Stereotactic pallidotomy lengthens the transcranial magnetic cortical stimulation silent period in Parkinson's disease

Anatomo-Functional Origins of the Cortical Silent Period: Spotlight on the Basal Ganglia

The so-called cortical silent period (CSP) refers to the temporary interruption of electromyographic signal from a muscle following a motor-evoked potential (MEP) triggered by transcranial magnetic stimulation (TMS) over the primary motor cortex (M1). The neurophysiological origins of the CSP are debated. Previous evidence suggests that both spinal and cortical mechanisms may account for the duration of the CSP. However, contextual factors such as cortical fatigue, experimental procedures, attentional load, as well as neuropathology can also influence the CSP duration. The present paper summarizes the most relevant evidence on the mechanisms underlying the duration of the CSP, with a particular focus on the central role of the basal ganglia in the "direct" (excitatory), "indirect" (inhibitory), and "hyperdirect" cortico-subcortical pathways to manage cortical motor inhibition. We propose new methods of interpretation of the CSP related, at least partially, to the inhibitory hyperdirect and indirect pathways in the basal ganglia. This view may help to explain the respective shortening and lengthening of the CSP in various neurological disorders. Shedding light on the complexity of the CSP's origins, the present review aims at constituting a reference for future work in fundamental research, technological development, and clinical settings.

Effect of Therapy on Motor Cortical Excitability in Parkinson’s Disease

Objective:

To assess the impact of the disease stage and therapy on motor cortical excitability in Parkinson’s disease (PD).

Methods:

Twenty newly diagnosed and medication-free, early stage patients, 20 late stage patients under antiparkinsonian therapy and 20 normal healthy controls were included. Motor threshold (MT), amplitudes of motor evoked potential (MEP), motor evoked potential amplitude/compound muscle action potential amplitude (MEP/CMAP) ratio, central motor conduction time (CMCT) and cortical silent period (CSP) were measured by stimulation of the motor cortex using a 13.5 cm circular coil and recordings from abductor digiti minimi muscle. Following the first study protocol, early stage patients were given therapy and the same protocol was repeated three months later.

Results:

Motor threshold was lower; and the MEP/CMAP ratio was higher in early and late stage patients than normals. In early stage patients after proper therapy, the MTs became higher than before therapy, but still remained lower than normals. In late stage patients, the CMCTs were shorter than the early stage patients before therapy and normals, but there was no difference between the early stage patients and normals. In early stage patients after therapy, the CMCT became longer than before therapy and this difference was significant in both late stage patients and normals. Although more prominent in late stage patients, the CSP duration in both PD groups was found shorter than normals. In early stage patients, after therapy, the CSP durations became significantly longer compared with before therapy.

Conclusion:

These findings suggest that the motor cortical excitability increases in PD because of the impairment of the corticomotoneuronal inhibitory system.

Primary motor cortex of the parkinsonian monkey: altered neuronal responses to muscle stretch

Exaggeration of the long-latency stretch reflex (LLSR) is a characteristic neurophysiologic feature of Parkinson's disease (PD) that contributes to parkinsonian rigidity. To explore one frequently-hypothesized mechanism, we studied the effects of fast muscle stretches on neuronal activity in the macaque primary motor cortex (M1) before and after the induction of parkinsonism by unilateral administration of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). We compared results from the general population of M1 neurons and two antidromically-identified subpopulations: distant-projecting pyramidal-tract type neurons (PTNs) and intra-telecenphalic-type corticostriatal neurons (CSNs). Rapid rotations of elbow or wrist joints evoked short-latency responses in 62% of arm-related M1 neurons. As in PD, the late electromyographic responses that constitute the LLSR were enhanced following MPTP. This was accompanied by a shortening of M1 neuronal response latencies and a degradation of directional selectivity, but surprisingly, no increase in single unit response magnitudes. The results suggest that parkinsonism alters the timing and specificity of M1 responses to muscle stretch. Observation of an exaggerated LLSR with no change in the magnitude of proprioceptive responses in M1 is consistent with the idea that the increase in LLSR gain that contributes to parkinsonian rigidity is localized to the spinal cord.

Safety of transcranial magnetic stimulation in Parkinson's disease: a review of the literature

BACKGROUND

Transcranial magnetic stimulation (TMS) has been used in both physiological studies and, more recently, the therapy of Parkinson's disease (PD). Prior TMS studies in healthy subjects and other patient populations demonstrate a slight risk of seizures and other adverse events. Our goal was to estimate these risks and document other safety concerns specific to PD patients.

METHODS

We performed an English-Language literature search through PudMed to review all TMS studies involving PD patients. We documented any seizures or other adverse events associated with these studies. Crude risks were calculated per subject and per session of TMS.

RESULTS

We identified 84 single pulse (spTMS) and/or paired-pulse (ppTMS) TMS studies involving 1091 patients and 77 repetitive TMS (rTMS) studies involving 1137 patients. Risk of adverse events was low in all protocols. spTMS and ppTMS risk per patient for any adverse event was 0.0018 (95% CI: 0.0002-0.0066) per patient and no seizures were encountered. Risk of an adverse event from rTMS was 0.040 (95% CI: 0.029-0.053) per patient and no seizures were reported. Other adverse events included transient headaches, scalp pain, tinnitus, nausea, increase in pre-existing pain, and muscle jerks. Transient worsening of Parkinsonian symptoms was noted in one study involving rTMS of the supplementary motor area (SMA).

CONCLUSION

We conclude that current TMS and rTMS protocols do not pose significant risks to PD patients. We would recommend that TMS users in this population follow the most recent safety guidelines but do not warrant additional precautions.

Rapid assessment of age-related differences in standing balance

As life expectancy continues to rise, in the future there will be an increasing number of older people prone to falling. Accordingly, there is an urgent need for comprehensive testing of older individuals to collect data and to identify possible risk factors for falling. Here we use a low-cost force platform to rapidly assess deficits in balance under various conditions. We tested 21 healthy older adults and 24 young adults during static stance, unidirectional and rotational displacement of their centre of pressure (COP). We found an age-related increase in postural sway during quiet standing and a reduction of maximal COP displacement in unidirectional and rotational displacement tests. Our data show that even low-cost computerized assessment tools allow for the comprehensive testing of balance performance in older subjects.

The role of exercise in facilitating basal ganglia function in Parkinson's disease

Epidemiological and clinical studies have suggested that exercise is beneficial for patients with Parkinson's disease (PD). Through research in normal (noninjured) animals, neuroscientists have begun to understand the mechanisms in the brain by which behavioral training and exercise facilitates improvement in motor behavior through modulation of neuronal function and structure, called experience-dependent neuroplasticity. Recent studies are beginning to reveal molecules and downstream signaling pathways that are regulated during exercise and motor learning in animal models of PD and that are important in driving protective and/or adaptive changes in neuronal connections of the basal ganglia and related circuitry. These molecules include the neurotransmitters dopamine and glutamate (and their respective receptors) as well as neurotrophic factors (brain-derived neurotrophic factor). In parallel, human exercise studies have been important in revealing 'proof of concept' including examining the types and parameters of exercise that are important for behavioral/functional improvements and brain changes; the feasibility of incorporating and maintaining an exercise program in individuals with motor disability; and, importantly, the translation and investigation of exercise effects observed in animal studies to exercise effects on brain and behavior in individuals with PD. In this article we highlight findings from both animal and human exercise studies that provide insight into brain changes of the basal ganglia and its related circuitry and that support potentially key parameters of exercise that may lead to long-term benefit and disease modification in PD. In addition, we discuss the current and future impact on patient care and point out gaps in our knowledge where continuing research is needed. Elucidation of exercise parameters important in driving neuroplasticity, as well as the accompanying mechanisms that underlie experience-dependent neuroplasticity may also provide insights towards new therapeutic targets, including neurorestorative and/or neuroprotective agents, for individuals with PD and related neurodegenerative disorders.

Enhancing neuroplasticity in the basal ganglia: the role of exercise in Parkinson's disease

Epidemiological and clinical trials have suggested that exercise is beneficial for patients with Parkinson's disease (PD). However, the underlying mechanisms and potential for disease modification are currently unknown. This review presents current findings from our laboratories in patients with PD and animal models. The data indicate that alterations in both dopaminergic and glutamatergic neurotransmission, induced by activity-dependent (exercise) processes, may mitigate the cortically driven hyper-excitability in the basal ganglia normally observed in the parkinsonian state. These insights have potential to identify novel therapeutic treatments capable of reversing or delaying disease progression in PD.

Pallidotomy does not ameliorate abnormal intracortical inhibition in Parkinson's disease

Motor cortex excitability was assessed in 12 patients with Parkinson's disease (PD) using transcranial magnetic stimulation. Patients were studied when mobile and medicated ("ON") and when immobile after medication withdrawal ("OFF"). Results were compared to eight age-matched and 11 young controls. Cortical excitability was assessed by measurement of resting motor threshold (RMT), intracortical inhibition and cortical silent period duration. In five patients, the studies included assessments following pallidotomy. Cortical excitability was abnormal in patients with PD with reduced RMT in "ON" and "OFF" states, and less effective intracortical inhibition. Pallidotomy did not affect cortical excitability in either "ON" or "OFF" states, indicating that enhanced motor cortex excitability in patients with PD is unaffected by pallidotomy despite clinical improvement in motor scores.

Establishing the definition and inter-rater reliability of cortical silent period calculation in subjects with focal hand dystonia and healthy controls

The purpose of this paper is to describe a clearly defined manual method for calculating cortical silent period (CSP) length that can be employed successfully and reliably by raters after minimal training in subjects with focal hand dystonia (FHD) and healthy subjects. A secondary purpose was to explore intra-subject variability of the CSP in subjects with FHD vs. healthy subjects. Two raters previously naïve to CSP identification and one experienced rater independently analyzed 170 CSP measurements collected in 6 subjects with focal hand dystonia (FHD) and 9 healthy subjects. Intraclass correlation coefficient (ICC) was calculated to quantify inter-rater reliability within the two groups of subjects. The relative variability of CSP in each group was calculated by the coefficient of variation (CV). Relative variation between raters within repeated measures of individual subjects was also quantified by CV. Reliability measures were as follows-mean of three raters: all subjects: ICC=0.976; within healthy subjects: ICC=0.965; in subjects with FHD: ICC=0.956. The median within-subject variability for the healthy group was CV=7.33% and in subjects with FHD:CV=11.78%. The median variability of calculating individual subject CSP duration between raters was CV=10.23% in subjects with dystonia and CV=10.46% in healthy subjects. Manual calculation of CSP results in excellent reliability between raters of varied levels of experience. Healthy subjects display less variability in CSP. Despite greater variability, the CSP in impaired subjects can be reliably calculated across raters.

The effect of exercise training in improving motor performance and corticomotor excitability in people with early Parkinson's disease

OBJECTIVES

To obtain preliminary data on the effects of high-intensity exercise on functional performance in people with Parkinson's disease (PD) relative to exercise at low and no intensity and to determine whether improved performance is accompanied by alterations in corticomotor excitability as measured through transcranial magnetic stimulation (TMS).

DESIGN

Cohort (prospective), randomized controlled trial.

SETTING

University-based clinical and research facilities.

PARTICIPANTS

Thirty people with PD, within 3 years of diagnosis with Hoehn and Yahr stage 1 or 2.

INTERVENTIONS

Subjects were randomized to high-intensity exercise using body weight-supported treadmill training, low-intensity exercise, or a zero-intensity education group. Subjects in the 2 exercise groups completed 24 exercise sessions over 8 weeks. Subjects in the zero-intensity group completed 6 education classes over 8 weeks.

MAIN OUTCOME MEASURES

Unified Parkinson's Disease Rating Scales (UPDRS), biomechanic analysis of self-selected and fast walking and sit-to-stand tasks; corticomotor excitability was assessed with cortical silent period (CSP) durations in response to single-pulse TMS.

RESULTS

A small improvement in total and motor UPDRS was observed in all groups. High-intensity group subjects showed postexercise increases in gait speed, step and stride length, and hip and ankle joint excursion during self-selected and fast gait and improved weight distribution during sit-to-stand tasks. Improvements in gait and sit-to-stand measures were not consistently observed in low- and zero-intensity groups. The high-intensity group showed lengthening in CSP.

CONCLUSIONS

The findings suggest the dose-dependent benefits of exercise and that high-intensity exercise can normalize corticomotor excitability in early PD.

Chronic epidural motor cortical stimulation for movement disorders

Recent data suggest that epidural chronic motor cortical stimulation could improve movement disorders. Because the procedure is safe, it might be a valuable therapeutic option. Although the therapeutic effects of cortical stimulation still need to be assessed in controlled studies, we discuss its rationale and the possible physiological mechanisms involved. There are several factors that support the use of chronic cortical stimulation in patients with movement disorders, including the strategic position of the motor cortex, the improvement induced in some motor disorders by cortical lesions, the functional imaging findings documenting widespread cortical dysfunction in movement disorders, and the improvement induced in patients with Parkinson's disease and dystonia by repetitive transcranial magnetic stimulation. Among the possible mechanisms of action of chronic motor cortex stimulation, besides modifications in the motor cortex itself, the most probable is that of eliciting distant bilateral changes through efferents and afferents that bilaterally connect the motor cortex with other cortical and subcortical structures.

Asymmetric corticomotor excitability correlations in early Parkinson's disease

We studied corticomotor excitability (CE) between the more and less affected sides in early Parkinson's disease (PD) patients using transcranial magnetic stimulation (TMS). Sixteen-PD patients within the first 3 years of diagnosis were studied with single-pulse TMS over each motor cortex with intensities from 40% to 100% stimulator output. Active motor evoked potentials (MEP) and cortical silent period durations (CSP) were recorded, fitted with sigmoid curves, summarized as maximal MEP/CSP, maximal MEP/CSP slope, and intensity where MEP/CSP is half-maximal (MEP/CSP-Int50), and correlated with Unified Parkinson's Disease Rating Scale scores (UPDRS). On the more affected side, higher (worse) UPDRS scores were correlated with shorter maximal CSP (r=-0.51, P=0.046). On the less affected side, higher UPDRS scores were correlated with higher MEP-Int50 (r=0.51, P=0.043) and CSP-Int50 (r=0.54, P=0.029). For the less affected side, altered CE, as indexed by higher MEP or CSP-Int50 intensities, may contribute to early clinical symptoms. On the more affected side, increases in CE, indexed by shorter CSP, may account for a greater proportion of PD symptoms. These findings are consistent with an evolution of neurophysiologic correlates in early PD patients from a less to more symptomatic state.

Pallidotomy effect on the cortical excitability in patients with severe Parkinson's disease

Surgical lesions in the medial pallidum have been shown to ameliorate motor deficits in patients with Parkinson's disease (PD). It is believed that interruption of the pallidothalamocortical projections to the motor cortex is required for the satisfactory results. In this report, we adopt cortico-cortical inhibition as the tool to assess the pallidotomy effect on cortical excitability in PD. Interstimulus interval between 1 and 15 msec were investigated. The average peak-to-peak amplitude was measured and calculated at each delay. A total of 8 patients (M:F = 4:4) 54.9 years of age (SD = 9.6) and 10 controls were recruited for the study. In the controls, the inhibitory phenomenon was observed from the 1-msec to the 4-msec delay points and the maximal inhibition was at the 3-msec delay point (33.69% +/- 6.50% of the control response). Mild facilitation was noticed since the 5-msec delay point and thereafter. In patients before operation, a similar trend of inhibition was also observed in the initial 4 msec with the maximal inhibition also at the 3-msec delay point (64.66 +/- 6.77% of the control response). In the postoperative group, the short interstimulus interval inhibition can no longer be observed and the conditioned response was 95.06 +/- 23.68% of the control at the 3-msec delay point. The suppression was gone at and after the 7-msec delay point. Results of repeated-measures analysis of variance show a significant difference among the controls and PD patients before and 3 months after pallidotomy (F = 3.40, P = 0.05). Post hoc examination revealed a significant difference between the controls and PD patients 3 months after pallidotomy at the 3-msec delay point (P = 0.004). However, no correlation was observed between the 3-msec inhibition and the Unified Parkinson's Disease Rating Scale Motor score or the dyskinesia score. The results suggest that pallidotomy can modulate the cortical inhibitory circuitry in patients with PD.

Stimulation du cortex moteur, Parkinson et dystonie : que nous enseigne la stimulation magnétique transcrânienne? revue de la littérature

INTRODUCTION

Over the last few years, deep brain stimulation techniques, with targets such as the subthalamic nucleus or the pallidum, have bee found to be beneficial in the treatment of Parkinson's disease and dystonia. Conversely, therapeutic strategies of cortical stimulation have not yet been validated in these diseases, although they are known to be associated with various cortical dysfunctions. Transcranial magnetic stimulation (TMS) is a valuable tool for non-invasive study of the role played by the motor cortex in the pathophysiology of movement disorders, in particular by assessing various cortical excitability determinants using single or paired pulse paradigms. In addition, repetitive TMS (rTMS) trains can be used to study the effects of transient activity changes of a targeted cortical area.

BACKGROUND

Studies with TMS revealed significant motor cortex excitability changes, particularly regarding intracortical inhibitory pathways, both in Parkinson's disease and in dystonia, and these changes can be distinguished owing to the resting state or to the phases of movement preparation or execution. However, more specific correlation between electrophysiological features and clinical symptoms remains to be established. In addition, the stimulation of various cortical targets by rTMS protocols applied at low or high frequencies have induced some clear clinical effects.

PERSPECTIVES

The TMS effects are and will remain applied in movement disorders to better understand the role played by the motor cortex, to assess various types of treatment and appraise the therapeutic potential of cortical stimulation.

CONCLUSION

TMS provides evidence for motor cortex dysfunction in Parkinson's disease or dystonia. Moreover, rTMS results have opened new perspectives for therapeutic strategies of implanted cortical stimulation. By these both aspects, TMS techniques show their usefulness in the assessment of movement disorders.

Motor cortex dysfunction revealed by cortical excitability studies in Parkinson's disease: influence of antiparkinsonian treatment and cortical stimulation

Single or paired pulse paradigms of transcranial magnetic stimulation (TMS) provide several parameters to test motor cortex excitability, such as motor threshold (MT), motor evoked potential (MEP) amplitude, electromyographic silent period to cortical stimulation (CSP) and intracortical facilitation (ICF) or inhibition (ICI). Various changes in TMS parameters, revealing motor cortex dysfunction, were found in patients with Parkinson's disease (PD). For instance, low MT and increased MEP size disclosed an enhanced corticospinal motor output at rest, while reduced ICF and failure of MEP size increase during contraction suggested defective facilitatory cortical inputs, particularly for movement execution. Inhibitory cortical pathways were also found less excitable at rest (reduced ICI) and sometimes during contraction (shortened CSP). By restoring cortical inhibition, dopaminergic drugs and deep brain stimulation probably overcome the difficulty to focus neuronal activity onto the appropriate network required for a specific motor task. The application of repetitive TMS trains over motor cortical areas also showed some effect on cortical excitability, opening perspectives to consider the motor cortex as a target for therapeutic neuromodulation in PD. However, systematic studies of cortical excitability remained to be performed in large series of patients with PD, taking into account disease stage, clinical symptoms and medication influence.

Preserved ipsilateral-to-lesion motor map organization in the unilateral 6-OHDA-treated rat model of Parkinson's disease

The classic view of dopamine (DA) loss in Parkinson's disease is that it produces a functional deafferentation in striatal-cortical circuitry that, in turn, contributes to sensorimotor deficits. The present study examines this view in the rat by assessing how DA-depletion affects the intracortical microstimulation (ICMS) topographic representation of movement in the rostral and caudal motor areas of the motor cortex. The ICMS map is used as an index of motor cortex function because it has been shown to reflect motor function and experience. Groups of rats received no training or skilled reach training and were then given unilateral 6-hydroxydopamine (6-OHDA) or sham lesions of the nigrostriatal bundle to deplete nigrostriatal DA. Lesion success was confirmed by abnormalities in skilled reaching, by apomorphine-induced rotation, and by loss of DA neurons in the substantia nigra. The size and threshold of the motor map in naive and skilled reach trained DA-depleted rats were preserved. In addition, there was an increase in distal limb representation in the caudal forelimb area (CFA) in the DA-depleted rats suggesting a possible plastic response to the behavioral effects of DA-depletion. The presence of preserved size and modified map organization in DA-depleted rats is discussed in relation to the hypothesis that preserved motor cortex functionality despite DA loss underlies the spared motor abilities of DA-depleted rats.

Improvement of motor performance and modulation of cortical excitability by repetitive transcranial magnetic stimulation of the motor cortex in Parkinson's disease

OBJECTIVE

To assess the effects of focal motor cortex stimulation on motor performance and cortical excitability in patients with Parkinson's disease (PD).

METHODS

Repetitive transcranial magnetic stimulation (rTMS) was performed on the left motor cortical area corresponding to the right hand in 12 'off-drug' patients with PD. The effects of subthreshold rTMS applied at 0.5 Hz (600 pulses) or at 10 Hz (2000 pulses) using a 'real' or a 'sham' coil were compared to those obtained by a single dose of l-dopa. The assessment included a clinical evaluation by the Unified Parkinson's Disease Rating Scale and timed motor tasks, and a neurophysiological evaluation of cortical excitability by single- and paired-pulse TMS techniques.

RESULTS

'Real' rTMS at 10 or 0.5 Hz, but not 'sham' stimulation, improved motor performance. High-frequency rTMS decreased rigidity and bradykinesia in the upper limb contralateral to the stimulation, while low-frequency rTMS reduced upper limb rigidity bilaterally and improved walking. Concomitantly, 10 Hz rTMS increased intracortical facilitation, while 0.5 Hz rTMS restored intracortical inhibition.

CONCLUSIONS

Low- and high-frequency rTMS of the primary motor cortex lead to significant but differential changes in patients with PD both on clinical and electrophysiological grounds. The effects on cortical excitability were opposite to previous observations made in healthy subjects, suggesting a reversed balance of cortical excitability in patients with PD compared to normals. However, the underlying mechanisms of these changes remain to determine, as well as the relationship with clinical presentation and response to l-dopa therapy.

SIGNIFICANCE

The present study gives some clues to appraise the role of the primary motor cortex in PD. Clinical improvement induced by rTMS was too short-lasting to consider therapeutic application, but these results support the perspective of the primary motor cortex as a possible target for neuromodulation in PD.

La stimulation cérébrale profonde dans la maladie de Parkinson

The present renewal of the surgical treatment of Parkinson's disease, almost abandoned for twenty Years, arises from two main reasons. The first is the better understanding of the functional organization of the basal ganglia. It was demonstrated in animal models of Parkinson's disease that the loss of dopaminergic neurons within the substantia nigra, at the origin of the striatal dopaminergic defect, induces an overactivity of the excitatory glutamatergic subthalamo-internal pallidum pathway. The decrease in this hyperactivity might lead to an improvement in the pakinsonian symptoms. The second reason is the improvement in stereotactic neurosurgery in relation with the progress in neuroimaging techniques and with intraoperative electrophysiological microrecordings and stimulations, which help determine the location of the deep brain targets. In the 1970s chronic deep brain stimulation in humans was applied to the sensory nucleus of the thalamus for the treatment of intractable pain. In 1987, Benabid and colleagues suggested high frequency stimulation of the ventral intermediate nucleus of the thalamus in order to treat drug-resistant tremors and to avoid the adverse effects of thalamotomies. How deep brain stimulation works is not well known but it has been hypothetized that it could change the neuronal activities and thus avoid disease-related abnormal neuronal discharges. Potential candidates for deep brain stimulation are selected according to exclusion and inclusion criteria. Surgery can be applied to patients in good general and mental health, neither depressive nor demented and who are severely disabled despite all available drug therapies but still responsive to levodopa. The first session of surgery consists in the location of the target by ventriculography and/or brain MRI. The electrodes are implanted during the second session. The last session consists in the implantation of the neurostimulator. The ventral intermediate nucleus of the thalamus was the first target in which chronic deep brain stimulation electrodes were implanted in order to alleviate tremor. This technique can be applied bilaterally without the adverse effects of bilateral thalamotomies. Like pallidotomy, internal globus pallidum stimulation has a dramatic beneficial effect on levodopa-induced dyskinesia but its effects on the parkinsonian triad are less constant and opposite motor effects are sometimes observed in relation with the stimulated contact. The inconstant results, perhaps related to the complexity of the structure led to the development of subthalamic nucleus stimulation. The alleviation of motor fluctuations and the improvement in all motor symptoms allows a significant decrease in levodopa daily dose and in levodopa-induced dyskinesia. Presently, deep brain stimulation is a fashionable neurosurgical technique to treat Parkinson's disease. Subthalamic nucleus stimulation seems to be the most suitable target to control the parkinsonian triad and the motor fluctuations. Because of the possible adverse effects it must be reserved for disabled parkinsonian patients. No large randomized study comparing different targets and different neurosurgical techniques has been performed yet. Such studies, including cost benefit studies would be useful to assess the respective value of these different techniques.

Extradural motor cortex stimulation for advanced Parkinson disease. Report of two cases

Motor cortex stimulation is a minimally invasive surgical procedure used for pain control. The authors report their results treating two patients with typical Parkinson disease. Unilateral motor cortex stimulation proved to be beneficial bilaterally. Motor cortex stimulation may represent a cost-effective alternative to deep brain stimulation.

Abnormal conditioning effect of transcranial magnetic stimulation on soleus H-reflex during voluntary movement in Parkinson's disease

OBJECTIVES

The objective of this study is to clarify the participation of cortical motor control abnormality in the motor dysfunction of Parkinson's disease (PD), especially at the onset of movement.

METHODS

Conditioning effects of transcranial magnetic simulation (TMS) on the soleus (SOL) H-reflex evoked with tibial nerve stimulation were examined in 19 patients with PD and 10 normal volunteers. Experiments were done at rest, during tonic plantarflexion (PF), and at PF onset. Stimulus intensity of TMS was maintained at less than 5% of the motor threshold in each situation. Seven patients underwent pallidotomy and were examined twice, once before and once after the operation.

RESULTS

Short latency subthreshold TMS stimulation did not facilitate the SOL H-reflex neither during tonic PF nor at PF onset in the patients with PD, though it was evident in normal subjects. In some patients, paradoxical inhibition appeared at PF onset. The facilitation increase at PF onset, as compared to that at rest, was negatively correlated with the motor part of the unified Parkinson's disease rating scale and with the rigidity grade. Pallidotomy improved both modulation and the clinical scores.

CONCLUSIONS

Cortical activity for the proper execution of reciprocal control between the agonist and antagonist seems to be disturbed in PD.

Applications of transcranial magnetic stimulation in movement disorders

The author reviews the applications of transcranial magnetic stimulation (TMS) in a series of movement disorders--namely, Parkinson's disease, corticobasal degeneration, multiple system atrophy, progressive supranuclear palsy, essential tremor, dystonia, Huntington's chorea, myoclonus, the ataxias, Tourette's syndrome, restless legs syndrome, Wilson's disease, Rett syndrome, and stiff-person syndrome. Single- and paired-pulse TMS studies have been done mainly for pathophysiologic purposes. Repetitive TMS has been used largely for therapy. Many TMS abnormalities are seen in the different diseases. They concur to show that motor cortical areas and their projections are the main target of the basal ganglia dysfunction typical of movement disorders. Interpretation has not always been clear, and sometimes there were discrepancies and contradictions. Largely, this may be the result of the extreme heterogeneity of the methods used and of the patients studied. It is premature to give repetitive TMS a role in treatment. Overall, however, TMS gives rise to a new, outstanding enthusiasm in the neurophysiology of movement disorders. There is reason to predict that TMS, with its continuous technical refinement, will prove even more helpful in the near future. Then, research achievements are reasonably expected to spill over into clinical practice.

Relation between changes in long-latency stretch reflexes and muscle stiffness in Parkinson's disease--comparison before and after unilateral pallidotomy

OBJECTIVE

To study the effects of posteroventral pallidotomy on both the size of long-latency stretch reflex (LLR) and the muscle stiffness in the wrist flexor muscles.

PATIENTS AND METHODS

Eleven consecutive patients (right-handed, 6 men and 5 women) underwent left-side microelectrode-guided pallidotomy. The LLR of the contralesional forearm was studied at baseline and 2-3 months after surgery while patients continued to take their optimal medical regimens ('on' period). Patients were instructed not to respond to the perturbation (passive mode) or to oppose the mechanical extensor perturbation (active mode).

RESULTS

The stretch reflex evoked by extension perturbations of the wrist consisted of a short-latency reflex (M1) and an LLR (M2). Pallidotomy had no effects on the size of M1 components in both passive and active mode and on that of M2 component in the passive mode, however, it significantly reduced M2 component in the active mode (P<0.05). The inherent muscle stiffness over 60 ms period of mechanical stretch was not influenced by pallidotomy in any experimental condition (preoperative vs. postoperative or passive mode vs. active mode). The hand displacement following M2 component increased significantly after pallidotomy in both passive (P<0.005) and active mode (P<0.05). The inverted value of the displacement following M2 component correlated with the size of M2 component (r=0.60, P<0.001).

CONCLUSIONS

Pallidotomy decreased the transcortical reflex gain, probably at cortical level, and consequently reduced muscle stiffness.

New graphical method to measure silent periods evoked by transcranial magnetic stimulation

OBJECTIVES

Manual methods of measuring duration of cortical silent periods (CSP) evoked by transcranial magnetic stimulation (TMS) depend upon subjective visual estimation of onset and offset. Because of this, the measurements are susceptible to poor rater reliability. We describe a graphical method to measure silent periods with greater precision. The statistical process underlying this new method is simple and particularly suited to signal detection in serially dependent data.

METHODS

TMS-evoked silent periods were recorded in 13 healthy subjects. Two investigators subjectively measured silent period duration on each subject to estimate rater reliability. Using the graphical method, the mean and 99.76% variation limits of pre-stimulus electromyogram (EMG) activity were computed. Each averaged trial was displayed and CSP onset and offset detected when post-stimulus EMG activity moved outside the 99.76% limits.

RESULTS

Maximum variation in silent period duration was 21.8 ms between the two investigators' subjective measurements. Silent period duration measured with the graphical method closely approximated measurements obtained using the manual method. It was possible to automate the procedure.

CONCLUSIONS

This graphical method allowed precise measurement of CSP duration, independent of subjective estimations of onset or offset points. Further studies are necessary to determine if this method can provide a framework for other physiologic measures.

Excitatory and inhibitory corticospinal responses to transcranial magnetic stimulation in patients with minor to moderate head injury

OBJECTIVES

The changes in excitatory and inhibitory responses to transcranial magnetic stimulation (TMS), as attested by motor evoked potential (MEP) and silent period (SP) parameters, were compared in patients who sustained minor to moderate head injury.

METHODS

A total of 38 patients with brain concussion, and diffuse, focal, and combined brain injury and 20 healthy volunteers were examined. The MEPs and SPs were recorded from the abductor pollicis brevis muscle after single pulse TMS 2 weeks after head trauma. The parameters assessed were the MEP resting threshold, the MEP/M wave amplitude ratio, the central motor conduction time (CMCT), the SP threshold, the interthreshold difference (ITD), and the SP duration (SPD).

RESULTS

The main finding was an increase in the ITD in patients with mild and moderate head injury due to the relatively greater augmentation of the MEP threshold. This was associated with a reduction of the MEP/M wave amplitude ratio. The degree of MEP and SP changes depended on severity of head injury and was not related to the type of brain lesions. The SPD did not differ significantly in brain concussion, or diffuse, focal and combined brain injury groups compared with the control group. The CMCT was prolonged in patients with diffuse and combined brain lesions. Among subjective complaints only fatigue was significantly related to ITD, MEP, and SP threshold abnormalities.

CONCLUSIONS

The results suggest that mechanisms involved in MEP and SP generation are differently affected in head injury, the first being impaired more severely. The increase of the ITD accompanied by reduction of the MEP/M wave amplitude ratio may reflect a dissociated impairment of inhibitory and excitatory components of central motor control in head trauma.

Pallidotomy for parkinson disease: a review of contemporary literature

OBJECT

The authors conducted an evidence-based review of contemporary published articles on pallidotomy to obtain an appraisal of this procedure in the treatment of Parkinson disease (PD).

METHODS

A search of the Pubmed database performed using the key word "pallidotomy" yielded 263 articles cited between January 1, 1992, and July 1, 1999. Articles that included original, nonduplicated descriptions of patients with PD treated with radiofrequency pallidotomy were selected. In 85 articles identified for critical review, 1959 patients with PD underwent pallidotomies at 40 centers in 12 countries. There were 1735 unilateral (88.6%) and 224 bilateral procedures (11.4%). The mean age of the patients was 61.4+/-3.6 years and the mean duration of PD symptoms in these patients was 12.3+/-1.9 years. Microelectrode recordings were used in 46.2% of cases. Outcomes were objectively documented using the Unified Parkinson Disease Rating Scale (UPDRS) in 501 (25.6%) of the cases at 6 months and in 218 (11.1%) of the cases at 1 year. There was a consensus on the benefits of pallidotomy for off period motor function and on period, drug-induced dyskinesias, with variations in the extent of symptomatic benefit across studies. At the 1-year assessment, the mean improvement in the UPDRS motor score during off periods was 45.3% and the mean improvement in contralateral dyskinesias during on periods was 86.4%. The overall mortality rate was 0.4% and the rate of persistent adverse effects was estimated at 14%. Major adverse events, including intracerebral hemorrhages, contralateral weakness, and visual field defects, occurred in 5.3% of patients reported.

CONCLUSIONS

Unilateral pallidotomy is effective and relatively safe in the treatment of PD; however, limited data are available on the long-term outcome of this procedure.

Neurophysiological characterization of parkinsonian syndromes

Electrophysiological examination can provide relevant information on functional abnormalities in patients with parkinsonism. The combined use of various electrodiagnostic techniques can contribute to the diagnosis of the illness, to its correct classification and differentiation from other diseases with a clinically similar presentation, and in particular the identification of the pathophysiological processes underlying some of the signs and symptoms characterizing the movement disorder. Tests which are useful in the differential diagnosis of various parkinsonian syndromes can now be performed in most electrodiagnostic laboratories. This article reviews some of the most relevant observations provided by neurophysiological studies on patients with parkinsonism, with a special focus on those that could be of more value in neurological clinical practice through their contribution to the characterization of the disease or to the recognition of underlying pathophysiological processes.

Magnetoelectric brain stimulation in the assessment of brain physiology and pathophysiology

OBJECTIVE

To review findings from transcranial magnetic stimulation (TMS)-induced motor evoked potentials in normal subjects, in various neurological diseases and with pharmacologic manipulation.

METHODS

MEDLINE was searched to identify pertinent articles and articles referenced therein were also reviewed.

RESULTS

TMS is a safe and non-invasive technique which has been used widely in the study of corticospinal and corticocortical connectivity as well as in the assessment of basal ganglia disorders, diffuse diseases, and neuropharmacology.

CONCLUSIONS

TMS motor measures have utility in examination of brain structure and function within and beyond the corticospinal tract. These measures have both research and clinical applications.

The effects of posteroventral pallidotomy on the preparation and execution of voluntary hand and arm movements in Parkinson's disease

We studied the effect of posteroventral pallidotomy on movement preparation and execution in 27 parkinsonian patients using various motor tasks. Patients were evaluated after overnight withdrawal of medication before and 3 months after unilateral pallidotomy. Surgery had no effect on initiation time in unwarned simple and choice reaction time tasks, whereas movement time measured during the same tasks was improved for the contralesional hand. Movement times also improved for isometric and isotonic ballistic movements. In contrast, repetitive, distal and fine movements measured in finger-tapping and pegboard tasks were not improved after pallidotomy. Preparatory processes were investigated using both behavioural and electrophysiological measures. A precued choice reaction time task suggested an enhancement of motor preparation for the contralesional hand. Similarly, movement-related cortical potentials showed an increase in the slope of the late component (NS2) when the patients performed joystick movements with the contralesional hand. However, no significant change was found for the early component (NS1) or when the patient moved the ipsilesional hand. The amplitude of the long-latency stretch reflex of the contralesional hand decreased after surgery. In summary, the data suggest that pallidotomy improved mainly the later stages of movement preparation and the execution of proximal movements with the contralesional limb. These results provide detailed quantitative data on the impact of posteroventral pallidotomy on previously described measures of upper limb akinesia in Parkinson's disease.

Ablative surgery and deep brain stimulation for Parkinson's disease

Surgical options for Parkinson's disease (PD) are rapidly expanding and include ablative procedures, deep brain stimulation, and cell transplantation. The target nuclei for ablative surgery and deep brain stimulation are the motor thalamus, the globus pallidus, and the subthalamic nucleus. Multiple factors have led to the resurgence of interest in the surgical treatment of PD: 1) recognition that long-term medical therapy for PD is often unsatisfactory, with patients eventually suffering from drug-induced dyskinesias, motor fluctuations, and variable responses to medication; 2) greater understanding of the pathophysiology of PD, providing a better scientific rationale for some previously developed procedures and suggesting new targets; and 3) use of improved techniques, such as computed tomography- and magnetic resonance imaging-guided stereotaxy and single-unit microelectrode recording, making surgical intervention in the basal ganglia more precise. We review the present status of ablative surgery and deep brain stimulation for PD, including theoretical aspects, surgical techniques, and clinical results.