Prospective Long-term Follow-up of Focused Ultrasound Unilateral Subthalamotomy for Parkinson Disease

BACKGROUND AND OBJECTIVES

Unilateral Magnetic Resonance-guided Focused Ultrasound subthalamotomy (FUS-STN) has been shown to improve the cardinal motor features of Parkinson's disease (PD). Whether this effect is sustained is not known. This study aims to report the long-term outcome of PD patients treated with unilateral FUS-STN.

METHODS

We conducted a prospective, open-label study of asymmetrical PD patients who underwent unilateral FUS-STN. All patients were evaluated up to 36 months after treatment. The primary outcome was the difference from baseline to 36 months after FUS-STN in the score of the Movement Disorders Society-Unified Rating scale (MDS-UPDRS) motor part (III) for the treated hemibody in the off-medication state. The safety outcome included all adverse events occurring during follow-up. Secondary outcomes were the change in the MDS-UPDRS III score on-medication; sub-scores of rigidity, bradykinesia, tremor, and axial features; total MDS-UPDRS III; and the MDS-UPDRS part IV. Functional disability and quality of life were assessed using the MDS-UPDRS II and the PDQ39, respectively. Patient impression of change and satisfaction with the treatment were self-assessed. The Wilcoxon signed-rank test with subsequent Bonferroni's correction was used for data analysis.

RESULTS

Thirty-two PD patients were evaluated 36 months after treatment. The mean (±SD) age at baseline was 56.0±10.1 years, with a mean disease duration of 6.8±2.8 years. The MDS-UPDRS III score for the treated hemibody off-medication was improved by 52.3% from baseline to 3 years (score reduction from 19.0±3.2 to 8.9±3.3, 95% confidence interval [95CI] 8.7 to 11.6, P<0.001), and all specific motor features were improved from baseline. No disabling or delayed adverse events were reported. The total MDS-UPDRS III off-medication score was 22.9% lower at 3 years than before treatment (36.8±7.4 vs 27.4±6.2, 95CI 6.0 to 11.5, P<0.001). The MDS-UPDRS II, IV, and PDQ39 scores and levodopa dose were equivalent to those at baseline.

DISCUSSION

The benefit of unilateral FUS-STN on PD motor features is sustained in the long term. FUS-STN contributes to better clinical control over several years of evolution. NCT02912871/03454425.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence on the utility of focused ultrasound unilateral subthalamotomy in the treatment of people with Parkinson's disease.

A circuit-based approach to modulate hypersexuality in Parkinson's disease

AIM

Impulse-control disorder is a common neuropsychiatric complication in Parkinson's disease (PD) under dopamine replacement therapy. Prior studies tested the balance between enhanced desire towards reward and cognitive control deficits, hypothesized to be biased towards the former in impulse control disorders. We provide evidence for this hypothesis by measuring behavioral and neural patterns behind the influence of sexual desire over response inhibition and tools towards functional restoration using repetitive transcranial stimulation in patients with hypersexuality as predominant impulsive disorder.

METHODS

The effect of sexual cues on inhibition was measured with a novel erotic stop-signal task under on and off dopaminergic medication. Task-related functional and anatomical connectivity models were estimated in 16 hypersexual and 17 nonhypersexual patients with PD as well as in 17 healthy controls. Additionally, excitatory neuromodulation using intermittent theta-burst stimulation (sham-controlled) was applied over the pre-supplementary motor area in 20 additional hypersexual patients with PD aiming to improve response inhibition.

RESULTS

Compared with their nonhypersexual peers, patients with hypersexuality recruited caudate, pre-supplementary motor area, ventral tegmental area, and anterior cingulate cortex while on medication. Reduced connectivity was found between pre-supplementary motor area and caudate nucleus in hypersexual compared with nonhypersexual patients (while medicated), a result paralleled by compensatory enhanced anatomical connectivity. Furthermore, stimulation over the pre-supplementary motor area improved response inhibition in hypersexual patients with PD when exposed to sexual cues.

CONCLUSION

This study, therefore, has identified a specific fronto-striatal and mesolimbic circuitry underlying uncontrolled sexual responses in medicated patients with PD where cortical neuromodulation halts its expression.

Neuroimaging biomarkers for clinical trials in atypical parkinsonian disorders: Proposal for a Neuroimaging Biomarker Utility System

INTRODUCTION

Therapeutic strategies targeting protein aggregations are ready for clinical trials in atypical parkinsonian disorders. Therefore, there is an urgent need for neuroimaging biomarkers to help with the early detection of neurodegenerative processes, the early differentiation of the underlying pathology, and the objective assessment of disease progression. However, there currently is not yet a consensus in the field on how to describe utility of biomarkers for clinical trials in atypical parkinsonian disorders.

METHODS

To promote standardized use of neuroimaging biomarkers for clinical trials, we aimed to develop a conceptual framework to characterize in more detail the kind of neuroimaging biomarkers needed in atypical parkinsonian disorders, identify the current challenges in ascribing utility of these biomarkers, and propose criteria for a system that may guide future studies.

RESULTS

As a consensus outcome, we describe the main challenges in ascribing utility of neuroimaging biomarkers in atypical parkinsonian disorders, and we propose a conceptual framework that includes a graded system for the description of utility of a specific neuroimaging measure. We included separate categories for the ability to accurately identify an intention-to-treat patient population early in the disease (Early), to accurately detect a specific underlying pathology (Specific), and the ability to monitor disease progression (Progression).

DISCUSSION

We suggest that the advancement of standardized neuroimaging in the field of atypical parkinsonian disorders will be furthered by a well-defined reference frame for the utility of biomarkers. The proposed utility system allows a detailed and graded description of the respective strengths of neuroimaging biomarkers in the currently most relevant areas of application in clinical trials.

Multimodal description of whole brain connectivity: A comparison of resting state MEG, fMRI, and DWI

Structural and functional connectivity (SC and FC) have received much attention over the last decade, as they offer unique insight into the coordination of brain functioning. They are often assessed independently with three imaging modalities: SC using diffusion‐weighted imaging (DWI), FC using functional magnetic resonance imaging (fMRI), and magnetoencephalography/electroencephalography (MEG/EEG). DWI provides information about white matter organization, allowing the reconstruction of fiber bundles. fMRI uses blood‐oxygenation level‐dependent (BOLD) contrast to indirectly map neuronal activation. MEG and EEG are direct measures of neuronal activity, as they are sensitive to the synchronous inputs in pyramidal neurons. Seminal studies have targeted either the electrophysiological substrate of BOLD or the anatomical basis of FC. However, multimodal comparisons have been scarcely performed, and the relation between SC, fMRI‐FC, and MEG‐FC is still unclear. Here we present a systematic comparison of SC, resting state fMRI‐FC, and MEG‐FC between cortical regions, by evaluating their similarities at three different scales: global network, node, and hub distribution. We obtained strong similarities between the three modalities, especially for the following pairwise combinations: SC and fMRI‐FC; SC and MEG‐FC at theta, alpha, beta and gamma bands; and fMRI‐FC and MEG‐FC in alpha and beta. Furthermore, highest node similarity was found for regions of the default mode network and primary motor cortex, which also presented the highest hubness score. Distance was partially responsible for these similarities since it biased all three connectivity estimates, but not the unique contributor, since similarities remained after controlling for distance. Hum Brain Mapp 37:20–34, 2016. © 2015 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc.

Alpha-band hypersynchronization in progressive mild cognitive impairment: a magnetoencephalography study

People with mild cognitive impairment (MCI) show a high risk to develop Alzheimer's disease (AD; Petersen et al., 2001). Nonetheless, there is a lack of studies about how functional connectivity patterns may distinguish between progressive (pMCI) and stable (sMCI) MCI patients. To examine whether there were differences in functional connectivity between groups, MEG eyes-closed recordings from 30 sMCI and 19 pMCI subjects were compared. The average conversion time of pMCI was 1 year, so they were considered as fast converters. To this end, functional connectivity in different frequency bands was assessed with phase locking value in source space. Then the significant differences between both groups were correlated with neuropsychological scores and entorhinal, parahippocampal, and hippocampal volumes. Both groups did not differ in age, gender, or educational level. pMCI patients obtained lower scores in episodic and semantic memory and also in executive functioning. At the structural level, there were no differences in hippocampal volume, although some were found in left entorhinal volume between both groups. Additionally, pMCI patients exhibit a higher synchronization in the alpha band between the right anterior cingulate and temporo-occipital regions than sMCI subjects. This hypersynchronization was inversely correlated with cognitive performance, both hippocampal volumes, and left entorhinal volume. The increase in phase synchronization between the right anterior cingulate and temporo-occipital areas may be predictive of conversion from MCI to AD.

Disparate connectivity for structural and functional networks is revealed when physical location of the connected nodes is considered

Macroscopic brain networks have been widely described with the manifold of metrics available using graph theory. However, most analyses do not incorporate information about the physical position of network nodes. Here, we provide a multimodal macroscopic network characterization while considering the physical positions of nodes. To do so, we examined anatomical and functional macroscopic brain networks in a sample of twenty healthy subjects. Anatomical networks are obtained with a graph based tractography algorithm from diffusion-weighted magnetic resonance images (DW-MRI). Anatomical connections identified via DW-MRI provided probabilistic constraints for determining the connectedness of 90 different brain areas. Functional networks are derived from temporal linear correlations between blood-oxygenation level-dependent signals derived from the same brain areas. Rentian Scaling analysis, a technique adapted from very-large-scale integration circuits analyses, shows that functional networks are more random and less optimized than the anatomical networks. We also provide a new metric that allows quantifying the global connectivity arrangements for both structural and functional networks. While the functional networks show a higher contribution of inter-hemispheric connections, the anatomical networks highest connections are identified in a dorsal-ventral arrangement. These results indicate that anatomical and functional networks present different connectivity organizations that can only be identified when the physical locations of the nodes are included in the analysis.