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Abstract
This article overviews the surgical options for hypertonia management in cerebral palsy, both spasticity and dystonia. We review the history and use of intrathecal baclofen. We contrast its use with the indications for selective dorsal rhizotomy and review how it is the optimal technique to lower tone in the ambulatory spastic diplegic patient with cerebral palsy. This article reviews the advent of deep brain stimulation, with an emphasis on selection criteria and expected outcomes in this population. The article reviews the principles and use of selective peripheral neurotomy as it is applied to focal spasticity not requiring systemic tone reduction.
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Affiliation(s)
- Sruthi P Thomas
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, 6701 Fannin Street, Suite 1280, Houston, TX 77030, USA; Department of Neurosurgery, Section of Pediatric Neurosurgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA. https://twitter.com/ThomasMDPhD
| | - Angela P Addison
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA
| | - Daniel J Curry
- Department of Neurosurgery, Section of Pediatric Neurosurgery, Baylor College of Medicine, 6701 Fannin Street, Suite 1230, Houston, TX 77030, USA.
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Bullard AJ, Hutchison BC, Lee J, Chestek CA, Patil PG. Estimating Risk for Future Intracranial, Fully Implanted, Modular Neuroprosthetic Systems: A Systematic Review of Hardware Complications in Clinical Deep Brain Stimulation and Experimental Human Intracortical Arrays. Neuromodulation 2019; 23:411-426. [DOI: 10.1111/ner.13069] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 08/05/2019] [Accepted: 09/10/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Autumn J. Bullard
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
| | | | - Jiseon Lee
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
| | - Cynthia A. Chestek
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
- Department of Electrical Engineering and Computer Science University of Michigan Ann Arbor MI USA
| | - Parag G. Patil
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
- Department of Neurosurgery University of Michigan Medical School Ann Arbor MI USA
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Tsuboi T, Wong JK, Okun MS, Ramirez-Zamora A. Quality of life outcomes after deep brain stimulation in dystonia: A systematic review. Parkinsonism Relat Disord 2019; 70:82-93. [PMID: 31767450 DOI: 10.1016/j.parkreldis.2019.11.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 11/07/2019] [Accepted: 11/15/2019] [Indexed: 12/16/2022]
Abstract
Dystonia is an incurable movement disorder which can cause not only physical but also mental problems, leading to impaired health-related quality of life (HRQoL). For patients with dystonia refractory to medical treatment, deep brain stimulation (DBS) is a well-established surgical treatment. The objective of this systematic review is to provide a better understanding of HRQoL outcomes after DBS for dystonia. A search of the literature was conducted using Medline (PubMed), Embase, and Cochrane Library databases in May 2019. HRQoL outcomes after DBS along with motor outcomes were reported in a total of 36 articles involving 610 patients: 21 articles on inherited or idiopathic isolated dystonia, 5 on tardive dystonia, 3 on cerebral palsy, 2 on myoclonus-dystonia, 1 on X-linked dystonia-parkinsonism, and 3 on mixed cohorts of different dystonia subtypes. DBS improved motor symptoms in various subtypes of dystonia. Most studies on patients with inherited or idiopathic isolated dystonia showed significant improvement in physical QoL, whereas gains in mental QoL were less robust and likely related to the complexity of associated neuropsychiatric problems. HRQoL outcomes beyond 5 years remain scarce. Although the studies on patients with other subtypes of dystonia also demonstrated improvement in HRQoL after DBS, the interpretation is difficult because of a limited number of articles with small cohorts. Most articles employed generic measures (e.g. Short Form Health Survey-36) and this highlights the critical need to develop and to utilize sensitive and disease-specific HRQoL measures. Finally, long-term HRQoL outcomes and predictors of HRQoL should also be clarified.
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Affiliation(s)
- Takashi Tsuboi
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA; Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
| | - Joshua K Wong
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
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Low HL, Alexander SK, Misbahuddin A, Gillett GT. Posterior subthalamic area deep brain stimulation for treatment of tremor and dystonia in Wilson's disease. Brain Stimul 2019; 12:1304-1306. [DOI: 10.1016/j.brs.2019.05.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 05/09/2019] [Accepted: 05/13/2019] [Indexed: 11/30/2022] Open
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55
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The neurobiological basis for novel experimental therapeutics in dystonia. Neurobiol Dis 2019; 130:104526. [PMID: 31279827 DOI: 10.1016/j.nbd.2019.104526] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/13/2019] [Accepted: 07/03/2019] [Indexed: 12/17/2022] Open
Abstract
Dystonia is a movement disorder characterized by involuntary muscle contractions, twisting movements, and abnormal postures that may affect one or multiple body regions. Dystonia is the third most common movement disorder after Parkinson's disease and essential tremor. Despite its relative frequency, small molecule therapeutics for dystonia are limited. Development of new therapeutics is further hampered by the heterogeneity of both clinical symptoms and etiologies in dystonia. Recent advances in both animal and cell-based models have helped clarify divergent etiologies in dystonia and have facilitated the identification of new therapeutic targets. Advances in medicinal chemistry have also made available novel compounds for testing in biochemical, physiological, and behavioral models of dystonia. Here, we briefly review motor circuit anatomy and the anatomical and functional abnormalities in dystonia. We then discuss recently identified therapeutic targets in dystonia based on recent preclinical animal studies and clinical trials investigating novel therapeutics.
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56
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Direct comparison of oscillatory activity in the motor system of Parkinson’s disease and dystonia: A review of the literature and meta-analysis. Clin Neurophysiol 2019; 130:917-924. [DOI: 10.1016/j.clinph.2019.02.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 01/29/2019] [Accepted: 02/16/2019] [Indexed: 12/12/2022]
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Wu YS, Ni LH, Fan RM, Yao MY. Meta-Regression Analysis of the Long-Term Effects of Pallidal and Subthalamic Deep Brain Stimulation for the Treatment of Isolated Dystonia. World Neurosurg 2019; 129:e409-e416. [PMID: 31146039 DOI: 10.1016/j.wneu.2019.05.165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 05/18/2019] [Accepted: 05/20/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVE The globus pallidus internus (GPi) and subthalamic nucleus (STN) are therapeutic targets for deep brain stimulation (DBS) in the treatment of isolated dystonia. We conducted a meta-regression analysis on long-term studies of bilateral DBS in the GPi and STN to compare the relative effects of the 2 approaches. METHODS We systematically searched the PubMed, Embase, and Cochrane Controlled Register of Trials databases to identify studies reporting the treatment outcomes of GPi DBS and STN DBS for isolated dystonia. The primary outcome measure was the change in the Burke-Fahn-Marsden dystonia rating scale movement score between the baseline and follow-up evaluations. We performed a regression analysis using a random effects model. RESULTS A total of 42 follow-up evaluations (30 for GPi and 12 for STN) nested in 19 studies (16 of GPi and 3 of STN) were included in our analysis. The results from univariate regression analysis suggested that shorter disease duration and STN stimulation were associated with a greater standardized change in the Burke-Fahn-Marsden dystonia rating scale movement score. On combining the factors into 1 model, only the disease duration remained significant. The regression analysis results of the GPi and STN subgroups revealed more persistent improvement after STN stimulation. CONCLUSIONS A shorter disease duration correlated positively with better DBS outcomes. The STN appeared to be an optimized stimulation target for the treatment of isolated dystonia, although randomized controlled trials are needed to compare the treatment efficacy of GPi DBS and STN DBS.
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Affiliation(s)
- Yi-Song Wu
- Department of Neurology, Xinyang Central Hospital, Xinyang, China.
| | - Lin-Hui Ni
- Department of Neurology, Xinyang Central Hospital, Xinyang, China; Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ru-Meng Fan
- Department of Neurology, Xinyang Central Hospital, Xinyang, China; Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ming-Yang Yao
- Department of Neurology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China; Department of Cardiology, Nanyang Central hospital, Nanyang, China
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58
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Mittal SO, Lenka A, Jankovic J. Cervical dystonia: an update on therapeutics. Expert Opin Orphan Drugs 2019. [DOI: 10.1080/21678707.2019.1613978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Shivam Om Mittal
- , Parkinson's Disease and Movement Disorders Clinic, Cleveland Clinic, Abu Dhabi, UAE
| | - Abhishek Lenka
- Department of Neurology, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Joseph Jankovic
- Department of Neurology, Baylor College of Medicine, Parkinson’s Disease Center and Movement Disorders Clinic, Houston, TX, USA
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59
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Iannone A, Allam N, Brasil-Neto JP. Safety of transcranial direct current stimulation in a patient with deep brain stimulation electrodes. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:174-178. [PMID: 30970130 DOI: 10.1590/0004-282x20190019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 12/04/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Transcranial direct current stimulation (tDCS) has been investigated in movement disorders, making it a therapeutic alternative in clinical settings. However, there is still no consensus on the most appropriate treatment protocols in most cases, and the presence of deep brain stimulation (DBS) electrodes has been regarded as a contraindication to the procedure. We recently studied the effects of cerebellar tDCS on a female patient already undergoing subthalamic nucleus deep brain stimulation (STN-DBS) for generalized dystonia. She also presented with chronic pain and depression. With STN-DBS, there was improvement of dystonia, and botulinum toxin significantly reduced pain. However, depressive symptoms were worse after STN-DBS surgery. METHODS Neuromodulation with 2 mA anodal cerebellar tDCS was initiated, targeting both hemispheres in each daily 30 minute session: 15 minutes of left cerebellar stimulation followed by 15 minutes of right cerebellar stimulation. The DBS electrodes were in place and functional, but the current was turned off during tDCS. RESULTS Although our goal was to improve dystonic movements, after 10 tDCS sessions there was also improvement in mood with normalization of Beck Depression Inventory scores. There were no complications in spite of the implanted STN-DBS leads. CONCLUSION Our results indicate that tDCS is safe in patients with DBS electrodes and may be an effective add-on neuromodulatory tool in the treatment of potential DBS partial efficacy in patients with movement disorders.
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Affiliation(s)
- Aline Iannone
- Universidade de Brasília, Laboratório de Neurociência e Comportamento, Instituto de Biologia, Brasília DF, Brasil
| | - Nasser Allam
- Universidade de Brasília, Laboratório de Neurociência e Comportamento, Instituto de Biologia, Brasília DF, Brasil
| | - Joaquim P Brasil-Neto
- Universidade de Brasília, Departamento de Ciências Fisiológicas, Instituto de Biologia, Brasília DF, Brasil
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60
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Dietz N, Neimat J. Neuromodulation: Deep Brain Stimulation for Treatment of Dystonia. Neurosurg Clin N Am 2019; 30:161-168. [PMID: 30898268 DOI: 10.1016/j.nec.2018.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Dystonia is a heterogeneous, hyperkinetic movement disorder with sustained or intermittent abnormal postures, hyperkinetic muscle contractions, or repetitive movements. Classification of dystonia involves 2 axes: axis I and axis II, defining relevant clinical features and etiology, respectively. Medical therapy varies based on subtype and includes intramuscular botulinum toxin injections and oral anticholinergic pharmaceuticals. Deep brain stimulation became widely incorporated in 1999 after several landmark studies and has been effectively used in targets of the thalamus, pallidum, and subthalamic nucleus. New insights into pathophysiology of dystonia and genetic analysis continue to guide surgical technique toward ever-effective treatment.
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Affiliation(s)
- Nicholas Dietz
- Department of Neurosurgery, University of Louisville, School of Medicine, 200 Abraham Flexner Highway, Louisville, KY 40202, USA
| | - Joseph Neimat
- Department of Neurosurgery, University of Louisville, School of Medicine, 200 Abraham Flexner Highway, Louisville, KY 40202, USA.
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61
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Woo KA, Lee JY, Jeon B. Familial Spinocerebellar Ataxia Type 2 Parkinsonism Presenting as Intractable Oromandibular Dystonia. Tremor Other Hyperkinet Mov (N Y) 2019; 9:611. [PMID: 30809419 PMCID: PMC6387793 DOI: 10.7916/d8087pb6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 12/10/2018] [Indexed: 11/25/2022] Open
Affiliation(s)
- Kyung Ah Woo
- Department of Neurology, Seoul National University Hospital, Seoul, KR,Department of Neurology, Seoul National University Boramae Hospital, Seoul, KR
| | - Jee-Young Lee
- Department of Neurology, Seoul National University Boramae Hospital, Seoul, KR,Seoul National University College of Medicine, Seoul, KR
| | - Beomseok Jeon
- Department of Neurology, Seoul National University Hospital, Seoul, KR,Seoul National University College of Medicine, Seoul, KR,*To whom correspondence should be addressed. E-mail:
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Eisinger RS, Cernera S, Gittis A, Gunduz A, Okun MS. A review of basal ganglia circuits and physiology: Application to deep brain stimulation. Parkinsonism Relat Disord 2019; 59:9-20. [PMID: 30658883 DOI: 10.1016/j.parkreldis.2019.01.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/07/2019] [Accepted: 01/09/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Drawing on the seminal work of DeLong, Albin, and Young, we have now entered an era of basal ganglia neuromodulation. Understanding, re-evaluating, and leveraging the lessons learned from neuromodulation will be crucial to facilitate an increased and improved application of neuromodulation in human disease. METHODS We will focus on deep brain stimulation (DBS) - the most common form of basal ganglia neuromodulation - however, similar principles can apply to other neuromodulation modalities. We start with a brief review of DBS for Parkinson's disease, essential tremor, dystonia, and Tourette syndrome. We then review hallmark studies on basal ganglia circuits and electrophysiology resulting from decades of experience in neuromodulation. The organization and content of this paper follow Dr. Okun's Lecture from the 2018 Parkinsonism and Related Disorders World Congress. RESULTS Information gained from neuromodulation has led to an expansion of the basal ganglia rate model, an enhanced understanding of nuclei dynamics, an emerging focus on pathological oscillations, a revision of the tripartite division of the basal ganglia, and a redirected focus toward individualized symptom-specific stimulation. Though there have been many limitations of the basal ganglia "box model," the construct provided the necessary foundation to advance the field. We now understand that information in the basal ganglia is encoded through complex neural responses that can be reliably measured and used to infer disease states for clinical translation. CONCLUSIONS Our deepened understanding of basal ganglia physiology will drive new neuromodulation strategies such as adaptive DBS or cell-specific neuromodulation through the use of optogenetics.
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Affiliation(s)
- Robert S Eisinger
- Department of Neuroscience, University of Florida, Gainesville, FL, USA
| | - Stephanie Cernera
- Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA.
| | - Aryn Gittis
- Biological Sciences and Center for Neural Basis of Cognition, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Aysegul Gunduz
- Department of Neuroscience, University of Florida, Gainesville, FL, USA; Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA; Department of Neurology, Fixel Center for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Department of Neuroscience, University of Florida, Gainesville, FL, USA; Department of Neurology, Fixel Center for Neurological Diseases, University of Florida, Gainesville, FL, USA
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63
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Post-operative electrode location and clinical efficacy of subthalamic nucleus deep brain stimulation in Meige syndrome. Parkinsonism Relat Disord 2019; 58:40-45. [DOI: 10.1016/j.parkreldis.2018.05.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 04/07/2018] [Accepted: 05/14/2018] [Indexed: 12/14/2022]
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64
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Wagle Shukla A, Ostrem JL, Vaillancourt DE, Chen R, Foote KD, Okun MS. Physiological effects of subthalamic nucleus deep brain stimulation surgery in cervical dystonia. J Neurol Neurosurg Psychiatry 2018; 89:1296-1300. [PMID: 29326293 PMCID: PMC7498178 DOI: 10.1136/jnnp-2017-317098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 11/21/2017] [Accepted: 12/26/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Subthalamic nucleus deep brain stimulation (STN DBS) surgery is clinically effective for treatment of cervical dystonia; however, the underlying physiology has not been examined. We used transcranial magnetic stimulation (TMS) to examine the effects of STN DBS on sensorimotor integration, sensorimotor plasticity and motor cortex excitability, which are identified as the key pathophysiological features underlying dystonia. METHODS TMS paradigms of short latency afferent inhibition (SAI) and long latency afferent inhibition (LAI) were used to examine the sensorimotor integration. Sensorimotor plasticity was measured with paired associative stimulation paradigm, and motor cortex excitability was examined with short interval intracortical inhibition and intracortical facilitation. DBS was turned off and on to record these measures. RESULTS STN DBS modulated SAI and LAI, which correlated well with the acute clinical improvement. While there were no changes seen in the motor cortex excitability, DBS was found to normalise the sensorimotor plasticity; however, there was no clinical correlation. CONCLUSION Modulation of sensorimotor integration is a key contributor to clinical improvement with acute stimulation of STN. Since the motor cortex excitability did not change and the change in sensorimotor plasticity did not correlate with clinical improvement, STN DBS demonstrates restricted effects on the underlying physiology. CLINICAL TRIAL REGISTRATION NCT01671527.
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Affiliation(s)
| | - Jill L Ostrem
- Department of Neurology, University of California, San Francisco, California, USA
| | - David E Vaillancourt
- Department of Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Robert Chen
- University Health Network, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kelly D Foote
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Michael S Okun
- Department of Neurology, University of Florida, Gainesville, Florida, USA
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Liu Y, Zhu G, Jiang Y, Wang X, Chen Y, Meng F, Zhang K, Yang A, Liu H, Zhang X, Zhang J. Comparison of Short-Term Stimulation of the Globus Pallidus Interna and Subthalamic Nucleus for Treatment of Primary Dystonia. World Neurosurg 2018; 123:e211-e217. [PMID: 30481618 DOI: 10.1016/j.wneu.2018.11.137] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 11/14/2018] [Accepted: 11/16/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To compare the efficacy and side effects of bilateral globus pallidus internus (GPi) and subthalamic nucleus (STN) deep brain stimulation (DBS) in the same patient with primary dystonia. METHODS Patients with primary dystonia from the department of functional neurosurgery in Beijing Tiantan Hospital were recruited for the study. Four electrodes were bilaterally implanted in the GPi and STN. A trial stimulation was applied to determine the preliminary therapeutic effects. Five evaluations were conducted: preoperative, postoperative (before stimulation), after sham stimulation, and after stimulation for 24 hours of GPi and STN using optimal parameters, judged by the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). RESULTS The BFMDRS movement score decreased after both short-term GPi stimulation (from 15.3 ± 6.9 to 7.6 ± 4.2, P < 0.05) and short-term STN stimulation (from 15.3 ± 6.9 to 8.6 ± 5.0, P < 0.05). There were significant reductions in facial (eyes and mouth) movement scores after short-term GPi and STN DBS compared with baseline (P < 0.05), but not in cervical symptoms (P > 0.05). The cervical symptoms of tonic dystonia had an improvement after long-term DBS treatment (P < 0.05). There were more adverse events with STN DBS; however, most side effects could be ameliorated by adjusting stimulation parameters. CONCLUSIONS Both short-term GPi and STN stimulation improved the motor symptoms of dystonia, but there was no significant difference between GPi DBS and STN DBS. There were more side effects associated with STN stimulation.
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Affiliation(s)
- Yuye Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guanyu Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yin Jiang
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Xiu Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yingchuan Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fangang Meng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Kai Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anchao Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Huanguang Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xin Zhang
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing, China; Beijing Key Laboratory of Neurostimulation, Beijing, China.
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Girach A, Vinagre Aragon A, Zis P. Quality of life in idiopathic dystonia: a systematic review. J Neurol 2018; 266:2897-2906. [PMID: 30460447 PMCID: PMC6851210 DOI: 10.1007/s00415-018-9119-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 11/03/2018] [Accepted: 11/09/2018] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Dystonia is characterised by sustained muscular contractions frequently producing repetitive, twisting and patterned movements. The primary aim of this systematic review was to establish how quality of life (QoL) is affected in idiopathic focal, multifocal and segmental dystonia. This review aimed to evaluate variations in QoL between different subtypes of dystonia, identify the determinants of QoL and assess the effects of different treatments on QoL. METHODOLOGY A systematic computer-based literature search was conducted using the PubMed database to search for papers on QoL in idiopathic focal, segmental, multifocal and generalized dystonia. We identified 75 studies meeting our inclusion criteria. Information was extracted regarding prevalence, demographics and response to treatment where indicated. RESULTS This review revealed QoL to be a significant yet often overlooked issue in idiopathic dystonia. Data consistently showed that dystonia has a negative effect on QoL in patients compared to healthy controls, when measured using disease-specific and generic QoL measures. The majority of studies (n = 25) involved patients with cervical dystonia, followed by benign-essential blepharospasm (n = 10). Along with the beneficial effect to the dystonia symptoms, treatment using Botulinum Toxin and Deep Brain Stimulation is also effective in improving overall QoL across the majority of subtypes. CONCLUSION The findings demonstrate that patients' QoL should routinely be assessed and monitored, as this may affect subsequent management. Further research will allow for more robust management of factors contributing to impaired QoL, aside from the physical defects found in dystonia.
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Affiliation(s)
- Ayesha Girach
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK.
| | - Ana Vinagre Aragon
- Academic Department of Neurosciences, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK
| | - Panagiotis Zis
- Academic Department of Neurosciences, Sheffield Teaching Hospitals, NHS Foundation Trust, Sheffield, UK.,Medical School, University of Cyprus, Nicosia, Cyprus
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Ravindran K, Ganesh Kumar N, Englot DJ, Wilson TJ, Zuckerman SL. Deep Brain Stimulation Versus Peripheral Denervation for Cervical Dystonia: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 122:e940-e946. [PMID: 30419402 DOI: 10.1016/j.wneu.2018.10.178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/26/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Cervical dystonia is a disabling medical condition that drastically decreases quality of life. Surgical treatment consists of peripheral nerve denervation procedures with or without myectomies or deep brain stimulation (DBS). The current objective was to compare the efficacy of peripheral denervation versus DBS in improving the severity of cervical dystonia through a systematic review and meta-analysis. METHODS A search of PubMed, MEDLINE, EMBASE, and Web of Science electronic databases was conducted in accordance with PRISMA guidelines. Preoperative and postoperative Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) total scores were used to generate standardized mean differences and 95% confidence intervals (CIs), which were combined in a random-effects model. Both mean percentage and absolute reduction in TWSTRS scores were calculated. Absolute reduction was used for forest plots. RESULTS Eighteen studies met the inclusion criteria, comprising 870 patients with 180 (21%) undergoing DBS and 690 (79%) undergoing peripheral denervation procedures. The mean follow-up time was 31.5 months (range, 12-38 months). In assessing the efficacy of each intervention, forest plots revealed significant absolute reduction in total postoperative TWSTRS scores for both peripheral denervation (standardized mean difference 1.54; 95% CI 1.42-1.66) and DBS (standardized mean difference 2.07; 95% CI 1.43-2.71). On subgroup analysis, DBS therapy was significantly associated with improvement in postoperative TWSTRS severity (standardized mean difference 2.08; 95% CI 1.66-2.50) and disability (standardized mean difference 2.12; 95% CI 1.57-2.68) but not pain (standardized mean difference 1.18; 95% CI 0.80-1.55). CONCLUSIONS Both peripheral denervation and DBS are associated with a significant reduction in absolute TWSTRS total score, with no significant difference in the magnitude of reduction observed between the 2 treatments. Further comparative data are needed to better evaluate the long-term results of both interventions.
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Affiliation(s)
- Krishnan Ravindran
- Department of Neurosurgery, Vanderbilt University Medical Center School, Nashville, Tennessee, USA
| | - Nishant Ganesh Kumar
- Department of Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Dario J Englot
- Department of Neurosurgery, Vanderbilt University Medical Center School, Nashville, Tennessee, USA
| | - Thomas J Wilson
- Department of Neurosurgery, Stanford University, Stanford, California, USA
| | - Scott L Zuckerman
- Department of Neurosurgery, Vanderbilt University Medical Center School, Nashville, Tennessee, USA.
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Abstract
Dystonia is a neurological condition characterized by abnormal involuntary movements or postures owing to sustained or intermittent muscle contractions. Dystonia can be the manifesting neurological sign of many disorders, either in isolation (isolated dystonia) or with additional signs (combined dystonia). The main focus of this Primer is forms of isolated dystonia of idiopathic or genetic aetiology. These disorders differ in manifestations and severity but can affect all age groups and lead to substantial disability and impaired quality of life. The discovery of genes underlying the mendelian forms of isolated or combined dystonia has led to a better understanding of its pathophysiology. In some of the most common genetic dystonias, such as those caused by TOR1A, THAP1, GCH1 and KMT2B mutations, and idiopathic dystonia, these mechanisms include abnormalities in transcriptional regulation, striatal dopaminergic signalling and synaptic plasticity and a loss of inhibition at neuronal circuits. The diagnosis of dystonia is largely based on clinical signs, and the diagnosis and aetiological definition of this disorder remain a challenge. Effective symptomatic treatments with pharmacological therapy (anticholinergics), intramuscular botulinum toxin injection and deep brain stimulation are available; however, future research will hopefully lead to reliable biomarkers, better treatments and cure of this disorder.
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Cortical Potentials Evoked by Subthalamic Stimulation Demonstrate a Short Latency Hyperdirect Pathway in Humans. J Neurosci 2018; 38:9129-9141. [PMID: 30201770 DOI: 10.1523/jneurosci.1327-18.2018] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 07/23/2018] [Accepted: 07/23/2018] [Indexed: 11/21/2022] Open
Abstract
A monosynaptic projection from the cortex to the subthalamic nucleus is thought to have an important role in basal ganglia function and in the mechanism of therapeutic subthalamic deep-brain stimulation, but in humans the evidence for its existence is limited. We sought physiological confirmation of the cortico-subthalamic hyperdirect pathway using invasive recording techniques in patients with Parkinson's disease (9 men, 1 woman). We measured sensorimotor cortical evoked potentials using a temporary subdural strip electrode in response to low-frequency deep-brain stimulation in patients undergoing awake subthalamic or pallidal lead implantations. Evoked potentials were grouped into very short latency (<2 ms), short latency (2-10 ms), and long latency (10-100 ms) from the onset of the stimulus pulse. Subthalamic and pallidal stimulation resulted in very short-latency evoked potentials at 1.5 ms in the primary motor cortex accompanied by EMG-evoked potentials consistent with corticospinal tract activation. Subthalamic, but not pallidal stimulation, resulted in three short-latency evoked potentials at 2.8, 5.8, and 7.7 ms in a widespread cortical distribution, consistent with antidromic activation of the hyperdirect pathway. Long-latency potentials were evoked by both targets, with subthalamic responses lagging pallidal responses by 10-20 ms, consistent with orthodromic activation of the thalamocortical pathway. The amplitude of the first short-latency evoked potential was predictive of the chronic therapeutic stimulation contact.SIGNIFICANCE STATEMENT This is the first physiological demonstration of the corticosubthalamic hyperdirect pathway and its topography at high spatial resolution in humans. We studied cortical potentials evoked by deep-brain stimulation in patients with Parkinson's disease undergoing awake lead implantation surgery. Subthalamic stimulation resulted in multiple short-latency responses consistent with activation of hyperdirect pathway, whereas no such response was present during pallidal stimulation. We contrast these findings with very short latency, direct corticospinal tract activations, and long-latency responses evoked through polysynaptic orthodromic projections. These findings underscore the importance of incorporating the hyperdirect pathway into models of human basal ganglia function.
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Hogg E, During E, E. Tan E, Athreya K, Eskenazi J, Wertheimer J, Mamelak AN, Alterman RL, Tagliati M. Sustained quality-of-life improvements over 10 years after deep brain stimulation for dystonia. Mov Disord 2018; 33:1160-1167. [DOI: 10.1002/mds.27426] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 11/10/2022] Open
Affiliation(s)
- Elliot Hogg
- Department of Neurology; Cedar-Sinai Medical Center; Los Angeles California USA
| | - Emmanuel During
- Department of Neurology; Cedar-Sinai Medical Center; Los Angeles California USA
| | - Echo E. Tan
- Department of Neurology; Cedar-Sinai Medical Center; Los Angeles California USA
| | - Kishore Athreya
- Department of Neurology; Cedar-Sinai Medical Center; Los Angeles California USA
| | - Jonathan Eskenazi
- Department of Neurology; Cedar-Sinai Medical Center; Los Angeles California USA
| | - Jeffrey Wertheimer
- Department of Neurology; Cedar-Sinai Medical Center; Los Angeles California USA
| | - Adam N. Mamelak
- Department of Neurosurgery; Cedar-Sinai Medical Center; Los Angeles California USA
| | - Ron L. Alterman
- Department of Neurosurgery; Beth Israel Deaconess Medical Center; Boston Massachusetts USA
| | - Michele Tagliati
- Department of Neurology; Cedar-Sinai Medical Center; Los Angeles California USA
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71
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Mahlknecht P, Georgiev D, Akram H, Brugger F, Vinke S, Zrinzo L, Hariz M, Bhatia KP, Hariz GM, Willeit P, Rothwell JC, Foltynie T, Limousin P. Parkinsonian signs in patients with cervical dystonia treated with pallidal deep brain stimulation. Brain 2018; 141:3023-3034. [DOI: 10.1093/brain/awy217] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 07/03/2018] [Indexed: 12/17/2022] Open
Affiliation(s)
- Philipp Mahlknecht
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - Dejan Georgiev
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neurology, Medical University Ljubljana, Ljubljana, Slovenia
| | - Harith Akram
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Florian Brugger
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Saman Vinke
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Ludvic Zrinzo
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Marwan Hariz
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Kailash P Bhatia
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Gun-Marie Hariz
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
- Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
- Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Peter Willeit
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - John C Rothwell
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Thomas Foltynie
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Patricia Limousin
- Sobell Department of Motor Neuroscience, UCL Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, UK
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72
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Albanese A, Di Giovanni M, Lalli S. Dystonia: diagnosis and management. Eur J Neurol 2018; 26:5-17. [DOI: 10.1111/ene.13762] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/20/2018] [Indexed: 01/01/2023]
Affiliation(s)
- A. Albanese
- Unità Operativa di Neurologia IRCCS Istituto Clinico Humanitas Rozzano Milano Italy
- Istituto di Neurologia Università Cattolica del Sacro Cuore Milano Italy
| | - M. Di Giovanni
- Unità Operativa di Neurologia IRCCS Istituto Clinico Humanitas Rozzano Milano Italy
| | - S. Lalli
- Unità Operativa di Neurologia IRCCS Istituto Clinico Humanitas Rozzano Milano Italy
- Istituto di Neurologia Università Cattolica del Sacro Cuore Milano Italy
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Abstract
Within the field of movement disorders, the conceptual understanding of dystonia has continued to evolve. Clinical advances have included improvements in recognition of certain features of dystonia, such as tremor, and understanding of phenotypic spectrums in the genetic dystonias and dystonia terminology and classification. Progress has also been made in the understanding of underlying biological processes which characterize dystonia from discoveries using approaches such as neurophysiology, functional imaging, genetics, and animal models. Important advances include the role of the cerebellum in dystonia, the concept of dystonia as an aberrant brain network disorder, additional evidence supporting the concept of dystonia endophenotypes, and new insights into psychogenic dystonia. These discoveries have begun to shape treatment approaches as, in parallel, important new treatment modalities, including magnetic resonance imaging-guided focused ultrasound, have emerged and existing interventions such as deep brain stimulation have been further refined. In this review, these topics are explored and discussed.
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Affiliation(s)
- Stephen Tisch
- Faculty of Medicine, University of New South Wales, Sydney, Australia.,Department of Neurology, St Vincent's Hospital, Sydney, Australia
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74
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Lin H, Cai XD, Zhang DD, Liu JL, Li WP. Both Deep Brain Stimulation and Thalamotomy in a 13-Year-Old Patient with Primary Dystonia. World Neurosurg 2018; 117:68-73. [PMID: 29890276 DOI: 10.1016/j.wneu.2018.05.248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Primary dystonia is a neurologic disease with characteristics of abnormal, involuntary twisting and turning movements, which greatly affect quality of life of patients. Treatments for dystonia consist of oral medications, botulinum neurotoxin injections, physical therapy, and surgery. For medication-refractory dystonia, surgery, especially deep brain stimulation (DBS), is the optimal option. CASE DESCRIPTION The patient was a 13-year-old boy suffering from extremely severe primary dystonia, with a Burke-Fahn-Marsden Dystonia Rating Scale-motor score of 118 and a Toronto Western Spasmodic Torticollis Rating Scale-severity score of 29. The examination of 173 genes, including DYT, failed to identify any abnormality. He responded ineffectively to medications. After both bilateral subthalamic nucleus DBS and unilateral thalamic lesion in ventralis intermedius nucleus and ventralis oralis nucleus (Vim-Vo thalamotomy), his movement disorder improved dramatically. Four and 7 months after the operation, the scores of 2 rating scales sharply decreased. Potential brain structural changes were reflected in sensorimotor-related cortical thickness, surface area, and gray matter volume from magnetic resonance imaging, which may reveal a valid method to evaluate surgical effect on the brain with enough patients. CONCLUSIONS DBS and thalamotomy is potentially an effective combination of treatments for severe medication-refractory dystonia.
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Affiliation(s)
- Hai Lin
- Department of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China; Shenzhen Key Laboratory of Neurosurgery, Shenzhen, Guangdong, China; Shenzhen University School of Medicine, Shenzhen, Guangdong, China
| | - Xiao-Dong Cai
- Department of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China; Shenzhen University School of Medicine, Shenzhen, Guangdong, China
| | - Dou-Dou Zhang
- Department of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China; Shenzhen University School of Medicine, Shenzhen, Guangdong, China
| | - Jia-Li Liu
- Department of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China; Shenzhen University School of Medicine, Shenzhen, Guangdong, China
| | - Wei-Ping Li
- Department of Neurosurgery, the First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, Guangdong, China; Shenzhen Key Laboratory of Neurosurgery, Shenzhen, Guangdong, China; Shenzhen University School of Medicine, Shenzhen, Guangdong, China.
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75
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Cury RG, Kalia SK, Shah BB, Jimenez-Shahed J, Prashanth LK, Moro E. Surgical treatment of dystonia. Expert Rev Neurother 2018; 18:477-492. [PMID: 29781334 DOI: 10.1080/14737175.2018.1478288] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Treatment of dystonia should be individualized and tailored to the specific needs of patients. Surgical treatment is an important option in medically refractory cases. Several issues regarding type of the surgical intervention, targets, and predict factors of benefit are still under debate. Areas covered: To date, several clinical trials have proven the benefit and safety of deep brain stimulation (DBS) for inherited and idiopathic isolated dystonia, whereas there is still insufficient evidence in combined and acquired dystonia. The globus pallidus internus (GPi) is the target with the best evidence, but data on the subthalamic nucleus seems also to be promising. Evidence suggests that younger patients with shorter disease duration experience greater benefit following DBS. Pallidotomy and thalamotomy are currently used in subset of carefully selected patients. The development of MRI-guided focused ultrasound might bring new options to ablation approach in dystonia. Expert commentary: GPi-DBS is effective and safe in isolated dystonia and should not be delayed when symptoms compromise quality of life and functionality. Identifying the best candidates to surgery on acquired and combined dystonias is still necessary. New insights about pathophysiology of dystonia and new technological advances will undoubtedly help to tailor surgery and optimize clinical effects.
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Affiliation(s)
- Rubens Gisbert Cury
- a Service de Neurologie, Centre Hospitalier Universitaire de Grenoble , Université Grenoble Alpes , Grenoble , France.,b Department of Neurology, School of Medicine , University of São Paulo , São Paulo , Brazil
| | - Suneil Kumar Kalia
- c Division of Neurosurgery and Krembil Research Institute, Department of Surgery , University of Toronto , Toronto , Canada
| | - Binit Bipin Shah
- d Parkinson's Disease and Movement Disorders Center, Department of Neurology , University of Virginia , Charlottesville , VA , USA
| | - Joohi Jimenez-Shahed
- e Parkinson's Disease Center and Movement Disorders Clinic , Baylor College of Medicine , Houston , TX , USA
| | | | - Elena Moro
- a Service de Neurologie, Centre Hospitalier Universitaire de Grenoble , Université Grenoble Alpes , Grenoble , France
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76
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Mandarelli G, Moretti G, Pasquini M, Nicolò G, Ferracuti S. Informed Consent Decision-Making in Deep Brain Stimulation. Brain Sci 2018; 8:E84. [PMID: 29751598 PMCID: PMC5977075 DOI: 10.3390/brainsci8050084] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 12/20/2022] Open
Abstract
Deep brain stimulation (DBS) has proved useful for several movement disorders (Parkinson’s disease, essential tremor, dystonia), in which first and/or second line pharmacological treatments were inefficacious. Initial evidence of DBS efficacy exists for refractory obsessive-compulsive disorder, treatment-resistant major depressive disorder, and impulse control disorders. Ethical concerns have been raised about the use of an invasive surgical approach involving the central nervous system in patients with possible impairment in cognitive functioning and decision-making capacity. Most of the disorders in which DBS has been used might present with alterations in memory, attention, and executive functioning, which may have an impact on the mental capacity to give informed consent to neurosurgery. Depression, anxiety, and compulsivity are also common in DBS candidate disorders, and could also be associated with an impaired capacity to consent to treatment or clinical research. Despite these issues, there is limited empirical knowledge on the decision-making levels of these patients. The possible informed consent issues of DBS will be discussed by focusing on the specific treatable diseases.
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Affiliation(s)
- Gabriele Mandarelli
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
| | - Germana Moretti
- Department of Mental Health, ASL Roma 5, 00034 Colleferro, Italy.
| | - Massimo Pasquini
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
| | - Giuseppe Nicolò
- Department of Mental Health, ASL Roma 5, 00034 Colleferro, Italy.
| | - Stefano Ferracuti
- Department of Human Neurosciences (Former Department of Neurology and Psychiatry), "Sapienza" University of Rome, 00185 Rome, Italy.
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Pallidal Deep-Brain Stimulation Disrupts Pallidal Beta Oscillations and Coherence with Primary Motor Cortex in Parkinson's Disease. J Neurosci 2018; 38:4556-4568. [PMID: 29661966 DOI: 10.1523/jneurosci.0431-18.2018] [Citation(s) in RCA: 84] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 03/27/2018] [Accepted: 04/05/2018] [Indexed: 01/15/2023] Open
Abstract
In Parkinson's disease (PD), subthalamic nucleus beta band oscillations are decreased by therapeutic deep-brain stimulation (DBS) and this has been proposed as important to the mechanism of therapy. The globus pallidus is a common alternative target for PD with similar motor benefits as subthalamic DBS, but effects of pallidal stimulation in PD are not well studied, and effects of pallidal DBS on cortical function in PD are unknown. Here, in 20 PD and 14 isolated dystonia human patients of both genders undergoing pallidal DBS lead implantation, we recorded local field potentials from the globus pallidus and in a subset of these, recorded simultaneous sensorimotor cortex ECoG potentials. PD patients had elevated resting pallidal low beta band (13-20 Hz) power compared with dystonia patients, whereas dystonia patients had elevated resting pallidal theta band (4-8 Hz) power compared with PD. We show that this results in disease-specific patterns of interaction between the pallidum and motor cortex: PD patients demonstrated relatively elevated phase coherence with the motor cortex in the beta band and this was reduced by therapeutic pallidal DBS. Dystonia patients had greater theta band phase coherence. Our results support the hypothesis that specific motor phenomenology observed in movement disorders are associated with elevated network oscillations in specific frequency bands, and that DBS in movement disorders acts in general by disrupting elevated synchronization between basal ganglia output and motor cortex.SIGNIFICANCE STATEMENT Perturbations in synchronized oscillatory activity in brain networks are increasingly recognized as important features in movement disorders. The globus pallidus is a commonly used target for deep-brain stimulation (DBS) in Parkinson's disease (PD), however, the effects of pallidal DBS on basal ganglia and cortical oscillations are unknown. Using invasive intraoperative recordings in patients with PD and isolated dystonia, we found disease-specific patterns of elevated oscillatory synchronization within the pallidum and in coherence between pallidum and motor cortex. Therapeutic pallidal DBS in PD suppresses these elevated synchronizations, reducing the influence of diseased basal ganglia on cortical physiology. We propose a general mechanism for DBS therapy in movement disorders: functional disconnection of basal ganglia output and motor cortex by coherence suppression.
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78
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Abstract
INTRODUCTION Essential tremor is the most common form of pathologic tremor. Surgical therapies disrupt tremorogenic oscillation in the cerebellothalamocortical pathway and are capable of abolishing severe tremor that is refractory to available pharmacotherapies. Surgical methods are raspidly improving and are the subject of this review. Areas covered: A PubMed search on 18 January 2018 using the query essential tremor AND surgery produced 839 abstracts. 379 papers were selected for review of the methods, efficacy, safety and expense of stereotactic deep brain stimulation (DBS), stereotactic radiosurgery (SRS), focused ultrasound (FUS) ablation, and radiofrequency ablation of the cerebellothalamocortical pathway. Expert commentary: DBS and SRS, FUS and radiofrequency ablations are capable of reducing upper extremity tremor by more than 80% and are far more effective than any available drug. The main research questions at this time are: 1) the relative safety, efficacy, and expense of DBS, SRS, and FUS performed unilaterally and bilaterally; 2) the relative safety and efficacy of thalamic versus subthalamic targeting; 3) the relative safety and efficacy of atlas-based versus direct imaging tractography-based anatomical targeting; and 4) the need for intraoperative microelectrode recordings and macroelectrode stimulation in awake patients to identify the optimum anatomical target. Randomized controlled trials are needed.
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Affiliation(s)
- Rodger J Elble
- a Neuroscience Institute , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Ludy Shih
- b Department of Neurology , Beth Israel Deaconess Medical Center, Harvard Medical School , Boston , Massachusetts USA
| | - Jeffrey W Cozzens
- a Neuroscience Institute , Southern Illinois University School of Medicine , Springfield , Illinois , USA
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Miocinovic S, Miller A, Swann NC, Ostrem JL, Starr PA. Chronic deep brain stimulation normalizes scalp EEG activity in isolated dystonia. Clin Neurophysiol 2017; 129:368-376. [PMID: 29288993 DOI: 10.1016/j.clinph.2017.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/21/2017] [Accepted: 11/21/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate cortical activity using scalp EEG in patients with isolated dystonia treated with chronic deep brain stimulation (DBS), on and off stimulation. METHODS We analyzed 64-channel scalp EEG in 12 isolated dystonia patients treated with chronic DBS (7 generalized, 5 cervical/segmental; 7 globus pallidus (GP), 5 subthalamic nucleus (STN)), and 20 healthy age-matched controls. Recordings during rest and movement task, and clinical motor scores, were collected with DBS-on and during a 90-min DBS washout. RESULTS Resting state alpha power in the dominant (or contralateral to more dystonic side) motor cortex channel during DBS was comparable to healthy controls, but it increased when DBS was stopped. Resting state and movement-related alpha coherence between bilateral motor cortex channels was increased off DBS. CONCLUSIONS Chronic DBS reduces exaggerated alpha oscillations and interhemispheric alpha coherence in the motor cortex of patients with isolated dystonia. SIGNIFICANCE These findings complement related studies in Parkinson's disease and support the view that network desynchronization is a prominent mechanism of DBS in movement disorders.
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Affiliation(s)
| | - Andrew Miller
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
| | - Nicole C Swann
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
| | - Jill L Ostrem
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States.
| | - Philip A Starr
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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Kroneberg D, Plettig P, Schneider GH, Kühn AA. Motor Cortical Plasticity Relates to Symptom Severity and Clinical Benefit From Deep Brain Stimulation in Cervical Dystonia. Neuromodulation 2017; 21:735-740. [PMID: 28961350 DOI: 10.1111/ner.12690] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Revised: 07/20/2017] [Accepted: 07/31/2017] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To investigate the relationship between motor cortical plasticity, intracortical inhibition, and clinical response to pallidal deep brain stimulation (DBS) in patients with cervical dystonia (CD). MATERIALS AND METHODS Response to paired associative stimulation (PAS) and short interval intracortical inhibition (SICI) were assessed in patients with CD before and after three months of DBS and correlated with severity of dystonic symptoms as assessed by Toronto-Western-Spasmodic Torticollis Rating Scale (TWSTRS) severity score. Relations of electrophysiological parameters with clinical improvement were explored with correlation analysis. RESULTS Patients with higher levels of plasticity before surgery showed higher symptom severity (R = 0.83, p = 0.008) but had also the larger clinical benefit following DBS (R = 0.88, p = 0.003). This correlation was independent from preoperative (preOP) TWSTRS motor score as revealed by partial correlation analysis. Intracortical inhibition was not altered in CD and not related to clinical outcome after DBS. CONCLUSIONS Our findings indicate that a high degree of preOP plasticity is associated with higher symptom severity, underlining the role of abnormal plasticity in the pathophysiology of dystonia. At the same time individual degree of plasticity may drive reestablishment of normal motor programs, leading to better clinical outcome with DBS. The latter suggests that individual PAS-response may indicate the susceptibility for neuromodulatory processes as an important factor for clinical DBS effects. It might therefore serve as a neurophysiological marker to predict outcome and guide patient selection.
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Affiliation(s)
- Daniel Kroneberg
- Department of Neurology, Charité Campus Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Philip Plettig
- Department of Neurology, Charité Campus Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Charité Campus Mitte, Charité - University Medicine Berlin, Berlin, Germany
| | - Andrea A Kühn
- Department of Neurology, Charité Campus Mitte, Charité - University Medicine Berlin, Berlin, Germany.,NeuroCure, Charité - University Medicine Berlin, Berlin, Germany.,Berlin School of Mind and Brain, Charité - University Medicine Berlin, Berlin, Germany.,German Center for Neurodegenerative Diseases (DZNE), Charité - University Medicine Berlin, Berlin, Germany
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81
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Affiliation(s)
- Isabel Alfradique-Dunham
- Parkinson’s Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
| | - Joseph Jankovic
- Parkinson’s Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX, USA
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Luthra NS, Mitchell KT, Volz MM, Tamir I, Starr PA, Ostrem JL. Intractable Blepharospasm Treated with Bilateral Pallidal Deep Brain Stimulation. Tremor Other Hyperkinet Mov (N Y) 2017; 7:472. [PMID: 28975046 PMCID: PMC5623756 DOI: 10.7916/d8sj1v9f] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 06/21/2017] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Blepharospasm can be present as an isolated dystonia or in conjunction with other forms of cranial dystonia, causing significant disability. CASE REPORT We report a case of a 69-year-old male with craniocervical dystonia, manifesting primarily as incapacitating blepharospasm refractory to medical treatments. He underwent bilateral globus pallidus (GP) deep brain stimulation (DBS) with complete resolution of his blepharospasm and sustained benefit at 12 months postoperatively. DISCUSSION This case illustrates successful treatment of blepharospasm with pallidal stimulation. GP-DBS should be considered a reasonable therapeutic option for intractable blepharospasm.
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Affiliation(s)
- Nijee S. Luthra
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Kyle T. Mitchell
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Monica M. Volz
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Idit Tamir
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Phillip A. Starr
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Jill L. Ostrem
- Department of Neurology, University of California, San Francisco, CA, USA
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Reese R, Volkmann J. Deep Brain Stimulation for the Dystonias: Evidence, Knowledge Gaps, and Practical Considerations. Mov Disord Clin Pract 2017; 4:486-494. [PMID: 30363085 PMCID: PMC6090587 DOI: 10.1002/mdc3.12519] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/10/2017] [Accepted: 06/17/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the globus pallidus internus (GPi-DBS) is among the most effective treatment options for dystonias. Because the term "dystonia" is defined by a characteristic phenomenology of involuntary muscle contractions, which may present with a large clinical and pathogenetic heterogeneity, decision making for or against GPi-DBS can be difficult in individual patients. METHODS A search of the PubMed database for research and review articles, focused on "deep brain stimulation" and "dystonia" was used to identify clinical trials and to determine current concepts in the surgical management of dystonia. Patient selection in previous studies was recategorized by the authors using the new dystonia classification put forward by a consensus committee of experts in dystonia research. The evidence and knowledge gaps are summarized and commented by the authors taking into account expert opinion and personal clinical experience for providing practical guidance in patient selection for DBS in dystonia. RESULTS The literature review shows that pallidal deep brain stimulation is most effective in patients with isolated dystonia irrespective of the underlying etiology. In contrast, patients with combined dystonias are less likely to benefit from DBS, because the associated neurological symptoms (e.g., hypotonia or ataxia), with the exception of myoclonus, do not respond to pallidal neurostimulation. CONCLUSIONS It is important to recognize the clinical features of dystonia, because the distinction between isolated and combined dystonia syndromes may predict the treatment response to pallidal deep brain stimulation. The aim of this review is to help guide clinicians with advising patients about deep brain stimulation therapy for dystonia and refering appropriate candidates to surgical centers.
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Affiliation(s)
- René Reese
- Department of NeurologyRostock University Medical CenterRostockGermany
- Department of NeurologyUniversity Hospital WürzburgWürzburgGermany
| | - Jens Volkmann
- Department of NeurologyUniversity Hospital WürzburgWürzburgGermany
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Margolesky J, Schoen N, Jermakowicz W, Sur S, Cajigas I, Singer C, Jagid J, C. Luca C. Subthalamic nucleus deep brain stimulation for the treatment of secondary dystonia: A case series and review of literature. Brain Stimul 2017; 10:870-872. [DOI: 10.1016/j.brs.2017.04.123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 04/14/2017] [Accepted: 04/15/2017] [Indexed: 10/19/2022] Open
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