Specific movement and disability improvements in Burke-Fahn-Marsden Dystonia Rating Scale derived from pallidotomy in refractory patients to medical treatment

BACKGROUND

Dystonia is a movement disorder associated with significant disability and is usually refractory to medical treatment. Pallidotomy may decrease dystonic movements. The aim of this study was to quantify movement and disability improvements through Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS).

METHODS

We carried out a longitudinal clinical study in patients with refractory primary and secondary dystonia, who underwent radiofrequency (RF) unilateral and bilateral lesions on the postero-ventro-lateral globus pallidus internus (GPi), evaluating the outcomes through BFMDRS and variables as age, time of evolution, etiology, body distribution, planned target coordinates, and lesion size, during a mean follow-up time of 35.67 months.

RESULTS

Nine RF pallidotomies were performed on 6 patients, 7 right-sided and 2 left-sided; three patients were treated unilaterally for one occasion, while the others underwent 2 surgeries, including one staged bilateral procedure. Mean BFMDRS scores for movement were 38.5 preoperative and 25.5 postoperative, and for disability were 20.4 preoperative and 17.3 postoperative. We noticed improvement in movement (32.54%, p = 0.001) and disability (17.23%, p = 0.002). There was one right GPi and internal capsule (IC) infarction with contralateral hemiparesis as sequelae.

CONCLUSIONS

RF pallidotomy is an effective and accessible procedure to reduce BFMDRS scores in refractory dystonia if patients are correctly selected by severity, evolution, and disability as determining factors.

Radiofrequency Ablation of Prelemniscal Radiations for the Treatment of Non-Parkinsonian Tremor

OBJECTIVE

Previous reports proposed prelemniscal radiations (Raprl) as a target to treat motor symptoms of Parkinson's disease, and this was found particularly effective to control rest and postural tremor. However, tremor of other etiologies has been seldom treated with deep brain stimulation or ablation in this target. We present a series of such cases successfully treated by Raprl radiofrequency (RF) lesions.

MATERIAL AND METHODS

Six patients with predominant unilateral tremor on the right arm: 4 intention, 1 cerebellar and 1 rubral tremor, incapacitating in spite of at least 2 regimes of medical treatment at maximal tolerated doses, were operated under local anesthesia. RF lesions were performed in Raprl contralateral to most prominent symptoms. Patients had monthly evaluation of tremor severity through the Fahn-Tolosa-Marin Tremor Rating Scale and disability through the Tremor Disability Scale along a 1-year follow-up.

RESULTS

In 4/6 patients tremor was stopped by the simple insertion of an RF electrode in Raprl; in the other 2 cases, stimulation through the RF electrode at 100 Hz, with 100 µs and 1.0-1.5 V, stopped the tremor without side effects. Tremor disappeared in all cases immediately after surgery and partially reappeared in 2 cases with an amplitude about 20% of the preoperative condition. RF lesions in postoperative MRI ranked from 1.8 to 2.6 mm in diameter.

CONCLUSIONS

RF lesioning in Raprl is a simple, highly effective, inexpensive way to treat tremor of different etiologies.

Evaluation of bilateral cingulotomy and anterior capsulotomy for the treatment of aggressive behavior

BACKGROUND

Agressiveness is a psychiatric symptom that may be part of schizophrenia, mental retardation, drug abuse and other conditions. Surgical treatment remains controversial and few therapeutic options are available. We undertook this study to perform a prospective analysis on the efficacy and safety of bilateral cingulotomy and anterior capsulotomy in the treatment of aggressiveness behavior.

METHODS

We studied 25 patients with a primary diagnosis of aggressiveness refractory to conventional treatment. Subjects were clinically evaluated with the Mayo-Portland adaptability inventory and the Global Assessment of Functioning score. Lesions were placed stereotactically in both targets and confirmed by postoperative magnetic resonance imaging. Significant changes were evaluated with Wilcoxon test after 3 and 6 months.

RESULTS

According to inclusion and exclusion criteria, only 12 patients were finally included and surgical treated. Lesions significantly decreased using the Mayo-Portland adaptability inventory and the Global Assessment of Functioning score (p <0.002) at 3 and 6 months follow-up. Only five patients showed either mild or transitory postsurgical complications.

CONCLUSIONS

Combined bilateral anterior capsulotomy and cingulotomy successfully reduced aggressiveness behavior and improved clinical evaluations. These effects were obtained with fewer complications than previously described targets.