1
|
Brozova H, Barnaure I, Ruzicka E, Stochl J, Alterman R, Tagliati M. Short- and Long-Term Effects of DBS on Gait in Parkinson's Disease. Front Neurol 2021; 12:688760. [PMID: 34690908 PMCID: PMC8531078 DOI: 10.3389/fneur.2021.688760] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/11/2021] [Indexed: 12/18/2022] Open
Abstract
The aim was to compare the short and long-term effects of subthalamic nucleus (STN) deep brain stimulation (DBS) on gait dysfunction and other cardinal symptoms of Parkinson's disease (PD). Two groups of patients were studied. The first group (short-term DBS, n = 8) included patients recently implanted with STN DBS (mean time since DBS 15.8 months, mean age 58.8 years, PD duration 13 years); the second group (long-term DBS, n = 10) included patients with at least 5 years of DBS therapy (mean time since DBS 67.6 months, mean age 61.7 years, PD duration 17.1 years). Both groups were examined using the Unified Parkinson's Disease Rating Scale (UPDRS) and Gait and Balance scale (GABS) during four stimulation/medication states (ON/OFF; OFF/OFF; OFF/ON; ON/ON). Data were analyzed using repeated measures ANOVA with time since implantation (years) between groups and medication or DBS effect (ON, OFF) within groups. In the short-term DBS group, stimulation improved all UPDRS subscores similar to dopaminergic medications. In particular, average gait improvement was over 40% (p = 0.01), as measured by the UPDRS item 29 and GABS II. In the long-term DBS group, stimulation consistently improved all clinical subscores with the exception of gait and postural instability. In these patients, the effect of levodopa on gait was partially preserved. Short-term improvement of gait abnormalities appears to significantly decline after 5 years of STN DBS in PD patients, while effectiveness for other symptoms remains stable. Progressive non-dopaminergic (non-DBS responsive) mechanisms or deleterious effects of high frequency STN stimulation on gait function may play a role.
Collapse
Affiliation(s)
- Hana Brozova
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Isabelle Barnaure
- Department of Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Evzen Ruzicka
- Department of Neurology and Centre of Clinical Neuroscience, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czechia
| | - Jan Stochl
- Department of Kinanthropology, Charles University in Prague, Prague, Czechia.,Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - Ron Alterman
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Michele Tagliati
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| |
Collapse
|
2
|
Cole SM, Sarangi S, Einstein D, McMasters M, Alterman R, Bruce J, Hertan L, Shih HA, Wong ET. Parkinsonism reversed from treatment of pineal non-germinomatous germ cell tumor. Surg Neurol Int 2021; 12:237. [PMID: 34221568 PMCID: PMC8248242 DOI: 10.25259/sni_595_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 04/08/2021] [Indexed: 11/08/2022] Open
Abstract
Background: Parkinsonism is a rare complication of non-germinomatous germ cell tumors (NGGCTs) arising from the pineal region. Case Description: We describe a 23-year-old man who presented with Parinaud syndrome, fatigue, and hypersomnia that were caused by a pineal region NGGCT with yolk sac component and an initial α-fetoprotein (AFP) of 1011.0 ng/ml. MRI revealed that the tumor was causing 10 mm of midline shift and compressing the cerebral aqueduct, the left thalamus, and the midbrain. Obstructive hydrocephalus was relieved by ventriculoperitoneal shunting. Six cycles of induction chemotherapy with ifosfamide, carboplatin, and etoposide reduced tumor size and decreased AFP levels in both serum and cerebrospinal fluid. Following the first cycle, the patient developed asymmetric, bilateral Parkinsonism consisting of bradykinesia, bradyphrenia, facial hypomimia, drooling, and dysphagia. Levodopa, amantadine, and methylphenidate were administered and resulted in symptom improvement. Second look neurosurgery revealed residual yolk sac tumor and a second induction regimen of gemcitabine, paclitaxel, and oxaliplatin was administered for rising AFP. The patient eventually received an autologous bone marrow transplant using a regimen of high-dose carboplatin, thiotepa, and etoposide with concomitant colony-stimulating factor and romiplostim support followed by consolidative proton craniospinal radiotherapy. Posttreatment head MRI showed that no evidence of tumor growth and serum AFP was within normal limits. His Parkinsonism eventually resolved and he was weaned off all dopaminergic drugs. Conclusion: Bilateral Parkinsonism from NGGCT in this patient is probably caused by pressure on nigrostriatal tracts, substantia nigra, or both. The Parkinsonian symptoms can be reversed by aggressive treatment of the tumor and administration of dopaminergic drugs.
Collapse
Affiliation(s)
- Sydni M Cole
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Sasmit Sarangi
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - David Einstein
- Department of Hematology/Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Malgorzata McMasters
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Ron Alterman
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Jeffrey Bruce
- Department of Neurosurgery, Columbia Presbyterian Medical Center, New York, United States
| | - Lauren Hertan
- Department of Radiation Oncology, Beth Israel Deaconess Medical Center, United States
| | - Helen A Shih
- Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Eric T Wong
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| |
Collapse
|
3
|
Richard A, Hsu J, Baum P, Alterman R, Simon DK. Efficacy of Deep Brain Stimulation in a Patient with Genetically Confirmed Chorea-Acanthocytosis. Case Rep Neurol 2019; 11:199-204. [PMID: 31543803 PMCID: PMC6738267 DOI: 10.1159/000500951] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/10/2019] [Indexed: 11/20/2022] Open
Abstract
Chorea-acanthocytosis (ChAc) is a rare autosomal recessive neurodegenerative disease due to mutation of the VPS13A gene encoding the protein chorein. ChAc is a slowly progressive disorder that typically presents in early adulthood, and whose clinical features include chorea and dystonia with involuntary lip, cheek, and tongue biting. Some patients also have seizures. Treatment for ChAc is symptomatic. A small number of ChAc patients have been treated with bilateral deep brain stimulation (DBS) of the globus pallidus interna (GPi), and we now present an additional case. Patient chart, functional measures, and laboratory findings were reviewed from the time of ChAc diagnosis until 6 months after DBS surgery. Here, we present a case of ChAc in a 31-year-old male positive for VPS13A gene mutations who presented with chorea, tongue biting, dysarthria, weight loss, and mild cognitive dysfunction. DBS using monopolar stimulation with placement slightly lateral to the GPi was associated with significant improvement in chorea and dysarthria. This case adds to the current state of knowledge regarding the efficacy and safety of bilateral GPi-DBS for symptomatic control of drug-resistant hyperkinetic movements seen in ChAc. Controlled trials are needed to better assess the impact and ideal target of DBS in ChAc.
Collapse
Affiliation(s)
- Alby Richard
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Joey Hsu
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Patricia Baum
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ron Alterman
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - David K Simon
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
4
|
Rughani A, Schwalb JM, Sidiropoulos C, Pilitsis J, Ramirez-Zamora A, Sweet JA, Mittal S, Espay AJ, Martinez JG, Abosch A, Eskandar E, Gross R, Alterman R, Hamani C. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Subthalamic Nucleus and Globus Pallidus Internus Deep Brain Stimulation for the Treatment of Patients With Parkinson's Disease: Executive Summary. Neurosurgery 2019. [PMID: 29538685 DOI: 10.1093/neuros/nyy037] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
QUESTION 1 Is bilateral subthalamic nucleus deep brain stimulation (STN DBS) more, less, or as effective as bilateral globus pallidus internus deep brain stimulation (GPi DBS) in treating motor symptoms of Parkinson's disease, as measured by improvements in Unified Parkinson's Disease Rating Scale, part III (UPDRS-III) scores? RECOMMENDATION Given that bilateral STN DBS is at least as effective as bilateral GPi DBS in treating motor symptoms of Parkinson's disease (as measured by improvements in UPDRS-III scores), consideration can be given to the selection of either target in patients undergoing surgery to treat motor symptoms. (Level I). QUESTION 2 Is bilateral STN DBS more, less, or as effective as bilateral GPi DBS in allowing reduction of dopaminergic medication in Parkinson's disease? RECOMMENDATION When the main goal of surgery is reduction of dopaminergic medications in a patient with Parkinson's disease, then bilateral STN DBS should be performed instead of GPi DBS. (Level I). QUESTION 3 Is bilateral STN DBS more, less, or as effective as bilateral GPi DBS in treating dyskinesias associated with Parkinson's disease? RECOMMENDATION There is insufficient evidence to make a generalizable recommendation regarding the target selection for reduction of dyskinesias. However, when the reduction of medication is not anticipated and there is a goal to reduce the severity of "on" medication dyskinesias, the GPi should be targeted. (Level I). QUESTION 4 Is bilateral STN DBS more, less, or as effective as bilateral GPi DBS in improving quality of life measures in Parkinson's disease? RECOMMENDATION When considering improvements in quality of life in a patient undergoing DBS for Parkinson's disease, there is no basis to recommend bilateral DBS in 1 target over the other. (Level I). QUESTION 5 Is bilateral STN DBS associated with greater, lesser, or a similar impact on neurocognitive function than bilateral GPi DBS in Parkinson disease? RECOMMENDATION If there is significant concern about cognitive decline, particularly in regards to processing speed and working memory in a patient undergoing DBS, then the clinician should consider using GPi DBS rather than STN DBS, while taking into consideration other goals of surgery. (Level I). QUESTION 6 Is bilateral STN DBS associated with a higher, lower, or similar risk of mood disturbance than GPi DBS in Parkinson's disease? RECOMMENDATION If there is significant concern about the risk of depression in a patient undergoing DBS, then the clinician should consider using pallidal rather than STN stimulation, while taking into consideration other goals of surgery. (Level I). QUESTION 7 Is bilateral STN DBS associated with a higher, lower, or similar risk of adverse events compared to GPi DBS in Parkinson's disease? RECOMMENDATION There is insufficient evidence to recommend bilateral DBS in 1 target over the other in order to minimize the risk of surgical adverse events. The full guideline can be found at: https://www.cns.org/guidelines/deep-brain-stimulation-parkinsons-disease.
Collapse
Affiliation(s)
- Anand Rughani
- Neuroscience Institute, Maine Medical Center, Portland, Maine
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Medical Gr-oup, West Bloomfield, Michigan
| | | | - Julie Pilitsis
- Departments of Neuroscience and Experimental Therapeutics and of Neurosurgery, Albany Medical College, Albany, New York
| | | | - Jennifer A Sweet
- Department of Neuro-surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Sandeep Mittal
- De-partment of Neurosurgery, Wayne State University, Detroit, Michigan
| | - Alberto J Espay
- James J. and Joan A. Gardner Center for Parkinson Disease and Movement Disorders, University of Cincinnati, Cincinnati, Ohio
| | | | - Aviva Abosch
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Emad Eskandar
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Robert Gross
- Department of Neu-rosurgery, Emory University, Atlanta, Georgia
| | - Ron Alterman
- Division of Neurosurgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massa-chusetts
| | - Clement Hamani
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| |
Collapse
|
5
|
Mubeen AM, Ardekani B, Tagliati M, Alterman R, Dhawan V, Eidelberg D, Sidtis JJ. Global and multi-focal changes in cerebral blood flow during subthalamic nucleus stimulation in Parkinson's disease. J Cereb Blood Flow Metab 2018; 38:697-705. [PMID: 28421851 PMCID: PMC5888853 DOI: 10.1177/0271678x17705042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Electrical stimulation of subthalamic nuclei (STN) is a widely used therapy in Parkinson's disease (PD). While deep brain stimulation (DBS) of the STN alters the neurophysiological activity in basal ganglia, the therapeutic mechanism has not been established. A positron emission tomography (PET) study of cerebral blood flow (CBF) during speech production in PD subjects treated with STN-DBS found significant increases in global (whole-brain) CBF.1 That study utilized a series of whole-slice regions of interest to obtain global CBF values. The present study examined this effect using a voxel-based principal component analysis (PCA) combined with Fisher's linear discriminant analysis (FLDA) to classify STN-DBS on versus STN-DBS off whole-brain images. The approach yielded wide-spread CBF changes that classified STN-DBS status with accuracy, sensitivity, and specificity approaching 90%. The PCA component of the analysis supported the observation of a global CBF change during STN-DBS. The FLDA component demonstrated wide-spread multi-focal CBF changes. Further, CBF measurements related to a number of subject characteristics when STN-DBS was off, but not when it was on, suggesting that the normal relationship between CBF and behavior may be disrupted by this form of neuromodulation.
Collapse
Affiliation(s)
- Asim M Mubeen
- 1 Brain and Behavior Laboratory, The Nathan Kline Institute for Psychiatric Research, Orangeburg, NY, USA
| | - Babak Ardekani
- 2 Center for Brain Imaging and Neuromodulation, The Nathan Kline Institute for Psychiatric Research, Orangeburg, NY, USA
| | - Michele Tagliati
- 3 Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ron Alterman
- 4 Division of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | - John J Sidtis
- 1 Brain and Behavior Laboratory, The Nathan Kline Institute for Psychiatric Research, Orangeburg, NY, USA
| |
Collapse
|
6
|
Sidtis JJ, Alken AG, Tagliati M, Alterman R, Van Lancker Sidtis D. Subthalamic Stimulation Reduces Vowel Space at the Initiation of Sustained Production: Implications for Articulatory Motor Control in Parkinson's Disease. J Parkinsons Dis 2017; 6:361-70. [PMID: 27003219 PMCID: PMC4927904 DOI: 10.3233/jpd-150739] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: Stimulation of the subthalamic nuclei (STN) is an effective treatment for Parkinson’s disease, but complaints of speech difficulties after surgery have been difficult to quantify. Speech measures do not convincingly account for such reports. Objective: This study examined STN stimulation effects on vowel production, in order to probe whether DBS affects articulatory posturing. The objective was to compare positioning during the initiation phase with the steady prolongation phase by measuring vowel spaces for three “corner” vowels at these two time frames. Methods: Vowel space was measured over the initial 0.25 sec of sustained productions of high front (/i/), high back (/u/) and low vowels (/a/), and again during a 2 sec segment at the midpoint. Eight right-handed male subjects with bilateral STN stimulation and seven age-matched male controls were studied based on their participation in a larger study that included functional imaging. Mean values: age = 57±4.6 yrs; PD duration = 12.3±2.7 yrs; duration of DBS = 25.6±21.2 mos, and UPDRS III speech score = 1.6±0.7. STN subjects were studied off medication at their therapeutic DBS settings and again with their stimulators off, counter-balanced order. Results: Vowel space was larger in the initiation phase compared to the midpoint for both the control and the STN subjects off stimulation. With stimulation on, however, the initial vowel space was significantly reduced to the area measured at the mid-point. For the three vowels, the acoustics were differentially affected, in accordance with expected effects of front versus back position in the vocal tract. Conclusions: STN stimulation appears to constrain initial articulatory gestures for vowel production, raising the possibility that articulatory positions normally used in speech are similarly constrained.
Collapse
Affiliation(s)
- John J Sidtis
- Brain and Behavior Laboratory, Geriatrics Division, The Nathan Kline Institute, Orangeburg, NY, USA.,Department of Psychiatry, New York University Langone School of Medicine, New York, NY, USA
| | - Amy G Alken
- Brain and Behavior Laboratory, Geriatrics Division, The Nathan Kline Institute, Orangeburg, NY, USA
| | - Michele Tagliati
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ron Alterman
- Neurosurgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Diana Van Lancker Sidtis
- Brain and Behavior Laboratory, Geriatrics Division, The Nathan Kline Institute, Orangeburg, NY, USA.,Department of Communicative Sciences and Disorders, NYU Steinhardt School of Culture, Education, and Human Development, New York, NY, USA
| |
Collapse
|
7
|
Horn A, Kühn AA, Merkl A, Shih L, Alterman R, Fox M. Probabilistic conversion of neurosurgical DBS electrode coordinates into MNI space. Neuroimage 2017; 150:395-404. [PMID: 28163141 DOI: 10.1016/j.neuroimage.2017.02.004] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Revised: 02/01/2017] [Accepted: 02/02/2017] [Indexed: 10/20/2022] Open
Abstract
In neurosurgical literature, findings such as deep brain stimulation (DBS) electrode positions are conventionally reported in relation to the anterior and posterior commissures of the individual patient (AC/PC coordinates). However, the neuroimaging literature including neuroanatomical atlases, activation patterns, and brain connectivity maps has converged on a different population-based standard (MNI coordinates). Ideally, one could relate these two literatures by directly transforming MRIs from neurosurgical patients into MNI space. However obtaining these patient MRIs can prove difficult or impossible, especially for older studies or those with hundreds of patients. Here, we introduce a methodology for mapping an AC/PC coordinate (such as a DBS electrode position) to MNI space without the need for MRI scans from the patients themselves. We validate our approach using a cohort of DBS patients in which MRIs are available, and test whether several variations on our approach provide added benefit. We then use our approach to convert previously reported DBS electrode coordinates from eight different neurological and psychiatric diseases into MNI space. Finally, we demonstrate the value of such a conversion using the DBS target for essential tremor as an example, relating the site of the active DBS contact to different MNI atlases as well as anatomical and functional connectomes in MNI space.
Collapse
Affiliation(s)
- Andreas Horn
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; Charité - University Medicine Berlin, Department of Neurology, Movement Disorder and Neuromodulation Unit, Germany.
| | - Andrea A Kühn
- Charité - University Medicine Berlin, Department of Neurology, Movement Disorder and Neuromodulation Unit, Germany
| | - Angela Merkl
- Charité - University Medicine Berlin, Department of Neurology, Movement Disorder and Neuromodulation Unit, Germany
| | - Ludy Shih
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Ron Alterman
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; Beth Israel Deaconess Medical Center, Neurosurgery Department, Harvard Medical School, Boston, MA 02215
| | - Michael Fox
- Berenson-Allen Center for Noninvasive Brain Stimulation, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA; Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA, USA
| |
Collapse
|
8
|
Parihar R, Alterman R, Papavassiliou E, Tarsy D, Shih LC. Comparison of VIM and STN DBS for Parkinsonian Resting and Postural/Action Tremor. Tremor Other Hyperkinet Mov (N Y) 2015. [PMID: 26196027 PMCID: PMC4502347 DOI: 10.7916/d81v5d35] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Resting tremor is common in Parkinson’s disease (PD), but up to 47% of PD patients have action tremor, which is sometimes resistant to medications. Deep brain stimulation (DBS) of the ventral intermediate nucleus (VIM) of the thalamus or subthalamic nucleus (STN) is effective for medication-refractory tremor in PD, though it remains unclear whether STN DBS is as effective as VIM DBS for postural/action tremor related to PD. Methods We carried out a single-center retrospective review of patients with medication-refractory resting, postural, and action PD tremor, treated with either VIM or STN DBS between August 2004 and March 2014. We assessed the degree of improvement using items 20 and 21 of the Unified Parkinson’s Disease Rating Scale (UPDRS) motor scale and examined the proportion of patients achieving tremor arrest. Results A total of 18 patients were analyzed, 10 treated with STN and eight treated with VIM, with similar off-medication motor UPDRS scores. There was no significant difference in improvement in tremor scores or in the proportion of patients experiencing tremor arrest between the two stimulation sites. Overall, 56% and 72% of patients experienced complete absence of postural/action tremor and resting tremor, respectively, at last follow-up. Discussion This study demonstrated excellent outcomes on both resting and postural/action tremor after either VIM or STN DBS. Resting tremor improved to a greater degree than postural/action tremor in both groups. These results suggest that a large randomized controlled trial is needed to show a superior effect of one target on PD tremor.
Collapse
Affiliation(s)
- Raminder Parihar
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ron Alterman
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Efstathios Papavassiliou
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Daniel Tarsy
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Ludy C Shih
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
9
|
Warren Olanow C, Bartus RT, Baumann TL, Factor S, Boulis N, Stacy M, Turner DA, Marks W, Larson P, Starr PA, Jankovic J, Simpson R, Watts R, Guthrie B, Poston K, Henderson JM, Stern M, Baltuch G, Goetz CG, Herzog C, Kordower JH, Alterman R, Lozano AM, Lang AE. Gene delivery of neurturin to putamen and substantia nigra in Parkinson disease: A double-blind, randomized, controlled trial. Ann Neurol 2015; 78:248-57. [PMID: 26061140 DOI: 10.1002/ana.24436] [Citation(s) in RCA: 176] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/27/2015] [Accepted: 05/04/2015] [Indexed: 11/09/2022]
Abstract
OBJECTIVE A 12-month double-blind sham-surgery-controlled trial assessing adeno-associated virus type 2 (AAV2)-neurturin injected into the putamen bilaterally failed to meet its primary endpoint, but showed positive results for the primary endpoint in the subgroup of subjects followed for 18 months and for several secondary endpoints. Analysis of postmortem tissue suggested impaired axonal transport of neurturin from putamen to substantia nigra. In the present study, we tested the safety and efficacy of AAV2-neurturin delivered to putamen and substantia nigra. METHODS We performed a 15- to 24-month, multicenter, double-blind trial in patients with advanced Parkinson disease (PD) who were randomly assigned to receive bilateral AAV2-neurturin injected bilaterally into the substantia nigra (2.0 × 10(11) vector genomes) and putamen (1.0 × 10(12) vector genomes) or sham surgery. The primary endpoint was change from baseline to final visit performed at the time the last enrolled subject completed the 15-month evaluation in the motor subscore of the Unified Parkinson's Disease Rating Scale in the practically defined off state. RESULTS Fifty-one patients were enrolled in the trial. There was no significant difference between groups in the primary endpoint (change from baseline: AAV2-neurturin, -7.0 ± 9.92; sham, -5.2 ± 10.01; p = 0.515) or in most secondary endpoints. Two subjects had cerebral hemorrhages with transient symptoms. No clinically meaningful adverse events were attributed to AAV2-neurturin. INTERPRETATION AAV2-neurturin delivery to the putamen and substantia nigra bilaterally in PD was not superior to sham surgery. The procedure was well tolerated, and there were no clinically significant adverse events related to AAV2-neurturin.
Collapse
Affiliation(s)
- C Warren Olanow
- Departments of Neurology and Neuroscience, Mount Sinai School of Medicine, New York, NY
| | | | | | - Stewart Factor
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Nicholas Boulis
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA
| | - Mark Stacy
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Dennis A Turner
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC
| | - William Marks
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Paul Larson
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Phillip A Starr
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA
| | - Joseph Jankovic
- Department of Neurology, Baylor College of Medicine, Houston, TX
| | - Richard Simpson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX
| | - Ray Watts
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL
| | - Barton Guthrie
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL
| | - Kathleen Poston
- Department of Neurology and Neurological Sciences, Stanford University Medical Center, Stanford, CA
| | - Jaimie M Henderson
- Department of Neurosurgery, Stanford University Medical Center, Stanford, CA
| | - Matthew Stern
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| | - Gordon Baltuch
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA
| | - Christopher G Goetz
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | | | - Jeffrey H Kordower
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL
| | - Ron Alterman
- Beth Israel-Deaconess Medical Center, Department of Neurosurgery, Boston, MA
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Anthony E Lang
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
10
|
Abstract
Dystonia is a movement disorder characterized by involuntary muscular contractions that generate twisting and repetitive movements and/or abnormal postures. It can affect a few muscle groups (focal dystonia) or spread to most muscles in the body (generalized dystonia). While botulinum toxin injections can be successfully used to treat focal dystonias, medical options for generalized dystonia are very limited. Surgical therapies--and in particular deep brain stimulation (DBS)--are becoming the standard of care for medically intractable, disabling dystonias. Advantages of DBS include reversibility, adjustability and continued access to the therapeutic target. Initial reports describing the use of DBS in generalized dystonia have been very encouraging and experience in the use of DBS to treat various forms of dystonia is continuously growing. This article reviews the issues related to DBS treatment of dystonia, including proper patient selection, surgical approaches to target choice and device implant, a description of the stimulating device and its programming principles, clinical results - with a focus on different outcomes for primary versus secondary and generalized versus cervical dystonia - and complications.
Collapse
Affiliation(s)
- Michele Tagliati
- Beth Israel Medical Center, 10 Union Square East, Suite 2R, New York, NY 1003, USA.
| | | | | | | |
Collapse
|
11
|
Cheung T, Nuño M, Hoffman M, Katz M, Kilbane C, Alterman R, Tagliati M. Longitudinal Impedance Variability in Patients with Chronically Implanted DBS Devices. Brain Stimul 2013; 6:746-51. [DOI: 10.1016/j.brs.2013.03.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2012] [Revised: 03/09/2013] [Accepted: 03/20/2013] [Indexed: 10/27/2022] Open
|
12
|
Bartus RT, Baumann TL, Siffert J, Herzog CD, Alterman R, Boulis N, Turner DA, Stacy M, Lang AE, Lozano AM, Olanow CW. Safety/feasibility of targeting the substantia nigra with AAV2-neurturin in Parkinson patients. Neurology 2013; 80:1698-701. [PMID: 23576625 DOI: 10.1212/wnl.0b013e3182904faa] [Citation(s) in RCA: 143] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVE In an effort to account for deficiencies in axonal transport that limit the effectiveness of neurotrophic factors, this study tested the safety and feasibility, in moderately advanced Parkinson disease (PD), of bilaterally administering the gene therapy vector AAV2-neurturin (CERE-120) to the putamen plus substantia nigra (SN, a relatively small structure deep within the midbrain, in proximity to critical neuronal and vascular structures). METHODS After planning and minimizing risks of stereotactically targeting the SN, an open-label, dose-escalation safety trial was initiated in 6 subjects with PD who received bilateral stereotactic injections of CERE-120 into the SN and putamen. RESULTS Two-year safety data for all subjects suggest the procedures were well-tolerated, with no serious adverse events. All adverse events and complications were expected for patients with PD undergoing stereotactic brain surgery. CONCLUSIONS Bilateral stereotactic administration of CERE-120 to the SN plus putamen in PD is feasible and this evaluation provides initial empirical support that it is safe and well-tolerated. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that bilateral neurturin gene delivery (CERE-120) to the SN plus putamen in patients with moderately advanced PD is feasible and safe.
Collapse
|
13
|
Cho C, Alterman R, Morris T, Moore S, Rucker J. Convergence Insufficiency Responsive to Bilateral Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease (P02.257). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p02.257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
14
|
Cheung T, Flatow V, Ben-Haim S, Osborn I, Cho C, Tagliati M, Alterman R. Status Dystonicus Following Deep Brain Stimulation Surgery in DYT1 Dystonia Patients (P01.227). Neurology 2012. [DOI: 10.1212/wnl.78.1_meetingabstracts.p01.227] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
15
|
Okun MS, Gallo BV, Mandybur G, Jagid J, Foote KD, Revilla FJ, Alterman R, Jankovic J, Simpson R, Junn F, Verhagen L, Arle JE, Ford B, Goodman RR, Stewart RM, Horn S, Baltuch GH, Kopell BH, Marshall F, Peichel D, Pahwa R, Lyons KE, Tröster AI, Vitek JL, Tagliati M. Subthalamic deep brain stimulation with a constant-current device in Parkinson's disease: an open-label randomised controlled trial. Lancet Neurol 2012; 11:140-9. [DOI: 10.1016/s1474-4422(11)70308-8] [Citation(s) in RCA: 296] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
16
|
Tagliati M, Martin C, Alterman R. Lack of motor symptoms progression in Parkinson's disease patients with long-term bilateral subthalamic deep brain stimulation. Int J Neurosci 2011; 120:717-23. [PMID: 20942586 DOI: 10.3109/00207454.2010.518777] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To evaluate the long-term progression of motor symptoms in Parkinson's disease (PD) patients treated with subthalamic nucleus deep brain stimulation (STN-DBS), we retrospectively analyzed data from 50 PD patients with bilateral STN-DBS. Clinical records at baseline and at several yearly intervals were reviewed. The Unified Parkinson's Disease Rating scale (UPDRS) was performed preoperatively after withholding medications for at least 12 hr (OFF) and after taking the usual dose of levodopa. Postoperative evaluations were completed in four clinical states: OFF medications—stimulators OFF (OFF/OFF); OFF medications—stimulators ON; ON medications—stimulators OFF; and ON medications—stimulators ON. The UPDRS motor scores OFF/OFF were virtually unmodified up to 5 years when compared with preoperative OFF scores. There was no significant difference between OFF/OFF score variations from baseline in patients with shorter (<11 years) and longer PD duration at the time of surgery. No consistent deterioration from untreated baseline was noted for each UPDRS motor subscore (tremor, rigidity, bradykinesia, and axial). Untreated PD motor scores did not worsen over time in patients undergoing STN-DBS, suggesting that there is no progression of motor severity. These results could be explained either by a natural stabilization of PD motor symptoms after many years or neuroprotective properties of STN-DBS.
Collapse
Affiliation(s)
- Michele Tagliati
- Department of Neurology, Mount Sinai School of Medicine, New York, New York 10029, USA.
| | | | | |
Collapse
|
17
|
Marks WJ, Bartus RT, Siffert J, Davis CS, Lozano A, Boulis N, Vitek J, Stacy M, Turner D, Verhagen L, Bakay R, Watts R, Guthrie B, Jankovic J, Simpson R, Tagliati M, Alterman R, Stern M, Baltuch G, Starr PA, Larson PS, Ostrem JL, Nutt J, Kieburtz K, Kordower JH, Olanow CW. Gene delivery of AAV2-neurturin for Parkinson's disease: a double-blind, randomised, controlled trial. Lancet Neurol 2010; 9:1164-1172. [PMID: 20970382 DOI: 10.1016/s1474-4422(10)70254-4] [Citation(s) in RCA: 457] [Impact Index Per Article: 32.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In an open-label phase 1 trial, gene delivery of the trophic factor neurturin via an adeno-associated type-2 vector (AAV2) was well tolerated and seemed to improve motor function in patients with advanced Parkinson's disease. We aimed to assess the safety and efficacy of AAV2-neurturin in a double-blind, phase 2 randomised trial. METHODS We did a multicentre, double-blind, sham-surgery controlled trial in patients with advanced Parkinson's disease. Patients were randomly assigned (2:1) by a central, computer generated, randomisation code to receive either AAV2-neurturin (5·4 × 10¹¹ vector genomes) injected bilaterally into the putamen or sham surgery. All patients and study personnel with the exception of the neurosurgical team were masked to treatment assignment. The primary endpoint was change from baseline to 12 months in the motor subscore of the unified Parkinson's disease rating scale in the practically-defined off state. All randomly assigned patients who had at least one assessment after baseline were included in the primary analyses. This trial is registered at ClinicalTrials.gov, NCT00400634. RESULTS Between December, 2006, and November, 2008, 58 patients from nine sites in the USA participated in the trial. There was no significant difference in the primary endpoint in patients treated with AAV2-neurturin compared with control individuals (difference -0·31 [SE 2·63], 95% CI -5·58 to 4·97; p=0·91). Serious adverse events occurred in 13 of 38 patients treated with AAV2-neurturin and four of 20 control individuals. Three patients in the AAV2-neurturin group and two in the sham surgery group developed tumours. INTERPRETATION Intraputaminal AAV2-neurturin is not superior to sham surgery when assessed using the UPDRS motor score at 12 months. However, the possibility of a benefit with additional targeting of the substantia nigra and longer term follow-up should be investigated in further studies. FUNDING Ceregene and Michael J Fox Foundation for Parkinson's Research.
Collapse
Affiliation(s)
- William J Marks
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | | | | | | | - Andres Lozano
- Department of Neurosurgery, University of Toronto, Toronto, Canada
| | - Nicholas Boulis
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Jerrold Vitek
- Department of Neurology, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Stacy
- Department of Neurology, Duke University, Durham, NC, USA
| | - Dennis Turner
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Leonard Verhagen
- Department of Neurology, Rush Medical University, Chicago, IL, USA
| | - Roy Bakay
- Department of Neurosurgery, Rush Medical University, Chicago, IL, USA
| | - Raymond Watts
- Department of Neurology, University of Alabama, Birmingham, AL, USA
| | - Barton Guthrie
- Department of Neurosurgery, University of Alabama, Birmingham, AL, USA
| | - Joseph Jankovic
- Department of Neurology, Baylor University, Houston, TX, USA
| | - Richard Simpson
- Department of Neurosurgery, Baylor University, Houston, TX, USA
| | - Michele Tagliati
- Department of Neurology, Mount Sinai School of Medicine, New York, NY, USA
| | - Ron Alterman
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, USA
| | - Matthew Stern
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Gordon Baltuch
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Philip A Starr
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Paul S Larson
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA
| | - Jill L Ostrem
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - John Nutt
- Department of Neurology, University of Oregon, Portland, OR, USA
| | - Karl Kieburtz
- Department of Neurology, University of Rochester, Rochester, NY, USA
| | | | - C Warren Olanow
- Department of Neurology, Mount Sinai School of Medicine, New York, NY, USA; Department of Neuroscience, Mount Sinai School of Medicine, New York, NY, USA; Institute of Neurology, IRCCS San Raffaele Pisana, Rome, Italy.
| |
Collapse
|
18
|
De Los Reyes K, Chandrasekhar SS, Tagliati M, Alterman R. Successful implantation of a deep brain stimulator for essential tremor in a patient with a preexisting cochlear implant: surgical technique: technical case report. Neurosurgery 2010; 66:372; discussion 372. [PMID: 20489530 DOI: 10.1227/01.neu.0000369646.01287.42] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Deep brain stimulation (DBS) has become routine for the treatment of Parkinson's disease and essential tremor. Because both of these disorders are common in patients older than the age of 60, neurosurgeons are likely to encounter increasing numbers of patients who require DBS surgery but who already have another electronic medical implant such as a cardiac pacemaker/defibrillator or intrathecal infusion pump, raising the concern that one device might interfere with the performance of the other. CLINICAL PRESENTATION Herein we report a modification of surgical technique resulting in the successful use of thalamic DBS to treat disabling essential tremor in a man with a previously implanted cochlear implant. INTERVENTION AND TECHNIQUE The presence of the cochlear implant necessitated a number of modifications to our standard surgical technique including surgical removal of the subgaleal magnet that holds the receiver to the scalp and the use of computed tomography instead of magnetic resonance imaging to target the thalamus. More than a year after surgery, the patient is enjoying continued tremor suppression and an enhanced quality of life. The presence of the DBS device has not interfered with the proper functioning of his cochlear implant. CONCLUSION DBS can be used successfully in patients with a previously implanted cochlear implant. The operating neurosurgeon should be aware of the limitations of intraoperative imaging and the need to coordinate with an otologic surgeon for maximum patient benefit.
Collapse
Affiliation(s)
- Kenneth De Los Reyes
- Department of Neurosurgery, The Mount Sinai Medical Center, New York, New York 10029, USA
| | | | | | | |
Collapse
|
19
|
Brozova H, Barnaure I, Ruzicka E, Stochl J, Alterman R, Tagliati M. 220 SHORT- AND LONG-TERM EFFECTS OF DBS ON GAIT IN PARKINSON'S DISEASE. Parkinsonism Relat Disord 2010. [DOI: 10.1016/s1353-8020(10)70221-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
20
|
Dumitriu D, Collins K, Alterman R, Mathew SJ. Neurostimulatory therapeutics in management of treatment-resistant depression with focus on deep brain stimulation. ACTA ACUST UNITED AC 2008; 75:263-75. [PMID: 18704979 DOI: 10.1002/msj.20044] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Treatment-resistant depression continues to pose a major medical challenge, as up to one-third of patients with major depressive disorder fail to have an adequate response to standard pharmacotherapies. An improved understanding of the complex circuitry underlying depressive disorders has fostered an explosion in the development of new, nonpharmacological approaches. Each of these treatments seeks to restore normal brain activity via electrical or magnetic stimulation. In this article, the authors discuss the ongoing evolution of neurostimulatory treatments for treatment-resistant depression, reviewing the methods, efficacy, and current research on electroconvulsive therapy, repetitive transcranial magnetic stimulation, magnetic seizure therapy, focal electrically administered stimulated seizure therapy, transcranial direct current stimulation, chronic epidural cortical stimulation, and vagus nerve stimulation. Special attention is given to deep brain stimulation, the most focally targeted approach. The history, purported mechanisms of action, and current research are outlined in detail. Although deep brain stimulation is the most invasive of the neurostimulatory treatments developed to date, it may hold significant promise in alleviating symptoms and improving the quality of life for patients with the most severe and disabling mood disorders.
Collapse
Affiliation(s)
- Dani Dumitriu
- Department of Neuroscience, Mount Sinai School of Medicine, New York, NY, USA.
| | | | | | | |
Collapse
|
21
|
Tagliati M, Alterman R, Okun MS, Fernandez HH, Rodriguez RL, Foote KD, Pourfar M, Metz S, Hagestuen R. What Is Deep Brain Stimulation “Failure” and How Do We Manage Our Own Failures?—Reply. ACTA ACUST UNITED AC 2005. [DOI: 10.1001/archneur.62.12.1938-b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
|
22
|
Abstract
Unilateral pallidotomy is a safe and effective treatment for medically refractory bradykinetic Parkinson's disease, especially in those patients with levodopa-induced dyskinesia and severe on-off fluctuations. The efficacy of bilateral pallidotomy is less certain. The authors completed 11 of 12 attempted bilateral pallidotomies among 150 patients undergoing pallidotomy at New York University. In all but one patient, the pallidotomies were separated by at least 9 months. Patients were selected for bilateral pallidotomy if they exhibited bilateral rigidity, bradykinesia, or levodopa-induced dyskinesia prior to treatment or if they exhibited disease progression contralateral to their previously treated side. The Unified Parkinson's Disease Rating Scale (UPDRS) and timed upper-extremity tasks of the Core Assessment Protocol for Intracerebral Transplantation (CAPIT) were administered to all 12 patients in the "off" state (12 hours without receiving medications) preoperatively and again at 6 and 12 months after each procedure. The median UPDRS and contralateral CAPIT scores improved 60% following the initial procedure (p = 0.008, Wilcoxon rank sums test). The second pallidotomy generated only an additional 10% improvement in the UPDRS and CAPIT scores ipsilateral to the original procedure (p = 0.05). Worsened speech was observed in two cases. In the 12th case, total speech arrest was noted during test stimulation. Speech returned within minutes after stimulation was halted. Lesioning was not performed. These results indicate that bilateral pallidotomy has a narrow therapeutic window. Motor improvement ipsilateral to the first lesion leaves little room for further improvement from the second lesion and the risk of speech deficit is greatly enhanced. Chronic pallidal stimulation contralateral to a previously successful pallidotomy may prove to be a safer alternative for the subset of patients who require bilateral procedures.
Collapse
Affiliation(s)
- R Kim
- New York University Center for the Study and Treatment of Movement Disorders, New York, New York, USA
| | | | | | | | | | | | | |
Collapse
|
23
|
Eidelberg D, Moeller JR, Kazumata K, Antonini A, Sterio D, Dhawan V, Spetsieris P, Alterman R, Kelly PJ, Dogali M, Fazzini E, Beric A. Metabolic correlates of pallidal neuronal activity in Parkinson's disease. Brain 1997; 120 ( Pt 8):1315-24. [PMID: 9278625 DOI: 10.1093/brain/120.8.1315] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
We have used [18F]fluorodeoxyglucose and PET to identify specific metabolic covariance patterns associated with Parkinson's disease and related disorders previously. Nonetheless, the physiological correlates of these abnormal patterns are unknown. In this study we used PET to measure resting state glucose metabolism in 42 awake unmedicated Parkinson's disease patients prior to unilateral stereotaxic pallidotomy for relief of symptoms. Spontaneous single unit activity of the internal segment of the globus pallidus (GPi) was recorded intraoperatively in the same patients under identical conditions. The first 24 patients (Group A) were scanned on an intermediate resolution tomograph (full width at half maximum, 8 mm); the subsequent 18 patients (Group B) were scanned on a higher resolution tomograph (full width half maximum, 4.2 mm). We found significant positive correlations between GPi firing rates and thalamic glucose metabolism in both patient groups (Group A: r = 0.41, P < 0.05; Group B: r = 0.69, P < 0.005). In Group B, pixel-based analysis disclosed a significant focus of physiological-metabolic correlation involving the ventral thalamus and the GPi (statistical parametric map: P < 0.05, corrected). Regional covariance analysis demonstrated that internal pallidal neuronal activity correlated significantly (r = 0.65, P < 0.005) with the expression of a unique network characterized by covarying pallidothalamic and brainstem metabolic activity. Our findings suggest that the variability in pallidal neuronal firing rates in Parkinson's disease patients is associated with individual differences in the metabolic activity of efferent projection systems.
Collapse
Affiliation(s)
- D Eidelberg
- Department of Neurology, North Shore University Hospital, Manhasset, NY, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Abstract
Unilateral pallidotomy is a safe and effective treatment for medically refractory bradykinetic Parkinson's disease, especially in those patients with levodopa-induced dyskinesia and severe on-off fluctuations. The efficacy of bilateral pallidotomy is less certain.
The authors completed 11 of 12 attempted bilateral pallidotomies among 150 patients undergoing pallidotomy at New York University. In all but one patient, the pallidotomies were separated by at least 9 months. Patients were selected for bilateral pallidotomy if they exhibited bilateral rigidity, bradykinesia, or levodopa-induced dyskinesia prior to treatment or if they exhibited disease progression contralateral to their previously treated side.
The Unified Parkinson's Disease Rating Scale (UPDRS) and timed upper-extremity tasks of the Core Assessment Protocol for Intracerebral Transplantation (CAPIT) were administered to all 12 patients in the “off” state (12 hours without receiving medications) preoperatively and again at 6 and 12 months after each procedure. The median UPDRS and contralateral CAPIT scores improved 60% following the initial procedure (p = 0.008, Wilcoxon rank sums test). The second pallidotomy generated only an additional 10% improvement in the UPDRS and CAPIT scores ipsilateral to the original procedure (p = 0.05). Worsened speech was observed in two cases. In the 12th case, total speech arrest was noted during test stimulation. Speech returned within minutes after stimulation was halted. Lesioning was not performed.
These results indicate that bilateral pallidotomy has a narrow therapeutic window. Motor improvement ipsilateral to the first lesion leaves little room for further improvement from the second lesion and the risk of speech deficit is greatly enhanced. Chronic pallidal stimulation contralateral to a previously successful pallidotomy may prove to be a safer alternative for the subset of patients who require bilateral procedures.
Collapse
|
25
|
Berić A, Sterio D, Dogali M, Alterman R, Kelly P. Electrical stimulation of the globus pallidus preceding stereotactic posteroventral pallidotomy. Stereotact Funct Neurosurg 1996; 66:161-9. [PMID: 9144871 DOI: 10.1159/000099685] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Physiological methods such as microelectrode recording of neuronal activity and electrical stimulation of target structures can improve the safety and efficacy of certain stereotactic surgeries. The globus pallidus (GP) was electrically stimulated in 136 patients with Parkinson's disease prior to unilateral posteroventral pallidotomy to identify functional areas and prevent deficits. We found that electrical stimulation of the GP elicited two principal responses: contractions of the contralateral hand and flashing lights. The mean voltage that evoked motor responses was 4.3 V (range 1.7-9.0 V), while higher intensity was necessary to elicit visual responses (mean 6.8 V; range 3.5-9.9 V). Contralateral tremor, speech impairment, paresthesias, and warm sensations were also elicited.
Collapse
Affiliation(s)
- A Berić
- Department of Neurology, New York University School of Medicine, Hospital for Joint Diseases, N.Y., USA
| | | | | | | | | |
Collapse
|