Assessments of plasma acyl-ghrelin levels in Parkinson's disease patients treated with deep brain stimulation

Gastrointestinal dysfunction is the most common non-motor symptom in Parkinson's disease (PD) with rates rising as the disease progresses. Deep brain stimulation of subthalamic nucleus (STN DBS) improves motor functions in advanced PD. However, the effect of STN DBS on ghrelin concentration and consequently on motility disturbances as well as body weight is unclear. The objective of this study was to assess acyl-ghrelin levels in comparison to weight in advanced PD patients treated with STN DBS. Plasma concentrations of acyl-ghrelin was measured in 29 PD patients in the fasting state and at 30, 60, 120, and 180 min after a standard meal preoperatively and 3 months after surgery. The level of acyl-ghrelin in PD patients were compared with 30 age and sex-matched healthy controls. We reported that mean plasma acyl-ghrelin levels were decreased in PD patients before STN DBS in fasting (p = 0.0003) and in 30 min postprandial phase (p = 0.04) compared with healthy controls. The plasma acyl-ghrelin levels after STN DBS increased in pre-prandial and postprandial phase in PD patients at the investigated time points. Body weight gained on average 2.33 kg during the first 3 months after surgery. There was no correlation between the acyl-ghrelin plasma levels and BMI. After STN DBS in fasting and postprandial phase plasma acyl-ghrelin levels were increased. The results showed that STN DBS therapy elicited a modification of ghrelin levels, increasing its concentration in pre- and postprandial state. In addition, body weight was increased during 3 months after surgery.

The effect of subthalamic deep brain stimulation on gastric motility in Parkinson's disease

OBJECTIVE

Deep brain stimulation of the subthalamic nucleus (STN-DBS) is well established for treating the motor symptoms for advanced Parkinson's disease (PD) but its effects on gastric myoelectrical activity and gastrointestinal symptoms have not been well studied. The aim of this study was to evaluate the effect of STN-DBS on gastric motility using electrogastrography (EGG).

METHODS

Twenty patients with PD (5 females, 15 males; mean aged 58.0 ± 9.0 years) who underwent STN-DBS were studied. EGG was performed in fasting and postprandial conditions before STN-DBS and 3 months after the surgery. We also evaluated the frequency and severity of gastrointestinal symptoms based on a structured gastrointestinal dysfunction questionnaire.

RESULTS

After STN-DBS the percentage of normogastria (47.8 ± 20.7 vs 51.3 ± 15.1) and period dominant power (PDP) (11.8 ± 1.2 vs 12.3 ± 0.9) significantly increased, the percentage of arrhythmia decreased compared to the baseline during fasting and postprandial state. Abnormal response to a meal (power ratio of PDP <1 after meal) decreased from 70% to 55% after 3 months follow-up. The abnormal EGG (the percentage of normogastria <70%) decreased in both fasting (from 80% to 65% patients) and postprandial state (from 80% to 60% patients), respectively after the surgery. The most common GI symptoms reported prior to the surgery were constipation 95%, difficulty with defecation 85% and dysphagia 50%. After STN-DBS all gastrointestinal symptoms improved, the greatest improvement was observed in difficulty with defecation.

CONCLUSION

Our results suggest that STN-DBS improves gastric motility as well as gastrointestinal symptoms in PD. Further studies of gastrointestinal motility in PD are warranted.

[Evaluation of heart rate and blood pressure variability in Parkinson's disease patients after bilateral subthalamic deep brain stimulation]

INTRODUCTION

Autonomic dysfunctions are the most common non-motor symptoms of Parkinson's disease (PD) and often precede the motor symptoms of the disease. Autonomic dysfunction may be a dominant symptom of the advanced stages of PD as well as a major cause of patient disability. Despite the wide use of neurostimulation in clinical practice, the effect of deep brain stimulation of subthalamic nucleus (STN DBS) on autonomic symptoms of PD still remains only partially understood. The aim of the study is evaluation of heart rate variability (HRV) and blood pressure variability (BPV) in patients with PD before STN DBS and following bilateral STN DBS.

MATERIAL AND METHODS

The study included 25 subjects aged between 31 and 71 years, diagnosed with the idiopathic PD and selected for treatment with STN DBS. All the patients were in advanced stages of PD, disease duration ranged from 5 to 22 years. The patients enrolled into this study underwent STN DBS. Neurological examination including assessment of the severity of parkinsonism according to UPDRS scale, a psychological examination and an electrophysiological examination of autonomic disturbances based on heart rate and blood pressure variability were conducted on all patients two weeks before and three months after STN DBS.

RESULTS

After STN DBS an improvement in terms of the analyzed parts of the UPDRS has been shown. The improvement of motor disorders assessed by III part UPDRS during the "off" medication/stimulation "on" was 67.8%. Orthostatic hypotension before the STN DBS procedure was observed in 56% of patients and after STN DBS in 53% of them. Before STN DBS the imbalance of the sympathetic--parasympathetic components with the predominance of the sympathetic based on HRV parameters--the ratio LF/HF-RRI (2.5) and a higher rate of LFnu (61.3%) than HFnu (38.6%) has been shown. Three months post STN DBS an increase parameters of spectral analysis of HRV in the low frequency LF-RRI, and high-frequency HF-RRI and the total power spectrum PSD-RRI was observed. After STN DBS an increase of parameters of spectral analysis of systolic BPV, very low frequency VLF-sBP, low frequency LF-sBP and total power spectrum PSD-sBP was noted.

CONCLUSIONS

Results of the study suggest that STN DBS is an effective treatment method of both motor symptoms and autonomic dysfunctions. The disturbances of HRV and BPV before and after STN DBS indicate the increase of autonomic system activity with sympathetic dominance.

Efficacy of deep brain stimulation of the subthalamic nucleus on autonomic dysfunction in patients with Parkinson's disease

Subthalamic nucleus (STN) deep brain stimulation (DBS) is well established for the treatment of the motor symptoms of Parkinson's disease (PD). However, the effect of STN DBS on autonomic symptoms has not been well studied. We examined 19 patients undergoing STN DBS for PD. The patients were administered a questionnaire to evaluate the pre-operative and post-operative autonomic function. All patients reported a significant post DBS improvement of one or more symptoms of the autonomic dysfunction (urinary and gastrointestinal function). In particular, we have shown the most significant improvement in the urinary function after STN DBS. Further larger studies are required with respect to the effect of STN DBS on the autonomic function.

Visual feedback training using WII Fit improves balance in Parkinson's disease

Postural instability including imbalance is the most disabling long term problem in Parkinson's disease (PD) that does not respond to pharmacotherapy. This study aimed at investigating the effectiveness of a novel visual-feedback training method, using Wii Fit balance board in improving balance in patients with PD. Twenty four patients with moderate PD were included in the study which comprised of a 6-week home-based balance training program using Nintendo Wii Fit and balance board. The PD patients significantly improved their results in Berg Balance Scale, Tinnet's Performance-Oriented Mobility Assessment, Timed Up-and-Go, Sit-to-stand test, 10-Meter Walk test and Activities-specific Balance Confidence scale at the end of the programme. This study suggests that visual feedback training using Wii-Fit with balance board could improve dynamic and functional balance as well as motor disability in PD patients.

[Effects of deep brain stimulation on dysfunctions of the autonomic nervous system in Parkinson's disease]

BACKGROUND

Deep brain stimulation (DBS) for alleviation of motor symptoms in advanced Parkinson's disease (PD) is well established. However, autonomic effects of DBS are less clear.

AIM

To review published data on autonomic dysfunctions in DBS-treated patients with PD.

METHODS

Medline bibliographic search was performed with the selected relevant keywords, through June 10th, 2010. Thirty three original papers meeting the criteria were identified.

RESULTS

Effect of DBS on autonomic dysfunctions observed in PD differs depending on the underlying etiology. DBS of the subthalamic nucleus has no direct effects on cardiovascular functions. Relative improvement results from reduced levodopa intake. Majority of gastrointestinal and urinary tract disorders improve with neurostimulation. However, prolonged body weight gain is observed. Furthermore, urinary tract functions normalize, and in male patients with Parkinson's disease sexual satisfaction increases. Sweating disorders are markedly reduced. On the contrary, chronic stimulation in the area of STN may induce autonomic adverse effects including sialorrhea and urinary retention. In exceptional cases withdrawal of medication before planned DBS surgery may result in life-threatening parkinsonism-hyperpyrexia syndrome. Thus discontinuation of levodopa should be an inpatient procedure.

CONCLUSIONS

Selection of patients who undergo DBS should weigh potential benefits and risks resulting from multidirectional effects of neurostimulation on autonomic nervous system.

Intracerebral haematoma in hydrocephalic shunted patients not related to ventricular cannula. Report of three cases and review of the literature

Intracerebral haematoma (ICH) distantly from the site of insertion of a ventriculoperitoneal shunt or external drain is an extremely rare complication. In contrast to ICH caused by disruption of small cerebral vessels by the catheter, the cause of haematoma distantly from the shunt is unclear. We report three cases of ICH occurring distantly from the tubing path. We also discuss possible mechanisms and provide a literature review of this complication.

[Direct surgical outcome of meningiomas obliterating the superior sagittal sinus]

BACKGROUND AND PURPOSE

Aggressive surgery for parasagittal meningiomas is considered when superior sagittal sinus is totally thrombosed by the tumour. However, there is potential risk of venous outflow injury resulting in an intracerebral haemorrhage. The aim of this study is to present surgical technique and early surgical outcome of patients with meningiomas obliterating the superior sagittal sinus.

MATERIAL AND METHODS

Ten patients (4 men and 6 women, mean age 58), operated for sagittal meningiomas with radiologically proved superior sagittal sinus obliteration, were analysed retrospectively. In all cases, radical surgery with the resection of invaded sagittal sinus was performed. The size of tumours varied between 35 and 100 mm; the mean was 53 mm. Five of them required reoperation because of tumour recurrence due to a previous incomplete resection. In five cases, bifrontal craniotomy was made, in four biparietal and in one parieto-occipital. Preoperative status and direct postoperative outcome were compared using the Karnofsky scale.

RESULTS

Very good outcome was achieved in 6 cases--the clinical status remained unchanged. In two, the outcome was good (in the first patient hemiparesis increased and in the second there was worsening of cortical visual disturbances). In two cases with an unfavorable outcome, one patient suffered quadriparesis and mutism; the other experienced cerebral edema with hemorrhagic infarct and died despite decompressive surgery. Both these patients were totally dependent before surgery (Karnofsky < 40).

CONCLUSIONS

In the radical resection of a tumour with occluded sinus, direct postoperative outcome ranges from good to very good in a significant number of cases. In dependent patients having a large tumour, there is the risk of an unfavourable outcome after radical surgery. In such cases, partial resection and further radiotherapy should be considered.

[Possibilities of data acquisition, recording and processing based on the system for continuous intracranial pressure and cerebral perfusion pressure monitoring designed at the Department of Neurosurgery of the Jagiellonian University in Cracow]

OBJECTIVES

To describe computer system for intracranial pressure (ICP) monitoring and for infusion testing (IT), and to present current possibilities of analysis of cerebrospinal fluid (CSF) pressure signal.

SYSTEM DESCRIPTION

Computer system for pressure signal measurement and acquisition consists of three sensors: for ICP, infusion pressure during IT, and blood pressure measurements. Electric signal from the sensors is transmitted to Temed RMN-201M cardiomonitor, and next after enhancement is subjected to Data Shuttle DS-12-8-5B-AO analog to digital converter. Digital output signal is recorded and analysed'on standard personal computer. Original Windows-compatible software was developed to control the system. The program consists of three blocs: configuration, measurement and readout, and enables selection of voltage range for each of the signal channels, measurement resolution, sampling frequency, calibration and zeroing of the sensors, visualisation of pressure signals on graph, data storage in text format and automatic analysis of IT. Main characteristics of the system include: high sampling frequency (up to 500 Hz), simultaneous data recording from all signal channels, and access to terminal cistern with one puncture needle on IT. Laboratory and clinical tests confirmed high precision of the developed system. ICP CURVE ANALYSIS: The developed software allows for evaluation of the main parameters, of CSF dynamics, prediction of IT course before a steady state is reached as well as spectral analysis of pressure signal.

CONCLUSIONS

Computer measurement system developed at our department is clinically useful and allows for high precision signal acquisition necessary for advanced scientific analyses of hydrocephalus and intracranial pressure.

[Mechanically detachable coils in the treatment of posterior circulation aneurysms: a comparison with surgical repair]

AIM

To compare craniotomy and clip application with endovascular coiling in patients with posterior circulation aneurysms.

MATERIAL AND METHODS

Among 676 consecutive patients with aneurysmal SAH who had been treated with either clipping or coiling, a group of 46 patients with aneurysms in the posterior circulation (32 treated surgically and 14 endovascularly) were selected for further investigation. Patient and aneurysm characteristics, procedural complications, and clinical and radiological results were compared retrospectively. The odds ratio for poor outcome (Glasgow outcome scale 1, 2, 3) adjusted for preoperative clinical condition parameters was assessed by logistic regression analysis. The group was not randomized.

RESULTS

In the endovascular group 6 patients (42.9%) had a poor outcome vs. 8 (25%) in the surgical group; the adjusted odds ratio for poor outcome after coiling vs. clipping was 3.21 (p = NS). The observed difference in outcome was consequent on higher incidence of severe neurological deficit (GOS 3) after embolisation, compared with clip application (26% and 9.4% of patients respectively); mortality was comparable in both groups (14.3% vs. 15.6%). Optimal or suboptimal aneurysm occlusion immediately after coiling was achieved in 12 patients (85.7%). Clipping was successful in 31 patients (96.9%).

CONCLUSION

There was no statistically significant difference in outcome between the two treatment groups. However, patients were less likely to be dependent when treated by craniotomy and clip application, compared with endovascular MDS embolisation.

[Bilateral cerebellar hematoma after supratentorial glioma surgery]

We present a case of bilateral hematoma in cerebellar hemispheres in a 30-year-old man after surgical treatment of extensive left frontal glioma. 16 hours after surgery the patient lost consciousness. An immediate CT revealed hematoma in both cerebellar hemispheres. The hematoma was subsequently removed via bilateral suboccipital craniectomy. After the operation the clinical status of the patient gradually improved - he was discharged in a good general condition. In the presented case the hematoma developed presumably as a consequence of extensive cerebrospinal fluid (CSF) loss (670 ml) via postoperative wound drainage. The resulting cerebellar displacement caused strain of the draining veins, affecting blood outflow, and causing parenchymal hemorrhage. In order to prevent the complication, massive CSF loss during and after operation should be avoided. Careful monitoring of the patient's condition in the postoperative period, even if the general status is good, is important because only an immediate intervention may prevent the development of irreversible consequences of cerebellar hematoma formation.

[Direct and late outcome in trigeminal neuralgia treated by means of microvascular decompression in cerebellopontine angle]

BACKGROUND

Microvascular decompression (MVD) is a method of choice in the surgical treatment of trigeminal neuralgia (TN).

OBJECTIVE

To evaluate direct and long-term results of MVD in TN.

MATERIAL AND METHODS

The authors analyzed 20 patients (9 women and 11 men, mean age 62.2 years) with TN who had been treated surgically at the Department of Neurosurgery of the University Hospital in Cracow between October 1998 and September 2002. MVD was performed using Janetta technique via suboccipital retro-sigmoid craniectomy. All patients underwent additional neurolysis. Indentations in portio major of the trigeminal nerve were present in 5 cases. Short- and long-term pain relief was assessed according to Slettebo-Eide scale.

RESULTS

Complete short-term pain relief was observed in 15 patients (75%), in 3 patients (15%) significant pain control was achieved. Very good and good long-term result was reported by 70% of patients. Pre-operative invasive treatment of neuralgia did not affect the long-term outcome. MVD of the trigeminal nerve indented by compression of the adjacent vessels yielded very good and good long-term result in 80% of patients compared with 66% in the group of patients with no trigeminal nerve indentation. In all of the 6 octogenarians very good or good pain control was observed. Duration of the history of trigeminal neuralgia did not influence the outcome. Severe postoperative complication (hemorrhagic cerebellar infarction) was observed in one case.

CONCLUSION

Microvascular decompression is safe and effective method in the treatment of trigeminal neuralgia. MVD yields beneficial results in elderly patients.

[Endovascular coiling and microsurgery of the cerebral arteriovenous malformations. Assessment of criteria of treatment and outcome]

BACKGROUND

Three available methods of therapy of arteriovenous malformations (AVM) i.e. microsurgical resection, intravascular embolization and stereotactic radiosurgery, make possible definitive treatment in the majority of patients. During qualification to these procedures the risk of complications and efficacy of each method should be considered.

OBJECTIVE

To analyze criteria of qualification, risk factors and results of embolization and surgical treatment of AVMs.

PATIENTS AND METHODS

Within four years (1999-2002) 53 patients were treated for arteriovenous malformations (AVMs) in the Department of Neurosurgery of the University Hospital in Krakow (24 women and 29 men). The group of 25 patients was treated with intravascular embolization, 20 patients were operated and 8 patients were treated conservatively or were qualified to radiotherapy. We retrospectively analyzed clinical findings, criteria of qualification and results of embolization as well as microsurgical treatment of AVMs with regard to Spetzler-Martin scale.

RESULTS

25 patients qualified for embolization underwent 39 embolization procedures. Complete embolization of AVM was obtained in 4 (16%) cases. 18 patients (72%) presented very good or good condition on discharge. In 5 (20%) serious complications were noted: in 2 hemorrhagic and in 3 ischemic. Three patients (12%) died. In the group of 18 operated patients, 13 (72%) patients presented very good or good condition on discharge and 1 patient died because of hemorrhagic complications.

CONCLUSIONS

1. Spetzler-Martin scale is very useful in evaluation of operative risk of AVM operations but, in our opinion, before operation there should be considered also such factors like number and diameter of feeding arteries, exact localization of AVM and initial condition of the patient. 2. Although intravascular embolization is less invasive than neurosurgical operation, the risk of hemorrhagic and ischemic complications is present. 3. Complete AVM embolization is possible in the minority of patients. The remaining group require follow up and control radiological examinations to establish indications for further treatment.