [PMID: 14638880 PMCID: PMC1757425 DOI: 10.1136/jnnp.74.12.1631] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Bilateral chronic high frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN) has emerged as an appropriate therapy for patients with advanced Parkinson's disease refractory to medical therapy. Advances in neuroimaging and neurophysiology have led to the development of varied targeting methods for the delivery of this treatment. Intraoperative neurophysiological and clinical monitoring is regarded by many to be mandatory for accurate STN localisation. We have examined efficacy of bilateral STN stimulation using a predominantly magnetic resonance imaging (MRI)-directed technique. METHODS DBS leads were stereotactically implanted into the STN using an MRI directed method, with intraoperative macrostimulation used purely for adjustment. The effects of DBS were evaluated in 16 patients followed up to 12 months, and compared with baseline assessments. Assessments were performed in both off and on medication states, and were based on the Unified Parkinson's Disease Rating Scale (UPDRS) and timed motor tests. Functional status outcomes were examined using the PDQ-39 quality of life questionnaire. A battery of psychometric tests was used to assess cognition. RESULTS After 12 months, stimulation in the off medication state resulted in significant improvements in Activities of Daily Living and Motor scores (UPDRS parts II and III) by 62% and 61% respectively. Timed motor tests were significantly improved in the off medication state. Motor scores (UPDRS part III) were significantly improved by 40% in the on medication state. Dyskinesias and off duration were significantly reduced and the mean dose of L-dopa equivalents was reduced by half. Psychometric test scores were mostly unchanged or improved. Adverse events were few. CONCLUSIONS An MRI directed targeting method for implantation of DBS leads into the STN can be used safely and effectively, and results are comparable with studies using intraoperative microelectrode neurophysiological targeting. In addition, our method was associated with an efficient use of operating time, and without the necessary costs of microelectrode recording.
Collapse
Affiliation(s)
- N K Patel
- Institute of Neurosciences, Frenchay Hospital, Bristol, UK
| | | | | | | | | | | |
Collapse
|
23
|
Whelan BM, Murdoch BE, Theodoros DG, Hall B, Silburn P. Defining a role for the subthalamic nucleus within operative theoretical models of subcortical participation in language. J Neurol Neurosurg Psychiatry 2003; 74:1543-50. [PMID: 14617713 PMCID: PMC1738254 DOI: 10.1136/jnnp.74.11.1543] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To investigate the effects of bilateral, surgically induced functional inhibition of the subthalamic nucleus (STN) on general language, high level linguistic abilities, and semantic processing skills in a group of patients with Parkinson's disease. METHODS Comprehensive linguistic profiles were obtained up to one month before and three months after bilateral implantation of electrodes in the STN during active deep brain stimulation (DBS) in five subjects with Parkinson's disease (mean age, 63.2 years). Equivalent linguistic profiles were generated over a three month period for a non-surgical control cohort of 16 subjects with Parkinson's disease (NSPD) (mean age, 64.4 years). Education and disease duration were similar in the two groups. Initial assessment and three month follow up performance profiles were compared within subjects by paired t tests. Reliability change indices (RCI), representing clinically significant alterations in performance over time, were calculated for each of the assessment scores achieved by the five STN-DBS cases and the 16 NSPD controls, relative to performance variability within a group of 16 non-neurologically impaired adults (mean age, 61.9 years). Proportions of reliable change were then compared between the STN-DBS and NSPD groups. RESULTS Paired comparisons within the STN-DBS group showed prolonged postoperative semantic processing reaction times for a range of word types coded for meanings and meaning relatedness. Case by case analyses of reliable change across language assessments and groups revealed differences in proportions of change over time within the STN-DBS and NSPD groups in the domains of high level linguistics and semantic processing. Specifically, when compared with the NSPD group, the STN-DBS group showed a proportionally significant (p<0.05) reliable improvement in postoperative scores achieved on the word test-revised (TWT-R), as well as a reliable decline (p<0.01) in the accuracy of lexical decisions about words with many meanings and a high degree of relatedness between meanings. CONCLUSIONS Bilateral STN-DBS affects certain aspects of linguistic functioning, supporting a potential role for the STN in the mediation of language processes.
Collapse
Affiliation(s)
- B-M Whelan
- Motor Speech Research Unit, Department of Speech Pathology and Audiology, University of Queensland, Brisbane, Australia.
| | | | | | | | | |
Collapse
|
24
|
Gill SS, Patel NK, Hotton GR, O'Sullivan K, McCarter R, Bunnage M, Brooks DJ, Svendsen CN, Heywood P. Direct brain infusion of glial cell line-derived neurotrophic factor in Parkinson disease. Nat Med 2003; 9:589-95. [PMID: 12669033 DOI: 10.1038/nm850] [Citation(s) in RCA: 907] [Impact Index Per Article: 43.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2002] [Accepted: 03/07/2003] [Indexed: 12/11/2022]
Abstract
Glial cell line-derived neurotrophic factor (GDNF) is a potent neurotrophic factor with restorative effects in a wide variety of rodent and primate models of Parkinson disease, but penetration into brain tissue from either the blood or the cerebro-spinal fluid is limited. Here we delivered GDNF directly into the putamen of five Parkinson patients in a phase 1 safety trial. One catheter needed to be repositioned and there were changes in the magnetic resonance images that disappeared after lowering the concentration of GDNF. After one year, there were no serious clinical side effects, a 39% improvement in the off-medication motor sub-score of the Unified Parkinson's Disease Rating Scale (UPDRS) and a 61% improvement in the activities of daily living sub-score. Medication-induced dyskinesias were reduced by 64% and were not observed off medication during chronic GDNF delivery. Positron emission tomography (PET) scans of [(18)F]dopamine uptake showed a significant 28% increase in putamen dopamine storage after 18 months, suggesting a direct effect of GDNF on dopamine function. This study warrants careful examination of GDNF as a treatment for Parkinson disease.
Collapse
Affiliation(s)
- Steven S Gill
- Frenchay Hospital, Institute of Neurosciences, Bristol, UK.
| | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Patel NK, Heywood P, O'Sullivan K, McCarter R, Love S, Gill SS. Unilateral subthalamotomy in the treatment of Parkinson's disease. Brain 2003; 126:1136-45. [PMID: 12690053 DOI: 10.1093/brain/awg111] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Hyperactivity in the subthalamic nucleus (STN) is seen in animal models of Parkinson's disease, and lesioning of the STN dramatically relieves the animal's parkinsonism. Deep brain stimulation (DBS) of the STN is an effective treatment for patients with advanced Parkinson's disease. We have studied the effects of a unilateral lesion placed in the STN in predominantly hemi-parkinsonian patients. Twenty-one patients with advanced idiopathic Parkinson's disease were studied. Seventeen had asymmetrical tremor-dominant Parkinson's disease and four had bilateral disease. All patients underwent radiofrequency lesioning of the dorsolateral part of the STN under stereotactic guidance. The four patients with bilateral disease had, in addition, an electrode implanted contralaterally in the STN. Twenty-one patients have been followed for a minimum of 12 months. Clinical evaluation included the use of the Unified Parkinson's Disease Rating Scale (UPDRS) before and after surgery. Post-operative high-resolution MRI was performed in each patient to confirm lesion location, and this was correlated with clinical outcome. There was improvement in contralateral tremor, rigidity and bradykinesia in all patients followed for 6, 12 and 24 months, with the effect on tremor being greatest. L-dopa equivalent daily intake was approximately halved, and this resulted in a significant reduction in dyskinesia. Psychometric test scores were mostly unchanged or improved. All lesions were successfully located in the dorsolateral STN. Nineteen of the 21 lesions extended beyond the STN to involve pallidofugal fibres (H2 field of Forel) and the zona incerta (ZI). Lesion-induced dyskinesias were not a management problem except in one patient, whose lesion was confined to the STN. This patient was successfully treated with deep brain stimulator placement in the region of H2/ZI. Unilateral STN lesions can be made safely and are an effective alternative to thalamotomy, pallidotomy and unilateral STN DBS for the treatment of asymmetrical tremor-dominant advanced Parkinson's disease. Com bined lesioning of the dorsolateral STN and H2/ZI is particularly effective.
Collapse
Affiliation(s)
- Nikunj K Patel
- Institute of Clinical Neurosciences, Frenchay Hospital, Bristol, UK
| | | | | | | | | | | |
Collapse
|
26
|
Abstract
Surgical therapy for Parkinson's disease (PD) has been a treatment option for over 100 years. Advances in the knowledge of basal ganglia physiology and in techniques of stereotactic neurosurgery and neuroimaging have allowed more accurate placement of lesions or "brain pacemakers" in the sensorimotor regions of target nuclei. This, in turn, has led to improved efficacy with fewer complications than in the past. Currently, bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN) or the internal segment of the globus pallidus (GPi) is the preferred option (and is approved by the US Food and Drug Administration) for the surgical treatment of PD. The most important predictors for outcome for DBS for PD are patient selection and electrode location. Patients should have a documented preoperative improvement from dopaminergic medication of at least 30% in the patient's Unified Parkinson's Disease Rating Scale motor disability scores. A levodopa challenge may be needed to document the best "on" state. Dementia or active cognitive decline must be excluded. Active psychiatric disease should be treated preoperatively. Patients should be motivated, with good support systems, and committed to the postoperative management of DBS therapy. Deep brain stimulation should be considered when the patient begins to experience dyskinesia and on-off fluctuations despite optimal medical therapy. Deep brain stimulation is not a good option at the final stages of the disease because of the increased incidence of dementia and severe comorbidity. The DBS electrode should be placed in the sensorimotor region of the GPi or STN. Subthalamic nucleus and GPi DBS can improve all motor aspects of PD, as well as predictable "on" time, without dyskinesia or fluctuations. On average, STN DBS results in a greater reduction of dopaminergic medication compared with GPi DBS. Because of the smaller size of the target region, the pulse generator battery life is longer with STN then with GPi DBS. Deep brain stimulation programming is a skill that is readily learned and may be required of all neurologists in the future. Emerging surgical therapies are restorative, and they aim to replace or regenerate degenerating dopaminergic neurons. These include embryonic mesencephalic tissue transplantation, human embryonic stem cell transplantation, and gene-derived methods of intracerebral implantation of growth factors and dopamine- producing cell lines. It will be important to determine whether DBS, if performed before the onset of motor response complications to medical therapy, may prevent this stage of disease altogether or delay it for a significant period of time. The same question applies to the future with restorative therapy.
Collapse
Affiliation(s)
- Helen Bronte-Stewart
- Department of Neurology, Stanford University Medical Center, 300 Pasteur Drive, Room A-343, Stanford, CA 94305-5235, USA.
| |
Collapse
|
27
|
Woods SP, Fields JA, Tröster AI. Neuropsychological sequelae of subthalamic nucleus deep brain stimulation in Parkinson's disease: a critical review. Neuropsychol Rev 2002; 12:111-26. [PMID: 12371602 DOI: 10.1023/a:1016806711705] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Neuropsychologists are increasingly involved in surgical candidacy evaluations and postoperative neurobehavioral assessments of patients with movement disorders, most notably those with Parkinson's disease (PD). We review here the initial studies regarding neuropsychological outcomes of deep brain stimulation (DBS) within the subthalamic nucleus (STN) for treatment of PD. Overall, these initial investigations provide preliminary support for the cognitive and neurobehavioral safety of STN DBS. Improvements in self-reported symptoms of depression and diminished verbal fluency were the most common findings, whereas changes in global cognitive abilities, memory, attention, and frontal/executive functions were inconsistent and most often described as nominal and/or transient. The generalizability of this literature is hindered by several methodological limitations, including small samples and the absence of appropriate control participants. The clinical and theoretical implications of these initial studies are highlighted and recommendations are offered to guide future research.
Collapse
Affiliation(s)
- Steven Paul Woods
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle 98195-6560, USA
| | | | | |
Collapse
|
28
|
Morel A, Loup F, Magnin M, Jeanmonod D. Neurochemical organization of the human basal ganglia: anatomofunctional territories defined by the distributions of calcium-binding proteins and SMI-32. J Comp Neurol 2002; 443:86-103. [PMID: 11793349 DOI: 10.1002/cne.10096] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The distribution of the calcium-binding proteins calbindin-D28K (CB), parvalbumin (PV) and calretinin (CR), and of the nonphosphorylated neurofilament protein (with SMI-32) was investigated in the human basal ganglia to identify anatomofunctional territories. In the striatum, gradients of neuropil immunostaining define four major territories: The first (T1) includes all but the rostroventral half of the putamen and is characterized by enhanced matriceal PV and SMI-32 immunoreactivity (-ir). The second territory (T2) encompasses most part of the caudate nucleus (Cd) and rostral putamen (PuT), which show enhanced matriceal CB-ir. The third and fourth territories (T3 and T4) comprise rostroventral parts of Cd and PuT characterized by complementary patch/matrix distributions of CB- and CR-ir, and the accumbens nucleus (Acb), respectively. The latter is separated into lateral (prominently enhanced in CB-ir) and medial (prominently enhanced in CR-ir) subdivisions. In the pallidum, parallel gradients also delimit four territories, T1 in the caudal half of external (GPe) and internal (GPi) divisions, characterized by enhanced PV- and SMI-32-ir; T2 in their rostral half, characterized by enhanced CB-ir; and T3 and T4 in their rostroventral pole and in the subpallidal area, respectively, both expressing CB- and CR-ir but with different intensities. The subthalamic nucleus (STh) shows contrasting patterns of dense PV-ir (sparing only the most medial part) and low CB-ir. Expression of CR-ir is relatively low, except in the medial, low PV-ir, part of the nucleus, whereas SMI-32-ir is moderate across the whole nucleus. The substantia nigra is characterized by complementary patterns of high neuropil CB- and SMI-32-ir in pars reticulata (SNr) and high CR-ir in pars compacta (SNc) and in the ventral tegmental area (VTA). The compartmentalization of calcium-binding proteins and SMI-32 in the human basal ganglia, in particular in the striatum and pallidum, delimits anatomofunctional territories that are of significance for functional imaging studies and target selection in stereotactic neurosurgery.
Collapse
Affiliation(s)
- Anne Morel
- Laboratory for Functional Neurosurgery, Neurosurgery Clinic, University Hospital Zurich, Zurich, Switzerland.
| | | | | | | |
Collapse
|
29
|
Valldeoriola F, Pilleri M, Tolosa E, Molinuevo JL, Rumià J, Ferrer E. Bilateral subthalamic stimulation monotherapy in advanced Parkinson's disease: long-term follow-up of patients. Mov Disord 2002; 17:125-32. [PMID: 11835449 DOI: 10.1002/mds.1278] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Bilateral subthalamic nucleus stimulation (STN-DBS) is used to improve parkinsonian symptoms and attenuate levodopa-induced motor complications. In some patients, such clinical improvement allows antiparkinsonian medication (ApMed) withdrawal. We show the clinical outcome at the long-term follow-up of patients with advanced Parkinson's disease (PD) in which STN-DBS was used in monotherapy, and compare the clinical results of patients without medication with those obtained in parkinsonian patients in which ApMed were reduced but could not be totally displaced after surgery. We analyzed clinical outcome of ten patients with PD in which all ApMed was withdrawn after bilateral subthalamic stimulation and 16 parkinsonian patients still taking antiparkinsonian medication after surgery. After 1.5 years, STN-DBS monotherapy produced UPDRS motor scores similar to those observed in the on-drug condition before surgery without the inconvenience of motor fluctuations and dyskinesias. No significant differences were seen in most of clinical outcome measures when comparing patients still taking ApMed with patients in STN-DBS monotherapy but a few patients still taking ApMed presented mild dyskinesias and motor fluctuations and patients with STN-DBS monotherapy did not. STN-DBS is useful in the treatment of advanced PD and in some patients it is possible to maintain this therapy alone in the long term. The therapeutic effect of STN-DBS on motor signs can be equipotent to that of levodopa with the additional benefit of avoiding motor fluctuations and dyskinesias.
Collapse
Affiliation(s)
- Francesc Valldeoriola
- Unitat de Parkinson i Moviments Anormals, Service of Neurology, Institut Clínic de Malalties del Sistema Nerviós, Institut d'Investigacions Biomèdiques August Pi i Suñer, Hospital Clínic Universitari, Barcelona, Spain.
| | | | | | | | | | | |
Collapse
|
30
|
Guridi J, Obeso JA. The subthalamic nucleus, hemiballismus and Parkinson's disease: reappraisal of a neurosurgical dogma. Brain 2001; 124:5-19. [PMID: 11133783 DOI: 10.1093/brain/124.1.5] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The subthalamic nucleus (STN) currently is considered to play a key role in the pathophysiological origin of the parkinsonian state and is therefore the main target for surgical treatment of Parkinson's disease. The authors review the incidence of hemichorea/ballism (HCB) as a complication of thalamotomy, pallidotomy or campotomy procedures before the introduction of levodopa therapy, including the few reported cases accompanied by a neuropathological study. The literature shows that only a small number of parkinsonian patients with HCB had a lesion of the STN. Preliminary data in Parkinson's disease patients submitted to a subthalamotomy with current functional stereotaxy also indicate that HCB is a very rare complication. To explain this observation, we suggest that the parkinsonian state is characterized by an increased threshold for the induction of dyskinesia following STN lesioning. This arises as a consequence of reduced activity in the 'direct' GABA projection to the globus pallidus medialis (GPm) which accompanies dopamine depletion. Lesioning of the STN reduces excitation of the GPm, and theoretically this should induce dyskinesias. However, an STN lesion also, simultaneously, further reduces the hypoactivity in the globus pallidus lateralis (GPl) that is a feature of Parkinson's disease, and hence may compensate for GPm hypoactivity, thus self-stabilizing basal ganglia output activity and reducing the risk of HCB. We conclude that lesioning of the STN in Parkinson's disease is a feasible approach in some circumstances.
Collapse
Affiliation(s)
- J Guridi
- Service of Neurosurgery, Hospital de Navarra, 31008 Pamplona, Spain
| | | |
Collapse
|