Surgical treatment for Parkinson's disease

Testing the contributions of striatal dopamine loss to the genesis of parkinsonian signs

The diverse and independently-varying signs of Parkinson's disease (PD) are often attributed to one simple mechanism: degeneration of the dopaminergic innervation of the posterolateral striatum. However, growing recognition of the dopamine (DA) loss and other pathology in extra-striatal brain regions has led to uncertainty whether loss of DA in the striatum is sufficient to cause parkinsonian signs. We tested this hypothesis by infusing cis-flupenthixol (cis-flu; a broad-spectrum D1/D2 receptor antagonist) into different regions of the macaque putamen (3 hemispheres of 2 monkeys) while the animal performed a visually-cued choice reaction time task in which visual cues indicated the arm to reach with and the peripheral target to contact to obtain food reward. Following reward delivery, the animal was required to self-initiate release of the peripheral target and return of the chosen hand to its home position (i.e., without the benefit of external sensory cues or immediate rewards). Infusions of cis-flu at 15 of 26 sites induced prolongations of reaction time (9 of 15 cases), movement duration (6 cases), and/or dwell time of the hand at the peripheral target (8 cases). Dwell times were affected more severely (+95%) than visually-triggered reaction times or movement durations (+25% and +15%, respectively). Specifically, the animal's hand often 'froze' at the peripheral target for up to 25-s, similar to the akinetic freezing episodes observed in PD patients. Across injections, slowing of self-initiation did not correlate in severity with prolongations of visually-triggered reaction time or movement duration, although the latter two were correlated with each other. Episodes of slowed self-initiation appeared primarily in the arm contralateral to the injected hemisphere and were not associated with increased muscle co-contraction or global alterations in behavioral state (i.e., inattention or reduced motivation), consistent with the idea that these episodes reflected a fundamental impairment of movement initiation. We found no evidence for an anatomic topography within the putamen for the effects elicited. We conclude that acute focal blockade of DA transmission in the putamen is sufficient to induce marked akinesia-like impairments. Furthermore, different classes of impairments can be induced independently, suggesting that specific parkinsonian signs have unique pathophysiologic substrates.

Deep brain stimulation and cognitive decline in Parkinson's disease: a clinical review

Parkinson’s disease is a common and often debilitating disorder, with a growing prevalence accompanying global population aging. Current drug therapy is not satisfactory enough for many patients, especially after a few years of symptom progression. This is mainly due to the motor complications that frequently emerge as disease progresses. Deep brain stimulation (DBS) is a useful therapeutic option in carefully selected patients that significantly improves motor symptoms, functional status, and quality of life. However, cognitive impairment may limit patient selection for DBS, as patients need to have sufficient mental capabilities in order to understand the procedure, as well as its benefits and limitations, and cooperate with the medical team throughout the process of selection, surgery, and postsurgical follow-up. On the other hand it has been observed that certain aspects of cognitive performance may decline after DBS, namely when the therapeutic target is the widely used subthalamic nucleus. These are important pieces of information for patients, their families, and health care professionals. This manuscript reviews these aspects and their clinical implications.

Effects of depression and social support on comprehension and recall of informed consent information among Parkinson disease patients and their caregivers

OBJECTIVE

Relatively little attention has focused on the impact of psychiatric conditions on human subjects' comprehension of consent information. The purpose of this randomized study was to determine whether depression affects comprehension and recall of informed consent information among persons with Parkinson's disease and their caregivers and to evaluate the effects of support on comprehension and recall during the consent process.

METHOD

Comprehension and recall of information were assessed using a modified version of the Modified Quality of Informed Consent Questionnaire, taken 1 week and 1 month later, and scored using a consensus-based algorithm. Participants also completed the Center for Epidemiologic Studies Depression Scale. Data analyses were conducted on 129 patients and caregivers (t-tests, Fisher's exact tests, and ANCOVAs).

RESULTS

T-tests showed no significant differences in comprehension and recall between depressed and nondepressed participants at 1 week and 1 month. However, ANCOVA showed patients with a support person present had significantly higher comprehension and recall at 1 week but not at 1 month compared with controls. Caregivers present with a patient had lower comprehension/recall than those without a patient present (p = 0.02).

CONCLUSIONS

Having a support person present during the informed consent process helps depressed PD patients better retain information in the short-term, but effects diminish over the long-term. Implications for interventions will be discussed.

Studies of properties of "Pain Networks" as predictors of targets of stimulation for treatment of pain

Two decades of functional imaging studies have demonstrated pain-related activations of primary somatic sensory cortex (S1), parasylvian cortical structures (PS), and medial frontal cortical structures (MF), which are often described as modules in a "pain network." The directionality and temporal dynamics of interactions between and within the cortical and thalamic modules are uncertain. We now describe our studies of these interactions based upon recordings of local field potentials (LFPs) carried out in an epilepsy monitoring unit over the one week period between the implantation and removal of cortical electrodes during the surgical treatment of epilepsy. These recordings have unprecedented clarity and resolution for the study of LFPs related to the experimental pain induced by cutaneous application of a Thulium YAG laser. We also used attention and distraction as behavioral probes to study the psychophysics and neuroscience of the cortical "pain network." In these studies, electrical activation of cortex was measured by event-related desynchronization (ERD), over SI, PS, and MF modules, and was more widespread and intense while attending to painful stimuli than while being distracted from them. This difference was particularly prominent over PS. In addition, greater perceived intensity of painful stimuli was associated with more widespread and intense ERD. Connectivity of these modules was then examined for dynamic causal interactions within and between modules by using the Granger causality (GRC). Prior to the laser stimuli, a task involving attention to the painful stimulus consistently increased the number of event-related causality (ERC) pairs both within the SI cortex, and from SI upon PS (SI > PS). After the laser stimulus, attention to a painful stimulus increased the number of ERC pairs from SI > PS, and SI > MF, and within the SI module. LFP at some electrode sites (critical sites) exerted ERC influences upon signals at multiple widespread electrodes, both in other cortical modules and within the module where the critical site was located. In summary, critical sites and SI modules may bind the cortical modules together into a "pain network," and disruption of that network by stimulation might be used to treat pain. These results in humans may be uniquely useful to design and optimize anatomically based pain therapies, such as stimulation of the S1 or critical sites through transcutaneous magnetic fields or implanted electrodes.

Site of deep brain stimulation and jaw velocity in Parkinson disease

OBJECT

While deep brain stimulation (DBS) has proven to be an effective treatment for many symptoms of Parkinson disease (PD), a deterioration of axial symptoms frequently occurs, particularly for speech and swallowing. These unfavorable effects of DBS may depend on the site of stimulation. The authors made quantitative measures of jaw velocity to compare the relative effectiveness of DBS in the globus pallidus internus (GPi) or the subthalamic nucleus (STN). This was a randomized, double-blind, and longitudinal study, with matched healthy controls.

METHODS

The peak velocities of self-scaled and externally scaled jaw movements were studied in 27 patients with PD before and after 6 months of bilateral DBS in the GPi or the STN. A mixed-effects model was used to identify differences in jaw velocity before DBS surgery (baseline) while off and on levodopa therapy, and after 6 months of DBS (postoperative) during 4 treatment conditions (off- and on-levodopa states with and without DBS).

RESULTS

Self-scaled jaw velocity was impaired by the DBS procedure in the STN; velocity was significantly decreased across all postoperative conditions compared with either the off- or on-levodopa baseline conditions. In contrast, the postoperative velocity in the GPi group was generally faster than the baseline off-levodopa state. Turning the DBS off and on had no effect on jaw velocity in either group. Unlike baseline, levodopa therapy postoperatively no longer increased jaw velocity in either group, and this lack of effect was not related to postoperative changes in dose. The externally scaled jaw velocity was little affected by PD, but DBS still slightly affected performance, with the STN group significantly slower than the GPi group for most conditions.

CONCLUSIONS

The authors' results suggest that either the electrode implant in STN or the subsequent period of continuous STN stimulation negatively affected voluntary jaw velocity, including the loss of the preoperative levodopa-induced improvement. While the GPi group showed some improvement in voluntary jaw velocity postoperatively, their performance during the combination of DBS and levodopa was not different from their best medical management presurgery. The results have implications for DBS target selection, particularly for those patients with oromotor dysfunctions.

Intrinsic dynamics and synaptic inputs control the activity patterns of subthalamic nucleus neurons in health and in Parkinson's disease

Neurons in the subthalamic nucleus occupy a pivotal position in the circuitry of the basal ganglia. They receive direct excitatory input from the cerebral cortex and the intralaminar nuclei of the thalamus, and directly excite the inhibitory basal ganglia output neurons in the internal segment of the globus pallidus and the substantia nigra. They are also engaged in a reciprocal synaptic arrangement with inhibitory neurons in the external segment of the globus pallidus. Although once viewed as a simple relay of extrinsic input to the basal ganglia, physiological studies of subthalamic neurons have revealed that activity in these neurons does not directly reflect their pattern of extrinsic excitation. Subthalamic neurons are autonomously active at rates comparable to those observed in vivo, and they generate complex patterns of intrinsic activity arising from the interactions between voltage sensitive ion channels on the somatodendritic and axonal membranes. Extrinsic synaptic excitation does not create the firing pattern of the subthalamic neuron, but rather controls the timing of action potentials generated intrinsically. The dopaminergic innervation of the subthalamic nucleus, although moderate, can directly influence firing patterns by acting both on synaptic transmission and voltage-sensitive ion channels responsible for intrinsic properties. Furthermore, chronic dopamine depletion in Parkinson's disease may modify both synaptic transmission and integration in the subthalamic nucleus, in addition to its effects on other regions of the basal ganglia.

The surgical management of Parkinson’s disease

SUMMARY Parkinson’s disease (PD) is one of the most frequently encountered neurodegenerative disorders in terms of worldwide prevalence. Although medications are typically effective at treating motor symptoms in early to moderately advanced stages, the efficacy of these agents often wanes as the disease progresses. With long-term pharmacologic therapy, many PD patients will also experience motor fluctuations, dyskinesias and unpredictable wearing off of the therapeutic benefit. Deep brain stimulation, the preferred surgical treatment for PD, often improves many of these complications. New surgical options are currently under clinical investigation for advanced PD patients including gene and cell-based therapies.

Pre- and post- GPi DBS neuropsychological profiles in a case of X-linked dystonia-Parkinsonism

We present the pre to post bilateral globus pallidus interna (GPi) deep brain stimulation neuropsychological profiles of a 69-year-old patient with a 12-year history of X-linked dystonia-Parkinsonism (XDP). Pre-operative cognitive function was impaired in almost all domains and this impaired performance was not dependent on his medications. Following DBS, changes in neuropsychological functioning were examined using Reliable Change Indices and standardized z-score comparisons. Results showed reductions in processing speed in the context of stable performance in language and visuospatial domains. Post-operative improvements occurred on a cognitive screening measure, verbal memory, and a test of problem-solving skills. This is the first report on an individual with XDP who was cognitively impaired, but had good outcome following GPi bilateral stimulation to treat debilitating motor symptoms. The possible mechanisms for his stable cognitive performance include the target of his DBS, reduced medication dosage, and improvement in dystonia that may in turn have reduced patient's pain.

Deep brain stimulation for psychiatric disorders

Medications, psychotherapy, and other treatments are effective for many patients with psychiatric disorders. However, with currently available interventions, a substantial number of patients experience incomplete resolution of symptoms, and relapse rates are high. In the search for better treatments, increasing interest has focused on focal neuromodulation. This focus has been driven by improved neuroanatomical models of mood, thought, and behavior regulation, as well as by more advanced strategies for directly and focally altering neural activity. Deep brain stimulation (DBS) is one of the most invasive focal neuromodulation techniques available; data have supported its safety and efficacy in a number of movement disorders. Investigators have produced preliminary data on the safety and efficacy of DBS for several psychiatric disorders, as well. In this review, we describe the development and justification for testing DBS for various psychiatric disorders, carefully consider the available clinical data, and briefly discuss potential mechanisms of action.

Propofol decreases neuronal population spiking activity in the subthalamic nucleus of Parkinsonian patients

BACKGROUND

Implantation of deep brain stimulation (DBS) electrodes in the subthalamic nucleus (STN) for the treatment of Parkinson disease is often performed using microelectrode recording (MER) of STN population spike activity. The extent to which sedative drugs interfere with MER is unknown. We recorded the population activity of STN neurons during propofol sedation and examined its effect on neuronal activity.

METHODS

The procedure was performed during DBS surgery for Parkinson disease. We administered propofol (50 μg/kg/min) at a constant electrode location in the STN until stable sedation was achieved. We recorded the electrical activity, and calculated its root mean square (RMS) before, during, and after the propofol infusions.

RESULTS

The activity of 24 electrode trajectories was recorded in 16 patients. The RMS of STN activity decreased significantly after propofol administration in 18 of the 24 trajectories. The average normalized RMS decreased by 23.2%± 9.1% (mean ± SD) during propofol administration (P < 0.001), and returned to baseline 9.3 ± 4.0 minutes after it was stopped.

CONCLUSIONS

Propofol administration leads to a significant decrease of STN neuronal activity. Thus, it may interfere with MER identification of the STN borders. However, activity returns to baseline shortly after administration stops. Therefore, propofol can be safely used until shortly before MER for DBS.

Current steering to control the volume of tissue activated during deep brain stimulation

BACKGROUND

Over the last two decades, deep brain stimulation (DBS) has become a recognized and effective clinical therapy for numerous neurological conditions. Since its inception, clinical DBS technology has progressed at a relatively slow rate; however, advances in neural engineering research have the potential to improve DBS systems. One such advance is the concept of current steering, or the use of multiple stimulation sources to direct current flow through targeted regions of brain tissue. The goals of this study were to develop a theoretical understanding of the effects of current steering in the context of DBS, and use that information to evaluate the potential utility of current steering during stimulation of the subthalamic nucleus.

METHODS

We used finite element electric field models, coupled to multi-compartment cable axon models, to predict the volume of tissue activated (VTA) by DBS as a function of the stimulation parameter settings.

RESULTS

Balancing current flow through adjacent cathodes increased the VTA magnitude, relative to monopolar stimulation, and current steering enabled us to sculpt the shape of the VTA to fit a given anatomical target.

CONCLUSIONS

These results provide motivation for the integration of current steering technology into clinical DBS systems, thereby expanding opportunities to customize DBS to individual patients, and potentially enhancing therapeutic efficacy.

Deep brain stimulation does not silence neurons in subthalamic nucleus in Parkinson's patients

Two broad hypotheses have been advanced to explain the clinical efficacy of deep brain stimulation (DBS) in the subthalamic nucleus (STN) for treatment of Parkinson's disease. One is that stimulation inactivates STN neurons, producing a functional lesion. The other is that electrical stimulation activates the STN output, thus "jamming" pathological activity in basal ganglia-corticothalamic circuits. Evidence consistent with both concepts has been adduced from modeling and animal studies, as well as from recordings in patients. However, the stimulation parameters used in many recording studies have not been well matched to those used clinically. In this study, we recorded STN activity in patients with Parkinson's disease during stimulation delivered through a clinical DBS electrode using standard therapeutic stimulus parameters. A microelectrode was used to record the firing of a single STN neuron during DBS (3-5 V, 80-200 Hz, 90- to 200-micros pulses; 33 neurons/11 patients). Firing rate was unchanged during the stimulus trains, and the recorded neurons did not show prolonged (s) changes in firing rate on termination of the stimulation. However, a brief (approximately 1 ms), short-latency (6 ms) postpulse inhibition was seen in 10 of 14 neurons analyzed. A subset of neurons displayed altered firing patterns, with a predominant shift toward random firing. These data do not support the idea that DBS inactivates the STN and are instead more consistent with the hypothesis that this stimulation provides a null signal to basal ganglia-corticothalamic circuitry that has been altered as part of Parkinson's disease.

Glutamate receptors as therapeutic targets for Parkinson's disease

Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor symptoms including tremor and bradykinesia. The primary pathophysiology underlying PD is the degeneration of dopaminergic neurons of the substantia nigra pars compacta. Loss of these neurons causes pathological changes in neurotransmission in the basal ganglia motor circuit. The ability of ionotropic and metabotropic glutamate receptors to modulate neurotransmission throughout the basal ganglia suggests that these receptors may be targets for reversing the effects of altered neurotransmission in PD. Studies in animal models suggest that modulating the activity of these receptors may alleviate the primary motor symptoms of PD as well as side effects induced by dopamine replacement therapy. Moreover, glutamate receptor ligands may slow disease progression by delaying progressive dopamine neuron degeneration. Antagonists of NMDA receptors have shown promise in reversing motor symptoms, levodopa-induced dyskinesias, and neurodegeneration in preclinical PD models. The effects of drugs targeting AMPA receptors are more complex; while antagonists of these receptors exhibit utility in the treatment of levodopa-induced dyskinesias, AMPA receptor potentiators show promise for neuroprotection. Pharmacological modulation of metabotropic glutamate receptors (mGluRs) may hold even more promise for PD treatment due to the ability of mGluRs to fine-tune neurotransmission. Antagonists of mGluR5, as well as activators of group II mGluRs and mGluR4, have shown promise in several animal models of PD. These drugs reverse motor deficits in addition to providing protection against neurodegeneration. Glutamate receptors therefore represent exciting targets for the development of novel pharmacological therapies for PD.

Long-term suppression of tremor by deep brain stimulation of the ventral intermediate nucleus of the thalamus combined with pallidotomy in hemiparkinsonian patients

Deep brain stimulation (DBS) of the ventral intermediate nucleus of the thalamus (VIM) is a powerful surgical option in the treatment of tremor-predominant Parkinson's disease. However, its therapeutic efficacy depends on the tremor distribution. DBS is highly efficient in relief of distal appendicular tremor but not other types of tremor. Also, it is generally thought that DBS of the VIM has no significant beneficial effects on other motor symptoms of Parkinson's disease. We report two hemiparkinsonian patients, in whom unilateral VIM DBS combined with posteroventral pallidotomy produced long-lasting suppression of not only hand tremor, but also leg or jaw tremor and other motor symptoms.

Deep brain stimulation activation volumes and their association with neurophysiological mapping and therapeutic outcomes

OBJECTIVE

Despite the clinical success of deep brain stimulation (DBS) for the treatment of Parkinson's disease (PD), little is known about the electrical spread of the stimulation. The primary goal of this study was to integrate neuroimaging, neurophysiology and neurostimulation data sets from 10 patients with PD, unilaterally implanted with subthalamic nucleus (STN) DBS electrodes, to identify the theoretical volume of tissue activated (VTA) by clinically defined therapeutic stimulation parameters.

METHODS

Each patient specific model was created with a series of five steps: (1) definition of the neurosurgical stereotactic coordinate system within the context of preoperative imaging data; (2) entry of intraoperative microelectrode recording locations from neurophysiologically defined thalamic, subthalamic and substantia nigra neurons into the context of the imaging data; (3) fitting a three dimensional brain atlas to the neuroanatomy and neurophysiology of the patient; (4) positioning the DBS electrode in the documented stereotactic location, verified by postoperative imaging data; and (5) calculation of the VTA using a diffusion tensor based finite element neurostimulation model.

RESULTS

The patient specific models show that therapeutic benefit was achieved with direct stimulation of a wide range of anatomical structures in the subthalamic region. Interestingly, of the five patients exhibiting a greater than 40% improvement in their Unified PD Rating Scale (UPDRS), all but one had the majority of their VTA outside the atlas defined borders of the STN. Furthermore, of the five patients with less than 40% UPDRS improvement, all but one had the majority of their VTA inside the STN.

CONCLUSIONS

Our results are consistent with previous studies suggesting that therapeutic benefit is associated with electrode contacts near the dorsal border of the STN, and provide quantitative estimates of the electrical spread of the stimulation in a clinically relevant context.

[Anesthesia considerations for deep-brain stimulation in a patient with type-2 pantothenate kinase deficiency (Hallervorden-Spatz disease)]

Neurodegeneration associated with pantothenate kinase deficiency is an autosomal recessive condition caused by mutations in the pantothenate kinase 2 gene (PANK2). Clinical characteristics include progressive motor impairment and dementia. Medical treatment is limited and the dystonia tends to be refractory, making stereotactic surgery with placement of deep-brain electrodes an option that is being adopted with greater frequency in these patients. We report the case of a 32-year-old woman with severe dystonia associated with PANK2 protein deficiency. The patient was scheduled for stereotactic bilateral placement of electrodes in the medial globus pallidus, guided by computed tomography and under general anesthesia, to treat the debilitating dystonia and generalized stiffness associated with her condition. Anesthesia was maintained with propofol, rocuronium and remifentanil in perfusion during the intervention, which was uneventful. After the procedure, the patient was transferred to the intensive care unit and sedation was provided with remifentanil to allow slow, gradual emergence from anesthesia. The patient was discharged from hospital after placement of the implanted pulse generator, and subsequent follow-up showed improvement of the dystonia.

Treatment of levodopa-induced motor complications

Chronic levodopa treatment for Parkinson's disease patients is frequently associated with the development of motor complications such as end-of-dose wearing-off and dyskinesias. In this review, we provide an overview of the strategies available for dealing with these problems. Medical management includes manipulation of levodopa dosing to establish the optimum treatment schedule, improving levodopa absorption, catechol-O-methyl transferase-inhibition (COMT), Monoamine oxidase-B (MAO-B) inhibition, dopaminergic agonists, amantadine, and continuous dopaminergic infusions. Surgical procedures and particularly deep brain stimulation are also reviewed. It should be noted that none of these treatments has been shown to provide anti-parkinsonian efficacy that is greater than what can be achieved with levodopa. We highlight the importance of initiating therapy with a treatment strategy that reduces the risk that a Parkinson's disease patient will develop motor complications in the first place. Key Words: Advanced PD, dyskinesias, motor fluctuations, levodopa, dopamine agonists, COMT inhibitors, MAO-B inhibitors.

How do you treat motor complications in Parkinson's disease: Medicine, surgery, or both?

The motor complications associated with levodopa therapy, namely, fluctuations in motor response and dyskinesias, occur in the majority of Parkinson's disease patients. These complications can impair a patient's quality of life and even cause pronounced disability. "Off" states that result in freezing of gait and falling are disabling for many patients. Dyskinesias most commonly occur at peak dose and typically alternate with the wearing-off state. Once these problems appear, they usually persist, and the physician needs to make continual adjustments in medications to minimize these problems. Medical treatments should be attempted before treatments such as deep brain stimulation are considered because of the potential adverse effects that are associated with surgery. The timing of surgery, however, is also important because younger patients and less advanced patients tend to have a better outcome. There is thus a need for experienced and knowledgeable physicians and surgeons who are able to handle these motor complications. This review discusses available medications and surgical approaches, and their outcomes.

Neural interfaces at the nanoscale

Bioelectrical neural interfaces provide a means of recording the activity from the nervous system and delivering therapeutic stimulation to restore neurological function lost during disease or injury. Although neural interfaces have reached clinical utility, reducing the size of the bioelectrical interface to minimize damage to neural tissue and maximize selectivity has proven problematic. Nanotechnology may offer a means of interfacing with the nervous system with unprecedented specificity. Emergent applications of nanotechnology to neuroscience include molecular imaging, drug delivery across the BBB, scaffolds for neural regeneration and bioelectrical interfaces. In particular, carbon nanotubes offer the promises of material stability and low electrical impedance at physical dimensions that could have a significant impact on the future on neural interfaces. The purpose of this review is to present recent advances in carbon nanotube-based bioelectrical interfaces for the nervous system and discuss research challenges and opportunities.

Effects of nigral stimulation on locomotion and postural stability in patients with Parkinson's disease

The physiopathology of gait and balance disorders in Parkinson's disease patients is still poorly understood. Levodopa treatment and subthalamic nucleus (STN) stimulation improve step length and walking speed, with less effect on postural instability. These disorders have been linked to dysfunction of the descending basal ganglia outputs to brainstem structures. In this study, we evaluated the effects of stimulation of the substantia nigra pars reticulata (SNr), on locomotion and balance in Parkinson's disease patients. Biomechanical parameters and leg muscle activity were recorded during gait initiation in seven selected patients operated for bilateral STN stimulation, out of 204 stimulated patients, with one contact of each electrode located within the SNr. Step length, anteroposterior and vertical velocities of the centre of gravity were studied, with special reference to the subjects' ability to brake the centre of gravity fall before foot-contact, and compared to seven controls. In Parkinson's disease patients, five treatment conditions were tested: (i) no treatment, (ii) levodopa treatment, (iii) STN stimulation, (iv) SNr stimulation and (v) combined levodopa treatment and STN stimulation. The effects of these treatments on motor parkinsonian disability were assessed with the UPDRS III scale, separated into 'axial' (rising from chair, posture, postural stability and gait) and 'distal' scores. Whereas levodopa and/or STN stimulation improved 'axial' and 'distal' motor symptoms, SNr stimulation improved only the 'axial' symptoms. Compared to controls, untreated Parkinson's disease patients showed reduced step length and velocity, and poor braking just prior to foot-contact, with a decrease in both soleus (S) and anterior tibialis (AT) muscle activity. Step length and velocity significantly increased with levodopa treatment alone or in combination with STN stimulation in both natural and fast gait conditions, and with STN stimulation alone in the fast gait condition. Conversely, SNr stimulation had no significant effect on these measures in either condition. In the natural gait condition, no fall in the centre of gravity occurred as step length was low and active braking was unnecessary. In the fast gait condition, braking was improved with STN or SNr stimulation but not with levodopa treatment, with an increase in the stance leg S muscle activity. These results suggest that anteroposterior (length and velocity) and vertical (braking capacity) gait parameters are controlled by two distinct systems within the basal ganglia circuitry, representing respectively locomotion and balance. The SNr, a major basal ganglia output known to project to pontomesencephalic structures, is postulated as being particularly involved in balance control during gait.

ELECTRODE POSITION DETERMINED BY FUSED IMAGES OF PREOPERATIVE AND POSTOPERATIVE MAGNETIC RESONANCE IMAGING AND SURGICAL OUTCOME AFTER SUBTHALAMIC NUCLEUS DEEP BRAIN STIMULATION

OBJECTIVE

The electrode position is important to the surgical outcome after subthalamic nucleus (STN) deep brain stimulation (DBS). The aim of this study was to compare the surgical outcome of bilateral STN DBS with the electrode position estimated using fused magnetic resonance imaging.

METHODS

Bilateral STN DBS was performed in 60 patients with advanced Parkinson's disease. Patients were evaluated with the Unified Parkinson's Disease Rating Scale, Hoehn and Yahr staging, Schwab and England Activities of Daily Living, L-dopa equivalent dose, and Short Form-36 Health Survey before and at 3 and 6 months after surgery. Brain magnetic resonance imaging (1.5-T) was performed in 53 patients at 6 months after STN DBS. The electrode position was estimated in the fused pre- and postoperative magnetic resonance images and correlated with the surgical results.

RESULTS

As a group, the Unified Parkinson's Disease Rating Scale, Hoehn and Yahr staging, Schwab and England Activities of Daily Living, and Short Form-36 Health Survey scores improved at 3 and 6 months after STN DBS. The L-dopa equivalent dose decreased by 60% at 3 and 6 months after STN DBS. The electrode position was divided into 6 types according to its relationship to the STN and the red nucleus. Most off-medication Unified Parkinson's Disease Rating Scale motor subscale scores improved regardless of the type of electrode position. The off-medication speech subscale score improved only in the patients whose electrodes were correctly positioned in the STN bilaterally.

CONCLUSION

The electrodes accurately positioned in the STN led to improved speech after bilateral STN DBS. An effort should be made in each patient to document the electrode position to monitor surgical performance and to improve the surgical outcome after STN DBS.

Engineered antibody fragments with infinite affinity as reporter genes for PET imaging

Reporter gene imaging has great potential for many clinical applications including the tracking of transplanted cells and monitoring of gene therapy. However, currently available reporter gene-reporter probe combinations have significant limitations with the biodistribution of the reporter probe and the specificity and immunogenicity of the reporter gene. The objective of the present study was to evaluate a new approach for reporter gene imaging based on cell surface expression of antibody fragments that can irreversibly bind to radiometal chelates.

METHODS

We developed a new reporter gene, designated 1,4,7,10-tetraazacyclodocecane-N,N',N'',N'''-tetraacetic acid (DOTA) antibody reporter 1 (DAbR1), which consists of the single-chain Fv (scFv) fragment of the anti-Y-DOTA antibody 2D12.5/G54C fused to the human T cell CD4 transmembrane domain. The corresponding reporter probe is yttrium-(S)-2-(4-acrylamidobenzyl)-DOTA (*Y-AABD), a DOTA complex that binds irreversibly to a cysteine residue in the 2D12.5/G54C antibody. U-87 glioma cells were stably transfected with a DAbR1 expression vector. Binding of *Y-AABD to transfected and wild-type cells was studied in vitro and in vivo.

RESULTS

Flow cytometry revealed high expression of the DAbR1 protein on the cell surface of tumor cells. Uptake of 90Y-AABD in DAbR1-expressing human U-87 glioma xenografts was 6.2 (+/-1.3) percentage injected dose per gram (%ID/g) at 1 h and 4.9 (+/-0.62) %ID/g at 24 h after injection. The corresponding tumor-to-plasma ratios were 45:1 and 428:1, respectively. Uptake by U-87 tumors without the DAbR1 gene was 0.16 (+/-0.02) %ID/g at 1 h and 0.05 (+/-0.03) %ID/g at 24 h. PET images in mice with 86Y-AABD demonstrated intense uptake in DAbR1-positive tumors and low background activity in the liver.

CONCLUSION

These findings indicate that cell surface expression of radiometal chelate binding antibodies such as 2D12.5/G54C is a promising strategy for reporter gene imaging.

Submyelin potassium accumulation may functionally block subsets of local axons during deep brain stimulation: a modeling study

Deep brain stimulation has been used for over a decade to relieve the symptoms of Parkinson's disease, although its mechanism of action remains poorly understood. To better understand the direct effects of DBS on central neurons, a computational model of a myelinated axon has been constructed which includes the effects of K(+) accumulation within the peri-axonal space. Using best estimates of anatomic and electrogenic model parameters for in vivo STN axons, the model predicts a functional block along the axon due to K(+) accumulation in the submyelin space. The functional block occurs for a range of model parameters: high stimulation frequencies (>130 Hz); high extracellular K(+) concentrations (>3 x 10(-3) M); low maximum Na(+)/K(+) ATPase current densities (<0.026 A m(-2)); low diffusion coefficients for K(+) diffusion out of the submyelin space (<2.4 x 10(-9) m(2) s(-1)); small periaxonal space widths of the myelin attachment sections (<2.7 x 10(-9) m) and perinodal/internodal sections (<8.4 x 10(-9) m). These results suggest that therapeutic DBS of the STN likely results in a functional block for many STN axons, although a subset of STN axons may also be activated at the stimulating frequency.

[Deep brain stimulation and Parkinson's disease]

Ten years after the therapeutic revolution that emerged from the discovery of l-dopa, some pioneer teams led the rebirth of a new nonablative stereotaxical surgical treatment, which came from the interest of high frequency stimulation. Three targets were retained as the main location of a reversible functional inhibition: Vim, GPI and STN. The unilateral or bilateral stimulation, adjustable and possibly reversible, led to an exceptional medicosurgical collaboration, within expert dedicated places, based on the control of the Parkinson's disease's (PD) triad. The stimulation was initially applied to the most advanced forms of PD, after the medical control period of the motor performance, when the pejorative effects of the evolution settled and/or when side effects of the treatment appeared. Subsequently, the research of selection criterions and the strict control of the stereotaxical procedure during the per- and postoperatory period, with the collaboration of the patient and his family, progressively brought different teams to an earlier indication of this new treatment option, up to now reserved for fully medicosurgical concerted cases. Apparition of cognitive and postural decline as well as the known resistance stage to l-dopa tend to become a real contra-indication. Despite the initial relative weakness of controlled studies with limited number of patients, the multiplication of follow-up studies among high quality multicentric cohorts enabled the validation of practices respecting the differences related to the initial background of each different team. In Europe first, the prevalence of the subthalamic target is now to be generally admitted. A new objective is now imposing itself: trying to maintain the patient's quality of life, beyond the only motor benefit. The social adaptation of a young patient is now also taken into account. If this exemplary clinical research approach, efficient for a few highly selected patients, has not transformed the long-term prognostic of the PD, it will continue to improve the comprehension of this degenerative pathology and its extension. It still remains hopeful for the future in the actual constant technological progress, and that probably beyond the only PD.

[Analysis of application form for Parkinson's disease provided by the specific diseases treatment research program of Ministry of Health, Labour and Welfare of Japan]

The Ministry of Health, Labour and Welfare (MHLW) of Japan has funded special research programs to investigate etiology and treatment of intractable neurodegenerative diseases. Individual health-care expenditures for registered patients with Parkinson's disease (PD) (Hoehn and Yahr Stage 3-5) have been evaluated by the government. The total number of patients registered with a diagnosis of degenerative parkinsonism including PD, progressive supranuclear palsy (PSP) and corticobasal degeneration (CBD) was 75,026 in 2004. We analyzed the data from a survey of application forms completed by 23,058 PD patients, which had been entered into the MHLW's computer. The male to female ratio was 1: 1.47, and the mean ages of all patients at registration and at onset were 71.3 years and 62.7 years, respectively. Incidence of young-onset Parkinson's disease was 2.7% of all PD patients. The percentage of PD patients at Hoehn and Yahr Stage 3 was 48.8%, at Stage 4, 23.1%, and at Stage 5, 25.2%. About 60% of patients resided at home, whereas 20% were admitted into the hospital and 20% into a nursing home. The percentages of patients with diurnal fluctuations, dyskinesia and psychotic symptoms were 37.3%, 16.8% and 18.4%, respectively. Ages of patients at registration and at disease onset who presented with diurnal fluctuations and dyskinesia were typically younger and the duration of disease was longer than for those presented without them (p < 0.0001). Patients with psychotic symptoms were older and the duration of disease was longer than those without them (p < 0.0001). Ages of patients receiving ablative surgery were younger than those who received deep brain stimulation (DBS) (57.4 versus 63.1 years, p < 0.01). Approximately 70% of all the patients who underwent stereotactic surgeries were treated within 10 years from onset. The percentage of patients with feeding tube was 6.6%, and the age at registration was older (75.6 versus 71.0 years, p < 0.0001) and duration of disease was longer (11.0 versus 8.4 years, p < 0.0001) in patients with feeding tube than in patients with oral feeding. This is the first analysis of results from the survey of questionnaire for PD provided by MHLW.

Globus pallidus stimulation improves both motor and nonmotor aspects of quality of life in advanced Parkinson's disease

Our purpose was to measure the change in quality of life (QoL) following deep brain stimulation of the globus pallidus interna (GPi-DBS) in advanced Parkinson 's disease (PD), and identifies any associations with changes in motor features of the disease. Eleven patients (age range 54-69 years, 2 women) underwent GPi-DBS (4 unilateral, 7 bilateral). Outcome measures included assessment of PD-specific QoL (mean 8 months postsurgery) using the PDQ-39 questionnaire, and standard motor assessments. Off-period UPDRS III motor scores fell by (43 +/- 8)% (mean +/- SEM). Dyskinesia severity was reduced on the abnormal involuntary movement scale by (80 +/- 3)% and UPDRS IVa by (58 +/- 8)%. QoL as assessed by the PDQ39SI improved by (30 +/- 5)%, with significant improvements in mobility, activities of daily living, bodily discomfort, emotional wellbeing, communication, and cognitions subscales. Bilateral and unilateral groups demonstrated equivalent PDQ39SI improvement. QoL improvement was highly correlated with dyskinesia reduction but not reduction in UPDRS score or age at surgery. GPi-DBS markedly improves QoL in advanced PD. The impacts are broad and improve QoL domains not directly affected by the motor symptoms of the disease. Reduced dyskinesia plays a major role in the improvement of QoL in GPi-DBS treated patients.

Clinical cases where lesion therapy was chosen over deep brain stimulation

Deep brain stimulation (DBS) surgery has become the gold standard for treatment of select refractory cases of Parkinson disease and essential tremor. Despite the usefulness of DBS surgery in many cases, there remain situations where lesion therapy (subthalamotomy, pallidotomy or thalamotomy) may provide a reasonable alternative to DBS. We reviewed the University of Florida Institutional Review Board-approved database for movement disorders surgery and identified 286 DBS leads placed in 189 patients as well as 4 additional patients who had lesion therapy. In these 4 cases we reviewed the clinical presentations that resulted in a multidisciplinary team opting for lesion therapy over DBS. Lesion therapy represents a viable alternative and has several important advantages, including a decreased need for access to specialists and clinical follow-up, improved affordability, and a lower infection risk.

Pallidal burst activity during therapeutic deep brain stimulation

Theoretical and experimental analyses of deep brain stimulation (DBS) in the subthalamic nucleus (STN) show both excitatory and inhibitory effects on the neural elements surrounding the electrode. Given these observations, the mechanism underlying the therapeutic effect of STN DBS on parkinsonian motor signs remains under debate. One hypothesis suggests that abnormal levels of bursting activity in the pallidum play a key role in the development of parkinsonian motor signs and that STN DBS may exert its beneficial effect by modifying this type of activity. We quantified the changes in bursting activity of globus pallidus internus (GPi) and externus (GPe) neurons before and during ineffective (subtherapeutic) and effective (therapeutic) STN DBS in two monkeys rendered parkinsonian by the neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP). Compared to pre-stimulation control values, the population mean firing rate increased during therapeutic stimulation significantly in both GPe (from 41.7 Hz+/-2.8 to 71.4 Hz+/-7.8) and GPi (from 58.8 Hz+/-4.2 to 71.5 Hz+/-6.2). The burst rate, however, increased significantly in GPe (from 80.1 bursts/min+/-10.0 to 103.1 bursts/min+/-11.1) and decreased significantly in GPi (from 104.2 bursts/min+/-8.3 to 75.8 bursts/min+/-10.8). Although both animals showed improvement in parkinsonian motor signs, changes in rate and bursting activity in GPi were significant only in one animal. These data suggest that while changes in rate and bursting activity may contribute to the improvement in PD motor signs during STN DBS, one cannot explain the therapeutic effects of stimulation in all cases solely on changes in these parameters. Other physiological changes that contribute to its therapeutic effect must also occur.

Computational analysis of deep brain stimulation

Chronic, high-frequency electrical stimulation of subcortical brain structures (deep brain stimulation [DBS]) is an effective clinical treatment for several medically refractory neurological disorders. However, the clinical successes of DBS are tempered by the limited understanding of the response of neurons to applied electric fields and scientific definition of the therapeutic mechanisms of DBS remains elusive. In addition, it is presently unclear which electrode designs and stimulation parameters are optimal for maximum therapeutic benefit and minimal side effects. Detailed computer modeling of DBS has recently emerged as a powerful technique to enhance our understanding of the effects of DBS and to create a virtual testing ground for new stimulation paradigms. This review summarizes the fundamentals of neurostimulation modeling and provides an overview of some of the scientific contributions of computer models to the field of DBS. We then provide a prospective view on the application of DBS-modeling tools to augment the clinical utility of DBS and to design the next generation of DBS technology.

Disappearance of resting tremor after thalamic stroke involving the territory of the tuberothalamic artery

Disappearance of resting tremor was observed in a 76-year-old patient with Parkinson's disease after a contralateral thalamic infarct involving the territory of the tuberothalamic artery. Based on the analysis of surgical data of Parkinson's disease patients, this might be explained by the lesion of the ventral lateral nucleus, which is supplied by the inferolateral and tuberothalamic arteries. Thalamic infarction in the territory of the tuberothalamic artery as well as the inferolateral artery can produce amelioration of tremor.

Movement without dopamine: striatal dopamine is required to maintain but not to perform learned actions

The different populations of dopaminergic neurons located in the ventral mesencephalon have long been associated with distinct functional roles. The nigrostriatal projection is considered necessary for efficient motor performance, while the mesolimbocortical projection is usually associated with reward signalling. However, a number of recent studies in our laboratory suggest that the divergence between these two functions of dopamine is not as delineated as it may once have seemed. In these experiments, we have been developing improved behavioural methods for assessing the nature of the deficit in rats with unilateral dopamine lesions, as well as the efficacy of various experimental cell and gene therapies for Parkinson's disease. The behavioural task we selected is a lateralized nose-poking task in which rats are trained to respond to stimulus lights on either side of their heads. This task not only allows us to accurately measure aspects of motor performance, but, because it requires extensive training, it also allows us to assess aspects of motor learning. The concurrence of motor performance parameters (which are considered to be dependent on striatal dopamine) and motor learning parameters (which are thought to be dependent on mesolimbocortical reward signalling) within the same task has revealed some surprising consequences of dopamine lesions and neuroprotective/neuroreparative approaches to repair in rat models of Parkinson's disease. The data generated using this task suggest that the motor deficits that occur as a consequence of dopamine lesions may be downstream of a deficit in reward signalling. If so, this could redefine our perception of the role of dopamine in controlling motor function.

StimExplorer: deep brain stimulation parameter selection software system

StimExplorer is a Windows-based software package intended to aid the clinical implementation of deep brain stimulation (DBS) technology. StimExplorer uses detailed computer models to provide a quantitative description of the 3D volume of tissue activated (VTA) by DBS as a function of the stimulation parameters and electrode location within the brain. The stimulation models are tailored to the individual patient by importing their magnetic resonance imaging (MRI) data and interactively scaling 3D anatomical nuclei to fit the patient anatomy. The user also inputs the DBS electrode orientation, location, and impedance data. The software then provides theoretically optimal stimulation parameter suggestions, intended to represent the start point for clinical programming of the DBS device. The software system is packaged into a clinician-friendly graphical user interface that allows for simultaneous interactive 3D visualization of the MRI, anatomical nuclei, DBS electrode, and VTAs for a wide range of stimulation parameter settings (contact, impedance, voltage, pulse width, and frequency). The goals of the StimExplorer system are to educate clinicians on the impact of stimulation parameter manipulation, and improve therapeutic outcomes by providing quantitative anatomical and electrical information useful for customizing DBS to individual patients.

Treadmill exercise suppresses nigrostriatal dopaminergic neuronal loss in 6-hydroxydopamine-induced Parkinson's rats

In Parkinson's disease, the progressive loss of dopaminergic neurons in the pars compacta of the substantia nigra leads to debilitating motor dysfunction. In the present study, we investigated the effects of treadmill exercise on the dopaminergic neuronal cell death in the substantia nigra and on the dopaminergic fiber loss in the striatum of Parkinson's rats. Parkinson's rats were made by injecting 6-hydroxydopamine into the striatum with using a stereotaxic instrument. The rats in the exercise groups were put on the treadmill to run for 30 min once a day for 14 consecutive days after 6-hydroxydopamine administration into the striatum. Two weeks after the intrastriatal injection of 6-hydroxydopamine, the rats without treadmill exercise displayed rotational asymmetry following injection of apomorphine (0.5 mg/kg, s.c.). In contrast, the rats undergoing treadmill exercise showed a significant reduction of rotational asymmetry. Analysis via immunohistochemistry for the tyrosine hydroxylase expression revealed a substantial loss of cell bodies in the substantia nigra and their projected fibers in the striatum ipsilateral to the lesion following 6-hydroxydapamine injection into the striatum. However, treadmill running enhanced the survival of dopaminergic neurons in the substantia nigra and also their fibers projecting into the striatum. The results of the present study show that treadmill exercise may provide therapeutic value for the treatment of Parkinson's disease patients.

Deep brain stimulation and the role of the neuropsychologist

Deep brain stimulation (DBS) now plays an important role in the treatment of Parkinson's disease, tremor, and dystonia. DBS may also have a role in the treatment of other disorders such as obsessive-compulsive disorder, Tourette's syndrome, and depression. The neuropsychologist plays a crucial role in patient selection, follow-up, and management of intra-operative and post-operative effects (Pillon, 2002; Saint-Cyr & Trepanier, 2000). There is now emerging evidence that DBS can induce mood, cognitive, and behavioral changes. These changes can have dramatic effects on patient outcome. There have been methodological problems with many of the studies of DBS on mood, cognition, and behavior. The neuropsychologist needs to be aware of these issues when following up patients, and constructing future studies. Additionally, this article will review all aspects of the DBS procedure that can result in mood, cognitive, and behavioral effects and what role(s) the neuropsychologist should play in screening and follow-up.

Neuroethical responsibilities

Neuroscience represents a dynamic area of biomedical research where neuroethical responsibilities for researchers are emerging. This paper is the companion piece to the French-language one also published in this issue of the Canadian Journal of Neurological Sciences. It serves as a review of recent advances in neuroethics through the lens of three cases: (1) incidental finding of anomalies in neuroimaging research; (2) creation of neurotechnologies that can lead to cognitive enhancement, and (3) responsible communication of research results. We propose and discuss a multidimensional framework of neuroethical responsibilities to help tackle these issues. The framework reiterates the fundamental role of scientific integrity, puts in the foreground social responsibilities pertaining to the eventual use of neuroscience knowledge, and highlights self-reflection in research and training of researchers.

Globus pallidus stimulation in advanced Parkinson’s disease

Deep brain stimulation (DBS) of the globus pallidus internus (GPi) has become an accepted therapeutic modality in selected Parkinson's disease (PD) patients with severe levodopa-induced dyskinesias (LID) and on-off motor fluctuations. In comparison to subthalamic nucleus DBS there is a paucity of data on GPi DBS outcomes. We present our experience with a group of 20 PD patients (9 unilateral, 11 bilateral) who underwent GPi stimulation. PD motor symptoms were assessed using the Unified Parkinson's Disease Rating Scale (UPDRS) part III scores and subscores, and dyskinesia using the Abnormal Involuntary Movement Scale (AIMS), UPDRS part IVa, and clinical global impression (CGI). At mean follow-up time of 7 months, bilateral stimulation reduced off-period motor scores by a mean of 46% and on-period motor scores by 18%. Unilateral stimulation reduced off-period motor scores by 18%. Dyskinesia severity was reduced by 76%, which was maintained after a mean follow-up time of 35 months. Antiparkinsonian medication dosage was unchanged. No major adverse effects were seen. Unilateral and bilateral GPi DBS provides lasting benefit in PD patients with severe LID. Beneficial effects on off-period motor symptoms are greater with bilateral stimulation; however, with maintenance of dopaminergic medication, unilateral procedures can also provide important and sustained benefits.

The influence of group III metabotropic glutamate receptor stimulation by (1S,3R,4S)-1-aminocyclo-pentane-1,3,4-tricarboxylic acid on the parkinsonian-like akinesia and striatal proenkephalin and prodynorphin mRNA expression in rats

Group III metabotropic glutamate receptors (mGluRs) are widely distributed in the basal ganglia, especially on the terminals of pathways which seem to be overactive in Parkinson's disease. The aim of the present study was to determine whether (1S,3R,4S)-1-aminocyclo-pentane-1,3,4-tricarboxylic acid (ACPT-1), an agonist of group III mGluRs, injected bilaterally into the globus pallidus (GP), striatum or substantia nigra pars reticulata (SNr), can attenuate the haloperidol-induced catalepsy in rats, and whether that effect was related to modulation of proenkephalin (PENK) or prodynorphin (PDYN) mRNA expression in the striatum. Administration of ACPT-1 (0.05-1.6 microg/0.5 microl/side) caused a dose-and-structure-dependent decrease in the haloperidol (0.5 mg/kg i.p. or 1.5 mg/kg s.c.)-induced catalepsy whose order was as follows: GP>striatum>SNr. ACPT-1, given alone to any of those structures, induced no catalepsy in rats. Haloperidol (3 x 1.5 mg/kg s.c.) significantly increased PENK mRNA expression in the striatum, while PDYN mRNA levels were not affected by that treatment. ACPT-1 (3 x 1.6 microg/0.5 microl/side) injected into the striatum significantly attenuated the haloperidol-increased PENK mRNA expression, whereas administration of that compound into the GP or SNr did not influence the haloperidol-increased striatal PENK mRNA levels. Our results demonstrate that stimulation of group III mGluRs in the striatum, GP or SNr exerts antiparkinsonian-like effects in rats. The anticataleptic effect of intrastriatally injected ACPT-1 seems to correlate with diminished striatal PENK mRNA expression. However, since the anticataleptic effect produced by intrapallidal and intranigral injection of ACPT-1 is not related to a simultaneous decrease in striatal PENK mRNA levels, it is likely that a decrease in enkephalin biosynthesis is not a necessary condition to obtain an antiparkinsonian effect.

Neuropsychological performance following staged bilateral pallidal or subthalamic nucleus deep brain stimulation for Parkinson's disease

Deep brain stimulation (DBS) has the potential to significantly reduce motor symptoms in advanced Parkinson's disease (PD). Controversy remains about non-motor effects of DBS and the relative advantages of treatment at two brain targets, the globus pallidus internus (GPi) and the subthalamic nucleus (STN). We investigated effects of DBS on neuropsychological functioning in 42 patients with advanced PD randomly assigned to receive staged bilateral DBS surgery of either the GPi or STN. Patients underwent neuropsychological assessment prior to and 6 months after unilateral surgery. Twenty-nine subsequently underwent surgery to the contralateral side and completed a second follow-up neuropsychological evaluation 15 months later. Unilateral treatment resulted in small but statistically significant reductions in performance on several measures, including verbal fluency and working memory. A similar pattern was observed after bilateral treatment. Reductions in verbal associative fluency were significant only after left-sided treatment. There were few significant differences related to treatment at the two surgical targets. Supplementary analyses suggested that decrements in select neuropsychological domains following DBS are unrelated to age or post-surgical reduction in dopaminergic medication dose. Findings are discussed with reference to possible causes of neuropsychological decline and the need for further controlled studies of specific neuropsychological effects of DBS.

IMPLANTATION OF ELECTRODES FORDEEP BRAIN STIMULATION OF THE SUBTHALAMIC NUCLEUS IN ADVANCED PARKINSON'S DISEASE WITH THE AID OF INTRAOPERATIVE MICRORECORDING UNDERGENERAL ANESTHESIA

OBJECTIVE

Deep brain stimulation (DBS) is widely accepted in the treatment of advanced Parkinson's disease (PD) and other movement disorders. The standard implantation procedure is performed under local anesthesia (LA). Certain groups of patients may not be eligible for surgery under LA because of clinical reasons, such as massive fear, reduced cooperativity, or coughing attacks. Microrecording (MER) has been shown to be helpful in DBS surgery. The purpose of this study was to evaluate the feasibility of MERfor DBS surgery under general anesthesia (GA) and to compare the data of intraoperative MERas well as the clinical data with that of the current literature of patients undergoing operation under LA.

CLINICAL PRESENTATION

The data of nine patients with advanced PD (mean Hoehn and Yahr status, 4.2) who were operated with subthalamic nucleus (STN) DBS under GA, owing to certain clinical circumstances ruling out DBS under LA, were retrospectively analyzed. All operations were performed under analgosedation with propofol or remifentanil and intraoperative MER. For MER, remifentanil was ceased completely and propofol was lowered as far as possible.

INTERVENTION

The STN could be identified intraoperatively in all patients with MER. The typical bursting pattern was identified, whereas a widening of the baseline noise could not be as adequately detected as in patients under LA. The daily off phases of the patients were reduced from 50 to 17%, whereas the Unified Parkinson's Disease Rating Scale III score was reduced from 43 (preoperative, medication off) to 19 (stimulation on, medication off) and 12 (stimulation on, medication on). Two patients showed a transient neuropsychological deterioration after surgery, but both also had preexisting episodes of disorientation. One implantable pulse generator infection was noticed. No further significant clinical complications were observed.

CONCLUSION

STN surgery for advanced PD with MERguidance is possible with good clinical results under GA. Intraoperative MERof the STN region can be performed under GA with a special anesthesiological protocol. In this setting, the typical STN bursting pattern can be identified, whereas the typical widening of the background noise baseline while entering the STN region is obviously absent. This technique may enlarge the group of patients eligible for STN surgery. Although the clinical improvements and parameter settings in this study were within the range of the current literature, further randomized controlled studies are necessary to compare the results of STN DBS under GA and LA, respectively.

Dopamine replacement therapy does not restore the full spectrum of normal pallidal activity in the 1-methyl-4-phenyl-1,2,3,6-tetra-hydropyridine primate model of Parkinsonism

Current physiological studies emphasize the role of neuronal oscillations and synchronization in the pathophysiology of Parkinson's disease; however, little is known about their specific roles in the neuronal substrate of dopamine replacement therapy (DRT). We investigated oscillatory activity and correlations throughout the different states of levodopa-naive parkinsonism as well as "Off-On" and dyskinetic states of DRT in the external globus pallidum (GPe) of tremulous (vervet) and rigid-akinetic (macaque) monkeys and in the internal globus pallidum (GPi) of the vervet monkey. We found that, although oscillatory activity of cells and interneuronal correlation in both pallidal segments increases after induction of parkinsonism with 1-methyl-4-phenyl-1,2,3,6-tetra-hydropyridine (MPTP) and decreases in response to DRT, important differences exist between the two pallidal segments. In the GPi, the fraction of oscillatory cells and relative power of oscillations were significantly higher than in the GPe, and the dominant frequency was within the range of 7.5-13.5 Hz compared with a range of 4.5-7.5 Hz within the GPe. The interneuronal correlations were mostly oscillatory in the GPi, whereas at least half are non-oscillatory in the GPe. We demonstrate that the tremor characteristics after exposure to DRT do not resemble those of the normal or the levodopa-naive state. Moreover, although DRT reverses the MPTP-induced neuronal changes (rate, pattern, and pairwise correlations), the balance between GPe and GPi fails to restore. We therefore suggest that this imbalance reflects additional abnormal organization of the basal ganglia networks in response to dopamine replacement and may constitute the physiological substrate of the limitations and side effects of chronic DRT.

Cognitive sequelae of subthalamic nucleus deep brain stimulation in Parkinson's disease: a meta-analysis

BACKGROUND

Deep brain stimulation of the subthalamic nucleus (STN DBS) is an increasingly common treatment for Parkinson's disease. Qualitative reviews have concluded that diminished verbal fluency is common after STN DBS, but that changes in global cognitive abilities, attention, executive functions, and memory are only inconsistently observed and, when present, often nominal or transient. We did a quantitative meta-analysis to improve understanding of the variability and clinical significance of cognitive dysfunction after STN DBS.

METHODS

We searched MedLine, PsycLIT, and ISI Web of Science electronic databases for articles published between 1990 and 2006, and extracted information about number of patients, exclusion criteria, confirmation of target by microelectrode recording, verification of electrode placement via radiographic means, stimulation parameters, assessment time points, assessment measures, whether patients were on levodopa or dopaminomimetics, and summary statistics needed for computation of effect sizes. We used the random-effects meta-analytical model to assess continuous outcomes before and after STN DBS.

FINDINGS

Of 40 neuropsychological studies identified, 28 cohort studies (including 612 patients) were eligible for inclusion in the meta-analysis. After adjusting for heterogeneity of variance in study effect sizes, the random effects meta-analysis revealed significant, albeit small, declines in executive functions and verbal learning and memory. Moderate declines were only reported in semantic (Cohen's d 0.73) and phonemic verbal fluency (0.51). Changes in verbal fluency were not related to patient age, disease duration, stimulation parameters, or change in dopaminomimetic dose after surgery.

INTERPRETATION

STN DBS, in selected patients, seems relatively safe from a cognitive standpoint. However, difficulty in identification of factors underlying changes in verbal fluency draws attention to the need for uniform and detailed reporting of patient selection, demographic, disease, treatment, surgical, stimulation, and clinical outcome parameters.

Responsabilités Neuroéthiques

Neuroscience represents a dynamic area of biomedical research where neuroethical responsibilities for researchers are emerging. This paper is the companion piece to the English-language one also published in this issue of the Canadian Journal of Neurological Sciences. It serves as a review of recent advances in neuroethics through the lens of three cases: (1) incidental finding of anomalies in neuroimaging research; (2) creation of neurotechnologies that can lead to cognitive enhancement, and (3) responsible communication of research results. We propose and discuss a multidimensional framework of neuroethical responsibilities to help tackle these issues. The framework reiterates the fundamental role of scientific integrity, puts in the foreground social responsibilities pertaining to the eventual use of neuroscience knowledge, and highlights self-reflection in research and training of researchers.