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De Bie RMA, Schuurman PR, Esselink RAJ, Bosch DA, Speelman JD. Bilateral pallidotomy in Parkinson's disease: a retrospective study. Mov Disord 2002; 17:533-8. [PMID: 12112203 DOI: 10.1002/mds.10090] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We evaluated the effects of bilateral pallidotomy in patients with advanced Parkinson's disease. Thirteen patients with Parkinson's disease had a staged bilateral pallidotomy if they had severe response fluctuations, dyskinesias, painful dystonia, or bradykinesia despite optimum pharmacological treatment. Assessment scales were the Unified Parkinson's Disease Rating scale (UPDRS), the Schwab and England scale, and a questionnaire on the effects of disability in activities of daily living and adverse effects. Postoperative magnetic resonance imaging was evaluated for lesion location and extension. The median off-phase UPDRS motor score was reduced from 43.5 to 29 after the first pallidotomy, and it was further reduced to 23.5 after the second pallidotomy (n = 8). The UPDRS activities of daily living off-phase score improved from 28.5 to 20.5 after the first pallidotomy and to 19 after the second pallidotomy (n = 6). The Schwab and England scale off-phase score showed an improvement after both procedures, first from 40 to 60, and thereafter to 90 (n = 8). On-phase dyskinesias were reduced substantially. Eight patients had adverse effects, of whom five had problems with speech. One patient became hemiplegic due to a delayed infarction. Ten patients experienced further benefit from the second procedure. Bilateral pallidotomy reduces dyskinesias. A second contralateral pallidotomy may reduce parkinsonism, although to a lesser degree compared with the first pallidotomy and with an increased risk for adverse effects.
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Affiliation(s)
- Rob M A De Bie
- Department of Neurology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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152
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Scott RB, Harrison J, Boulton C, Wilson J, Gregory R, Parkin S, Bain PG, Joint C, Stein J, Aziz TZ. Global attentional-executive sequelae following surgical lesions to globus pallidus interna. Brain 2002; 125:562-74. [PMID: 11872613 DOI: 10.1093/brain/awf046] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
It has been demonstrated that selective unilateral surgical ablation of posteroventral globus pallidus interna relieves the movement disorders associated with advanced Parkinson's disease, without necessarily incurring the executive cognitive sequelae that have been observed following gross pathological lesions to this brain region. This finding is consistent with established theory that underlying neuronal circuitry is functionally segregated into parallel cortico-striatal-pallidal-thalamo-cortical 'loops'. We have studied a series of 12 patients with advanced Parkinson's disease at baseline, and then following bilateral pallidotomy, with a battery of neuropsychological tests including the Cambridge Neuro psychological Test Automated Battery. We identified a selective and universal loss of individual patients' ability to shift attention to novel dimensions in a test of abstract rule-learning following surgery, which was not reliably associated with any other change in cognition, personality, mood or medication. This finding is rare in its specificity and has implications for theoretical models of the functional architecture and pathophysiology of the globus pallidus, and the clinical practice of pallidotomy.
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153
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Jahanshahi M, Rowe J, Saleem T, Brown RG, Limousin-Dowsey P, Rothwell JC, Thomas DGT, Quinn NP. Striatal contribution to cognition: working memory and executive function in Parkinson's disease before and after unilateral posteroventral pallidotomy. J Cogn Neurosci 2002; 14:298-310. [PMID: 11970793 DOI: 10.1162/089892902317236911] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The basal ganglia are intimately connected to the frontal cortex via five fronto-striatal circuits. While the role of the frontal cortex in cognition has been extensively studied, the contribution of the basal ganglia to cognition has remained less clear. In Parkinson's disease, posteroventral pallidotomy (PVP) involves surgical lesioning of the internal section of the globus pallidus (GPi, the final output pathway from the basal ganglia) to relieve the motor symptoms of the disorder. PVP in Parkinson's disease provides a unique opportunity to investigate the impact of disruption of striatal outflow to the frontal cortex on cognition. We assessed executive function and working memory after withdrawal of medication in 13 patients with Parkinson's disease before and 3 months after unilateral PVP compared to 12 age- and IQ-matched normals assessed twice with an interval of 3 months. The tests used were: Wisconsin Card Sorting (WCST), Self-Ordered Random Number Sequences, Missing Digit Test, Paced Visual Serial Addition Test (PVSAT), and Visual Conditional Associative Learning Test (VCALT). After PVP, the patients performed significantly better on the Self-Ordered Random Number Sequences and the WCST, an improvement that was also observed in the normals across the two assessment and is therefore likely to reflect practice effects. Relative to the normals, the patients showed significant differential change following PVP on the Missing Digit Test and PVSAT, on which they performed worse after compared to before surgery, while the controls performed better on the second assessment. For the patients, performance on the VCALT also indicated deterioration after PVP, but the changes approached significance. The side of PVP had no effect on the results. The pattern of change observed 3 months after PVP was maintained at 15-month follow-up. The results suggest that striatal outflow to the frontal cortex may be essential for those aspects of executive function that showed deterioration after PVP.
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Affiliation(s)
- M Jahanshahi
- Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, London, UK.
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154
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Morel A, Loup F, Magnin M, Jeanmonod D. Neurochemical organization of the human basal ganglia: anatomofunctional territories defined by the distributions of calcium-binding proteins and SMI-32. J Comp Neurol 2002; 443:86-103. [PMID: 11793349 DOI: 10.1002/cne.10096] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The distribution of the calcium-binding proteins calbindin-D28K (CB), parvalbumin (PV) and calretinin (CR), and of the nonphosphorylated neurofilament protein (with SMI-32) was investigated in the human basal ganglia to identify anatomofunctional territories. In the striatum, gradients of neuropil immunostaining define four major territories: The first (T1) includes all but the rostroventral half of the putamen and is characterized by enhanced matriceal PV and SMI-32 immunoreactivity (-ir). The second territory (T2) encompasses most part of the caudate nucleus (Cd) and rostral putamen (PuT), which show enhanced matriceal CB-ir. The third and fourth territories (T3 and T4) comprise rostroventral parts of Cd and PuT characterized by complementary patch/matrix distributions of CB- and CR-ir, and the accumbens nucleus (Acb), respectively. The latter is separated into lateral (prominently enhanced in CB-ir) and medial (prominently enhanced in CR-ir) subdivisions. In the pallidum, parallel gradients also delimit four territories, T1 in the caudal half of external (GPe) and internal (GPi) divisions, characterized by enhanced PV- and SMI-32-ir; T2 in their rostral half, characterized by enhanced CB-ir; and T3 and T4 in their rostroventral pole and in the subpallidal area, respectively, both expressing CB- and CR-ir but with different intensities. The subthalamic nucleus (STh) shows contrasting patterns of dense PV-ir (sparing only the most medial part) and low CB-ir. Expression of CR-ir is relatively low, except in the medial, low PV-ir, part of the nucleus, whereas SMI-32-ir is moderate across the whole nucleus. The substantia nigra is characterized by complementary patterns of high neuropil CB- and SMI-32-ir in pars reticulata (SNr) and high CR-ir in pars compacta (SNc) and in the ventral tegmental area (VTA). The compartmentalization of calcium-binding proteins and SMI-32 in the human basal ganglia, in particular in the striatum and pallidum, delimits anatomofunctional territories that are of significance for functional imaging studies and target selection in stereotactic neurosurgery.
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Affiliation(s)
- Anne Morel
- Laboratory for Functional Neurosurgery, Neurosurgery Clinic, University Hospital Zurich, Zurich, Switzerland.
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155
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Favre J, Taha JM, Burchiel KJ. An Analysis of the Respective Risks of Hematoma Formation in 361 Consecutive Morphological and Functional Stereotactic Procedures. Neurosurgery 2002. [DOI: 10.1227/00006123-200201000-00010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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156
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Favre J, Taha JM, Burchiel KJ. An analysis of the respective risks of hematoma formation in 361 consecutive morphological and functional stereotactic procedures. Neurosurgery 2002; 50:48-56; discussion 56-7. [PMID: 11844234 DOI: 10.1097/00006123-200201000-00010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/1998] [Accepted: 08/16/2001] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE The risk of hematoma formation in stereotactic procedures is generally considered to range between 1 and 4%, and it has been speculated that morphological procedures may have a higher risk of bleeding than functional procedures. METHODS Between 1989 and 1999, all patients who underwent a stereotactic procedure performed by the same surgeon were enrolled sequentially onto the study. All patients had normal preoperative prothrombin time, partial thromboplastin time, and platelet count. High-resolution computed tomography or magnetic resonance imaging with a 1.5-T machine were used for the target definition. None of the patients had an angiogram before surgery. RESULTS A total of 361 procedures was performed comprising 175 morphological procedures (139 biopsies, 18 lesion evacuations [cysts, abscesses, and hematomas], and 18 drain implantations) and 186 functional procedures (137 lesions [thalamotomy or pallidotomy], 47 deep brain electrode implantations, and two physiological explorations without lesions or implantations). There were no infections or seizures in either group. Three hematomas (1.7%) occurred in the morphological group, two of them in inflammatory lesions in immunocompromised patients (one death) and one in a pineal tumor. Three hematomas (1.6%) occurred in the functional group (no mortality). There was no statistically significant difference (P > 0.05; Fisher's exact test) in the risk of hematoma formation between morphological and functional stereotactic procedures. The morbidity and mortality related to bleeding also were not statistically different (P > 0.05; Fisher's exact test) between these two groups. CONCLUSION In this series, the risk of bleeding was not higher for morphological procedures than for functional procedures. This suggests that the risk of bleeding for stereotactic procedures is related more to the patient than to the type of procedure performed. Our study confirms an overall risk of bleeding of 1.7% for any type of stereotactic procedure, resulting in a mortality of 0.3% and a morbidity of 1.4%.
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Affiliation(s)
- Jacques Favre
- Department of Neurosurgery, Oregon Health Sciences University, Portland, Oregon, USA.
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157
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Defebvre LJP, Krystkowiak P, Blatt JL, Duhamel A, Bourriez JL, Périna M, Blond S, Guieu JD, Destée A. Influence of pallidal stimulation and levodopa on gait and preparatory postural adjustments in Parkinson's disease. Mov Disord 2002; 17:76-83. [PMID: 11835442 DOI: 10.1002/mds.1262] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
In order to assess the influence of the bilateral internal globus pallidus (GPi) stimulation on gait and postural instability in Parkinson's disease (PD), we compared gait kinematic parameters and preparatory postural adjustments before and 3 months after stimulation in off- and on-drug conditions for seven patients. Gait kinematic parameters and displacements of centre of pressure (CP) and shoulder computed before a lateral raising task of the leg, were recorded using optoelectric Vicon system. Levodopa (L-dopa) induced a clear benefit for gait velocity (related to an increase of stride length) and also an increase of swing phase duration. GPi stimulation had a limited effect, since the increase of gait velocity was induced by a concomitant increase of stride length and cadence corresponding to a compensatory mechanism. The benefit on swing phase duration was also moderate. Displacements of CP were improved mainly by L-dopa. GPi stimulation and L-dopa had the same beneficial effect on the speed at which the CP was transferred back towards the support side, the ankle velocity, the onset time for ankle displacement, and the decrease of shoulder amplitude towards the support side, which reflects a better postural adjustment phase. This study, based on an objective method, revealed that chronic bilateral GPi stimulation may improve gait and preparatory postural adjustments in severe PD patients with a more limited effect than L-dopa.
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Affiliation(s)
- Luc J P Defebvre
- Department of Gait Analysis, University of Lille, Lille, France.
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158
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Abstract
Neuroleptic induced tardive dyskinesia and L-dopa-induced dyskinesia are the two most common types of drug-induced abnormal involuntary movements. These two drug-induced dyskinesias are clearly different with respect to the offending drugs and the underlying disease, but they both share a number of intriguing similarities in terms of clinical phenomenology, epidemiology, risk factors, pathophysiological mechanisms and therapeutic responses. In both instances, it is believed that some dysregulation occurring at the level of the striatal dopaminergic receptors, and related non-dopaminergic neurotransmitters systems are playing a crucial role in the development and persistence of the mechanisms causing dyskinesia. These long-lasting functional changes, known as the "priming" phenomenon, are responsible for an impaired balance within the relays of the cortico-subcortical motor loops that release an inadequate output from the basal ganglia leading to an abnormal motor behavior. From a therapeutic perspective, there are also many similarities in the strategies proposed to manage these two dyskinesias. In both cases, unprimed patients not previously exposed to the offending drugs, are offered alternative medications to reduce, at least partly, the risk of occurrence of future dyskinesia: "atypical" neuroleptics in the place of "typical" neuroleptics, and dopamine agonists in the place of L-dopa. In both cases, once dyskinesias are present, in already "primed" patients, both types of dyskinesia appear to be poorly and only partly reversible. Based on limited clinical evidence, it is a common proposal to switch the dyskinetic subject from "typical" to "atypical" neuroleptics for tardive dyskinesia, or to switch from (or more pragmatically to substitute as much as possible) L-dopa to a dopamine agonist for L-dopa-induced dyskinesia. In both cases, efficacious symptomatic antidyskinetic interventions, to reduce the severity of a ready present dyskinesia, are rare. There are some uncontrolled data suggesting that dopamine depleting agents, like tetrabenazine, are possibly useful for tardive dyskinesia; however, there is more clinical evidence to support the efficacy of amantadine and functional surgery in parkinsonian patients with L-dopa-induced dyskinesia.
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Affiliation(s)
- O Rascol
- Department of Clinical Pharmacology, Clinical Investigation Center, INSERM U 455, Toulouse University-Hospital, 37 allees J. Guesde, 31073 Toulouse Cedex, France
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159
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Ahmad SO, Mu K, Scott SA. Meta-analysis of functional outcome in Parkinson patients treated with unilateral pallidotomy. Neurosci Lett 2001; 312:153-6. [PMID: 11602333 DOI: 10.1016/s0304-3940(01)02218-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Parkinson's disease (PD) profoundly affects activities of daily living (ADL) and quality of human life. Although unilateral pallidotomy has become a common surgical treatment for persons with advanced PD, functional outcome data from previous reports have failed to uniformly support this procedure. In the present investigation, results from 12 studies meeting specific inclusion criteria were subjected to meta-analysis. Only reports featuring unilateral pallidotomy as the exclusive surgery, a sample size of at least five patients, explicit assessment of ADL, and sufficient quantitative data were subjected to analysis. Type of research design was not a factor in the selection process. The results of our analysis suggest that unilateral pallidotomy successfully enhances functional outcome in patients with clinically advanced PD.
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Affiliation(s)
- S O Ahmad
- Department of Occupational Therapy, School of Pharmacy and Allied Health Professions, Creighton University, 2500 California Plaza, Omaha, NE 68178, USA.
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160
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Abstract
Motor fluctuations and dyskinesia are common complications of long-term levodopa therapy. The neural and molecular mechanisms underlying their development are partially understood. A variety of clinical strategies may reduce the unpredictability of motor fluctuations and reduce their impact. Prevention of these complications remains an elusive goal.
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Affiliation(s)
- J G Nutt
- Department of Neurology, School of Medicine, Oregon Health Sciences University, Portland, OR 97201-3098, USA.
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161
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Obeso JA, Olanow CW, Rodriguez-Oroz MC, Krack P, Kumar R, Lang AE. Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson's disease. N Engl J Med 2001; 345:956-63. [PMID: 11575287 DOI: 10.1056/nejmoa000827] [Citation(s) in RCA: 1012] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Increased neuronal activity in the subthalamic nucleus and the pars interna of the globus pallidus is thought to account for motor dysfunction in patients with Parkinson's disease. Although creating lesions in these structures improves motor function in monkeys with induced parkinsonism and patients with Parkinson's disease, such lesions are associated with neurologic deficits, particularly when they are created bilaterally. Deep-brain stimulation simulates the effects of a lesion without destroying brain tissue. METHODS We performed a prospective, double-blind, crossover study in patients with advanced Parkinson's disease, in whom electrodes were implanted in the subthalamic nucleus or pars interna of the globus pallidus and who then underwent bilateral high-frequency deep-brain stimulation. We compared scores on the motor portion of the Unified Parkinson's Disease Rating Scale when the stimulation was randomly assigned to be turned on or off. We performed unblinded evaluations of motor function preoperatively and one, three, and six months postoperatively. RESULTS Electrodes were implanted bilaterally in 96 patients in the subthalamic-nucleus group and 38 patients in the globus-pallidus group. Three months after the procedures were performed, double-blind, crossover evaluations demonstrated that stimulation of the subthalamic nucleus was associated with a median improvement in the motor score (as compared with no stimulation) of 49 percent, and stimulation of the pars interna of the globus pallidus with a median improvement of 37 percent (P<0.001 for both comparisons). Between the preoperative and six-month visits, the percentage of time during the day that patients had good mobility without involuntary movements increased from 27 percent to 74 percent (P<0.001) with subthalamic stimulation and from 28 percent to 64 percent (P<0.001) with pallidal stimulation. Adverse events included intracranial hemorrhage in seven patients and infection necessitating removal of the leads in two. CONCLUSIONS Bilateral stimulation of the subthalamic nucleus or pars interna of the globus pallidus is associated with significant improvement in motor function in patients with Parkinson's disease whose condition cannot be further improved with medical therapy.
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162
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de Bie RM, Schuurman PR, Bosch DA, de Haan RJ, Schmand B, Speelman JD. Outcome of unilateral pallidotomy in advanced Parkinson's disease: cohort study of 32 patients. J Neurol Neurosurg Psychiatry 2001; 71:375-82. [PMID: 11511714 PMCID: PMC1737559 DOI: 10.1136/jnnp.71.3.375] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVES In a randomised trial to study the efficacy of unilateral pallidotomy in patients with advanced Parkinson's disease, patients having pallidotomy within 1 month after randomisation were compared with patients having pallidotomy 6 months after the primary outcome assessment. Of the 37 patients enrolled 32 had a unilateral pallidotomy. The follow up study of these patients is presented to report (1) clinical outcome; (2) adverse effects; (3) cognitive and behavioural effects; (4) relation between lesion location and outcome; and (5) preoperative patient characteristics predictive for good outcome. METHODS Outcome measures were the motor section of the unified Parkinson's disease rating scale (UPDRS), levodopa induced dyskinesias, disability, quality of life, and a comprehensive neuropsychological assessment. Multivariate logistic regression was used to identify preoperative patient characteristics independently associated with good outcome. RESULTS Off phase assessment showed a reduction in parkinsonism from 49 to 36.5 points on the UPDRS 6 months after surgery. Improvements were also demonstrated for activities of daily living and quality of life. In the on phase dyskinesias were reduced. All effects lasted up to 12 months after surgery. Three patients had major permanent adverse effects. Besides worsening of verbal fluency after left sided surgery, systematic cognitive deterioration was not detected. Patients taking less than 1000 levodopa equivalent units (LEU)/day were more likely to improve. CONCLUSIONS The positive effects of unilateral pallidotomy are stable up to 1 year after surgery. Patients taking less than 1000 LEU per day were most likely to improve.
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Affiliation(s)
- R M de Bie
- Department of Neurology (H2-222), Academic Medical Centre, PO Box 22700, University of Amsterdam, 1100 DE Amsterdam, The Netherlands
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163
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Abstract
A review of functional surgery for dystonia is presented. Recently renewed interest in stereotaxy for dystonia has followed the resurgence of pallidotomy and the introduction of deep brain stimulation (DBS) in Parkinson's disease (PD) in the early 1990s. However, even since the 1950s, small series of patients treated with ablative surgery have been carefully studied, providing useful information, notably regarding the tolerability of surgery. In the setting of dystonia, thalamotomy was first performed with substantial benefits, but some authors outlined the great variability in outcome, and the high incidence of operative side-effects. In the 'modern' era of functional surgery for movement disorders, the globus pallidus internus (GPi) has emerged to be currently the best target for dystonia, based on small series of patients published in the last few years. Both bilateral posteroventral pallidotomy (PVP) and bilateral pallidal stimulation, performed by several teams, have benefited a variety of patients with severe dystonia, the most dramatic improvements being seen in primary dystonia with a mutation in the DYT1 gene. Whereas patients with secondary dystonia have often shown a lesser degree of improvement, some publications have nevertheless reported major benefit. There is today a strong need for carefully controlled studies comparing secondary and primary dystonia, DYT1 and non-DYT1 dystonia, ablative surgery and DBS, with additional assessment of neuropsychological changes, especially in children treated with bilateral pallidal procedures.
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Affiliation(s)
- P Krack
- Neurology Department, University of Kiel, Niemannsweg 147, 24105 Kiel, Germany.
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164
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Siderowf A, Gollump SM, Stern MB, Baltuch GH, Riina HA. Emergence of complex, involuntary movements after gamma knife radiosurgery for essential tremor. Mov Disord 2001; 16:965-7. [PMID: 11746633 DOI: 10.1002/mds.1178] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Gamma knife radiosurgery is generally considered a safer alternative to traditional pallidotomy or thalamotomy. We report the case of a 59-year-old patient with essential tremor who developed a complex, disabling movement disorder following gamma knife thalamotomy. This case illustrates the need for long-term follow-up to fully evaluate the potential for complications following radiosurgery.
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Affiliation(s)
- A Siderowf
- Department of Neurology, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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165
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Lehman RM, Micheli-Tzanakou E, Medl A, Hamilton JL. Quantitative on-line analysis of physiological data for lesion placement in pallidotomy. Stereotact Funct Neurosurg 2001; 75:1-15. [PMID: 11416260 DOI: 10.1159/000048378] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
A computerized method of determining the focal point of electrical activity in the pallidum of parkinsonian patients was developed using on-line quantitative physiological data analysis. Thirty patients in a series of 70 were studied in depth. Neuronal activity was recorded from the pallidum using a semi-microelectrode. The signal is inspected visually while its average power, characteristic frequency and complexity are computed. The target locus was indicated by the highest level of global activity in the vicinity of the electrode (signal power maximum), maximal signal complexity and minimal characteristic frequency. Most often, the vertical coordinate required correction. The postoperative clinical and imaging results have indicated the effectiveness of this method.
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Affiliation(s)
- R M Lehman
- Division of Neurosurgery, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, N.J., USA.
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166
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Bhatia K, Brooks DJ, Burn DJ, Clarke CE, Grosset DG, MacMahon DG, Playfer J, Schapira AH, Stewart D, Williams AC. Updated guidelines for the management of Parkinson's disease. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2001; 62:456-70. [PMID: 11530583 DOI: 10.12968/hosp.2001.62.8.1621] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
New data on diagnosis, drug therapy, surgery and psychosocial concerns have emerged since the publication of the 1998 Guidelines for the Management of Parkinson's Disease. This article reviews new data and addresses issues left unanswered in the previous guidelines.
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Affiliation(s)
- K Bhatia
- University Department of Clinical Neurology, Institute of Neurology, London
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167
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Katayama Y, Kasai M, Oshima H, Fukaya C, Yamamoto T, Ogawa K, Mizutani T. Subthalamic nucleus stimulation for Parkinson disease: benefits observed in levodopa-intolerant patients. J Neurosurg 2001; 95:213-21. [PMID: 11780890 DOI: 10.3171/jns.2001.95.2.0213] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT A blinded evaluation of the effects of subthalamic nucleus (STN) stimulation was performed in levodopa-intolerant patients with Parkinson disease (PD). These patients (Group I, seven patients) were moderately or severely disabled (Hoehn and Yahr Stages III-V during the off period), but were receiving only a small dose of medication (levodopa-equivalent dose [LED] 0-400 mg/day) because they suffered unbearable side effects. The results were analyzed in comparison with those obtained in patients with advanced PD (Group II, seven patients) who were severely disabled (Hoehn and Yahr Stages IV and V during the off period), but were treated with a large dose of medication (500-990 mg/day). METHODS The patients were evaluated twice at 6 to 8 months after surgery. To determine the actual benefits afforded by STN stimulation to their overall daily activities, the patients were maintained on their medication regimen with optimal doses and schedules. Stimulation was turned off overnight for at least 12 hours. It was turned on in the morning (or remained turned off), and each patient's best and worst scores on the Unified Parkinson's Disease Rating Scale during waking daytime activity were recorded as on- and off-period scores, respectively. The order of assessment with respect to whether stimulation was occurring was determined randomly. The STN stimulation markedly improved daily activity and total motor scores in Group I patients. The percentage time of immobility (Hoehn and Yahr Stages IV and V) became 0% in patients who were intermittently immobile while not receiving stimulation. Improvements were demonstrated in tremor, rigidity. akinesia, and gait subscores. The STN stimulation produced less marked but still noticeable improvements in the daily activity and total motor scores in Group II patients. The percentage time of immobility as well as the LED was reduced in patients who displayed intermittent immobility with pronounced motor fluctuations while not receiving stimulation. Improvements were demonstrated in tremor, rigidity, and dyskinesia subscores in these patients. In contrast, STN stimulation did not improve the overall daily activities at all in patients who had become unresponsive to a tolerable dose of levodopa and were continuously immobile, even though these patients' tremor and rigidity subscores were still improved by stimulation. CONCLUSIONS Consistent with earlier findings, the great benefit of STN stimulation in levodopa-intolerant patients is that STN stimulation can reduce the level of required levodopa medication. This suggests that STN stimulation could be a therapeutic option for patients with less-advanced PD by allowing levodopa medication to be maintained at as low a dose as possible, and to prevent adverse reactions to the continued use of large-dose levodopa.
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Affiliation(s)
- Y Katayama
- Department of Neurological Surgery, Nihon University School of Medicine, Tokyo, Japan.
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168
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Abstract
Deep brain stimulation (DBS) is making a major impact in patients with advanced Parkinson's disease who continue to be disabled despite the best available medical therapy. Stimulation of the internal segment of the globus pallidus (GPi) or the subthalamic nucleus (STN) can improve tremor, rigidity, bradykinesia and gait disturbances in Parkinson's disease and improve the day-to-day activities of patients with these disabling symptoms. While the mechanism of action of DBS remains poorly understood, the success of technique in the treatment of movement disorders is bringing into question traditional concepts of the organization and of the basal ganglia and spearheading a re-examination of the nature and function of brain areas involved in the control of movement. Future developments in this rapidly advancing area will include the elucidation of the mechanism of action of DBS and technical advances in surgical techniques, in electrode design and in choosing better stimulation parameters. These advances will improve the scope and effectiveness of DBS and expand its clinical indications.
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Affiliation(s)
- A M. Lozano
- Division of Neurosurgery, The Toronto Western Hospital, 399 Bathurst Street, Suite 2-433 McL, ON M5T 258, Toronto, Canada
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169
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Levy R, Dostrovsky JO, Lang AE, Sime E, Hutchison WD, Lozano AM. Effects of apomorphine on subthalamic nucleus and globus pallidus internus neurons in patients with Parkinson's disease. J Neurophysiol 2001; 86:249-60. [PMID: 11431506 DOI: 10.1152/jn.2001.86.1.249] [Citation(s) in RCA: 203] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study examines the effect of apomorphine (APO), a nonselective D(1)- and D(2)-dopamine receptor agonist, on the firing activity of neurons in the subthalamic nucleus (STN) and internal segment of the globus pallidus (GPi) in patients with Parkinson's disease (PD). Single-unit microelectrode recordings were conducted in 13 patients undergoing implantation of deep brain stimulation electrodes in STN and 6 patients undergoing a pallidotomy. Doses of APO (2.5-8 mg) were sufficient to produce an ON state, but not intended to induce dyskinetic movements. Following baseline recordings from a single neuron, APO was administered and the activity of the neuron followed for an average of 15 min. The spontaneous discharge of neurons encountered before (n = 309), during (n = 146, 10-60 min), and after the effect of APO had waned (n = 127, >60 min) was also sampled, and the response to passive joint movements was noted. In both nuclei, APO increased the overall proportion of spikes in burst discharges (as detected with Poisson "surprise" analysis), and a greater proportion of cells with an irregular discharge pattern was observed. APO significantly decreased the overall firing rates of GPi neurons (P < 0.01), but there was no change in the overall firing rate of neurons in the STN (P = 0.68). However, the mean firing rates of STN neurons during APO-induced movements (choreic or dystonic dyskinesias) that occurred in four patients were significantly lower than OFF-period baseline values (P < 0.05). Concurrent with a reduction in limb tremor, the percentage of cells with tremor-related activity (TCs) was found to be significantly reduced from 19 to 6% in the STN and 14 to 0% in the GPi following APO administration. APO also decreased the firing rate of STN TCs (P < 0.05). During the OFF state, more than 15% of neurons tested (STN = 93, GPi = 63) responded to passive movement of two or more joints. After APO, this proportion decreased significantly to 7% of STN cells and 4% of GPi cells (STN = 28, GPi = 26). These findings suggest that the APO-induced amelioration of parkinsonian symptoms is not solely due to a decrease in overall activity in the GPi or STN as predicted by the current model of basal ganglia function in PD.
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Affiliation(s)
- R Levy
- Department of Physiology, Faculty of Medicine, University of Toronto, Ontario M5S 1A8, Canada
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170
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Teive HA, Sá DS, Grande CV, Antoniuk A, Werneck LC. Bilateral pallidotomy for generalized dystonia. ARQUIVOS DE NEURO-PSIQUIATRIA 2001; 59:353-7. [PMID: 11460178 DOI: 10.1590/s0004-282x2001000300008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of bilateral pallidotomies in five patients with generalized dystonia. BACKGROUND Generalized dystonias are frequently a therapeutic challenge, with poor responses to pharmacological treatment. GPi (globus pallidus internus) pallidotomies for Parkinson's disease ameliorate all kinds of dyskinesias/dystonia, and recent studies reported a marked improvement of refractory dystonias with this procedure. METHODS Five patients with generalized dystonias refractory to medical treatment were selected; one posttraumatic and four idiopathic. The decision to perform bilateral procedures was based on the predominant axial involvement in these patients. Dystonia severity was assessed with the Burke-Fahn-Marsden Dystonia Scale (BFM). Simultaneous procedures were performed in all but one patient, who had a staged procedure. They were reevaluated with the same scale (BFM) by an unblinded rater at 1, 2, 3, 30, 60, 90, 120 and 180 days post-operatively. RESULTS The four patients with idiopathic dystonia showed a progressive improvement up to three months; the patient with posttraumatic dystonia relapsed at three months. One patient had a marked improvement, being able to discontinue all the medications. A mean decrease in the BFM scores of 52,58% was noted. One patient had a trans-operative motor seizure followed by a transient hemiparesis secondary to rack hemorrhage; other was lethargic up to three days after the procedure. CONCLUSIONS Our results show that bilateral GPi pallidotomies may be a safe and effective approach to medically refractory generalized dystonias; it can also be speculated that the posttraumatic subgroup may not benefit with this procedure.
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Affiliation(s)
- H A Teive
- Division of Neurology, Department of Internal Medicine, Hospital de Clínicas, Federal University of Paraná, PR, Brazil. hagteive@@mps.com.br
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171
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Hariz MI, Bergenheim AT. A 10-year follow-up review of patients who underwent Leksell's posteroventral pallidotomy for Parkinson disease. J Neurosurg 2001; 94:552-8. [PMID: 11302652 DOI: 10.3171/jns.2001.94.4.0552] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The clinical condition of patients with Parkinson disease (PD) who had undergone posteroventral pallidotomy (PVP) between 1985 and 1990 was evaluated at a mean of 10 years postsurgery. These patients were part of a larger series described in the first paper on Leksell's PVP that was published in 1992. METHODS Thirteen consecutive patients who had undergone pallidotomy at the University Hospital of Northern Sweden were tracked. Hospital and clinic records that had been updated regularly by the patients' various neurologists, geriatricians, and other clinicians were reviewed. Emphasis was placed on assessing the evolution of PD symptoms after surgery, and changes in the general health and social condition of the patients. The mean follow-up duration was 10.5 years (range 3-13.5 years). Five patients underwent a total of seven subsequent surgeries for their PD, 4 months to 11 years after the initial pallidotomy. The mean Hoehn and Yahr stage was 3 at the first surgery and 3.7 at the last follow-up review (p < 0.005). Dosages of levodopa and dopamine agonists were increased in all patients, without recurrence or induction of dyskinesias contralateral to the pallidotomy. Contralateral tremor, if it was initially controlled by surgery, remained improved. However, most patients exhibited a gradual recurrence of akinesia and an increase in gait freezing. Cognitive decline and presentation with diseases unrelated to PD were not uncommon. CONCLUSIONS The long-term effect of PVP on dyskinesias was not only curative but also appeared to be prophylactic. Contralateral tremor was improved in the majority of patients, although additional surgeries for PD were needed in some patients. Further progression of axial and akinetic symptoms, and an eventual decline in cognition together with other concomitant illnesses, contributed to increased disability in several patients.
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Affiliation(s)
- M I Hariz
- Department of Neurosurgery, University Hospital of Northern Sweden, Umeå.
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172
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Landy HJ, Weiner WJ, Calancie B, Harris W, Shulman LM, Singer C, Abrams L, Bowen B. Electromyography during stereotactic pallidotomy for Parkinson's disease. Stereotact Funct Neurosurg 2001; 74:21-9. [PMID: 11124661 DOI: 10.1159/000056459] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
In stereotactic pallidotomy for Parkinson's disease, care must be taken to avoid internal capsule injury while maximizing improvement of rigidity and tremor. In 21 patients, intraoperative electromyography (EMG) was used to assess stimulation thresholds required for capsular responses and to monitor muscle tone and tremor. Surface EMG electrodes were placed on the face and multiple muscle groups of the extremities. The stimulation and lesion electrode was introduced via MRI-guided stereotaxis toward a point 2-3 mm anterior to the midcommissural point, 5-6 mm inferior to the AC-PC plane, and 21-22 mm lateral to the midline. Exact targets were modified according to MRI-visualized anatomy. With stimulation at 5 and 50 Hz, thresholds for detection of EMG responses were usually seen at 4-5 mA. EMG responses were consistently seen prior to visual observation of muscle activity. Timing of EMG response relative to stimulus aided in differentiating stimulus-related movement from spontaneous tremor. Resting spontaneous EMG activity was seen to decrease as rigidity was improved by incremental lesion production. EMG activity related to tremor was recorded; tremor decrease by lesion production was documented by EMG recording. Patient cooperation with physiologic testing during stimulation and lesion production may become limited. Intraoperative EMG monitoring provides an adjunct to improve reliability of assessment of capsular stimulation and rigidity while providing documentation of lesion impact on rigidity and tremor.
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Affiliation(s)
- H J Landy
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL 33136, USA
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173
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Wu YR, Levy R, Ashby P, Tasker RR, Dostrovsky JO. Does stimulation of the GPi control dyskinesia by activating inhibitory axons? Mov Disord 2001; 16:208-16. [PMID: 11295772 DOI: 10.1002/mds.1046] [Citation(s) in RCA: 143] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
A 69-year-old woman with Parkinson's disease and levodopa-induced dyskinesias had a deep brain stimulation (DBS) electrode inserted into the right globus pallidus internus (GPi). During the operation, the GPi was mapped with dual microelectrode recordings. Stimulation through one microelectrode in GPi inhibited the firing of GPi neurons recorded with another microelectrode 600--1,000 microm distant. The inhibition could be obtained with pulse widths of 150 micros and intensities as low as 10 microA. Single stimuli inhibited GPi neurons for approximately 50 ms. Trains of 300 Hz stimuli inhibited GPi neuron firing almost completely. Postoperatively, stimulation through macroelectrode contacts located in the posterior ventral pallidum controlled the patient's dyskinesias. The effect could be obtained with pulse widths of 50 micros and frequencies as low as 70--80 Hz. We postulate stimulation of the ventral pallidum controls dyskinesias by activating large axons which inhibit GPi neurons.
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Affiliation(s)
- Y R Wu
- Second Department of Neurology, Chang-Gung Memorial Hospital, Taipei, Taiwan
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174
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Intemann PM, Masterman D, Subramanian I, DeSalles A, Behnke E, Frysinger R, Bronstein JM. Staged bilateral pallidotomy for treatment of Parkinson disease. J Neurosurg 2001; 94:437-44. [PMID: 11235949 DOI: 10.3171/jns.2001.94.3.0437] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Several investigators have described the motor benefits derived from performing unilateral stereotactic pallidotomy for the treatment of Parkinson disease (PD), but little is known about the efficacy and complication rates of bilateral procedures. The goal of this study was to assess both these factors in 12 patients. METHODS Eleven patients with medically intractable PD underwent staged bilateral pallidotomy and one patient underwent a simultaneous bilateral procedure. Unilateral pallidotomy resulted in an improvement in the patients' Unified Parkinson Disease Rating Scale (UPDRS) total scores and motor subscores, Hoehn and Yahr stages, and Schwab and England Activities of Daily Living scores. There were no complications. The second procedures were performed 5 to 25 months after the first, and nearly complete 3-month follow-up data are available for eight of these patients. Staged bilateral pallidotomy did result in further improvements in some symptoms, but the patients proved to be less responsive to levodopa. In contrast to outcomes of the initial unilateral pallidotomy, there were significant complications. One patient suffered an acute stroke, two patients suffered delayed infarctions of the internal capsule, four patients had mild-to-moderate worsening of speech and increased drooling, and one patient complained of worsening memory. CONCLUSIONS Bilateral pallidotomy results in modest benefits but is associated with an increased risk of complications.
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Affiliation(s)
- P M Intemann
- Department of Neurology, University of California at Los Angeles School of Medicine, 90024, USA
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175
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Van Horn G, Hassenbusch SJ, Zouridakis G, Mullani NA, Wilde MC, Papanicolaou AC. Pallidotomy: a comparison of responders and nonresponders. Neurosurgery 2001; 48:263-71; discussion 271-3. [PMID: 11220368 DOI: 10.1097/00006123-200102000-00002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE We reviewed a prospective series of 32 unilateral, large-volume, microelectrode-guided posteroventral pallidotomies to determine the differences between responsive and nonresponsive patients. METHODS Our patients underwent extensive pre- and postoperative evaluations. One year postoperatively, we correlated the outcomes of 25 patients with their histories, physical findings, neuropsychological assessments, and lesion characteristics to further understand the indications, limitations, and pitfalls of unilateral pallidotomy. Our group judged responsiveness by comparing the preoperative total Unified Parkinson's Disease Rating Scale off-state scores with those obtained 1 year postoperatively. A score indicating greater than 20% improvement at 1-year follow-up was rated a good outcome; improvement of greater than 40% was rated an excellent outcome. RESULTS Although most patients sustained long-term benefits, some demonstrated little or no improvement. Patient and lesion factors influenced outcome. Younger age (<60 yr), tremor, unilateral predominance, L-dopa responsiveness, motor fluctuations with dyskinesia, and good lesion placement predicted a good response to unilateral pallidotomy. Advanced age (>70 yr), absence of tremor, increased duration of disease, reduced responsiveness to L-dopa, frontal behavioral changes, prominent apraxic phenomena, and improper lesion placement predicted a poor response. CONCLUSION Unilateral, large-volume pallidotomy with precise lesion control provides long-lasting benefits for carefully selected patients.
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Affiliation(s)
- G Van Horn
- Department of Neurology, University of Texas Health Science Center, University of Texas Medical School, Houston, USA.
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176
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Van Horn G, Hassenbusch SJ, Zouridakis G, Mullani NA, Wilde MC, Papanicolaou AC. Pallidotomy: A Comparison of Responders and Nonresponders. Neurosurgery 2001. [DOI: 10.1227/00006123-200102000-00002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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177
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Alvarez L, Macias R, Guridi J, Lopez G, Alvarez E, Maragoto C, Teijeiro J, Torres A, Pavon N, Rodriguez-Oroz MC, Ochoa L, Hetherington H, Juncos J, DeLong MR, Obeso JA. Dorsal subthalamotomy for Parkinson's disease. Mov Disord 2001; 16:72-8. [PMID: 11215596 DOI: 10.1002/1531-8257(200101)16:1<72::aid-mds1019>3.0.co;2-6] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
We report our experience of unilateral subthalamotomy in patients with Parkinson's disease (PD). Eleven patients were included in a pilot, open-labeled study to assess the effect of unilateral lesion of the subthalamic nucleus (STN) with a minimum of 12 months of follow-up. The guidelines of CAPIT (Core Assessment Program for Intracerebral Transplantation) were followed for recruitment into the study and follow-up assessment. Levodopa equivalents daily intake (mean 967 mg) were unchanged during the first 12 months in all but one patient who stopped medication. The sensorimotor region of the STN was defined by semimicrorecording and stimulation and a thermolytic lesion was placed accordingly. There was a significant reduction in both UPDRS parts II and III in the "off" state at 1-, 6-, and 12-month follow-up. This effect was maintained in four patients up to 24 months. The dyskinesia score did not change postoperatively. Lesion-induced dyskinesias were not a management problem except in one patient who developed a large infarction several days postsurgery. This initial study indicates that a lesion of the STN is not generally associated with hemiballismus in PD. Subthalamotomy may induce considerable motor benefit and could become another surgical option under specific circumstances.
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Affiliation(s)
- L Alvarez
- Movement Disorders Clinic and Functional Neurosurgery Service, Centro Internacional de Restauracion Neurologica, La Habana, Cuba
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Hoff JI, van den Plas AA, Wagemans EA, van Hilten JJ. Accelerometric assessment of levodopa-induced dyskinesias in Parkinson's disease. Mov Disord 2001; 16:58-61. [PMID: 11215593 DOI: 10.1002/1531-8257(200101)16:1<58::aid-mds1018>3.0.co;2-9] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Our objective was to develop parameters for objective ambulatory measurements of levodopa-induced dyskinesias (LID) in patients with Parkinson's disease (PD). Twenty-three PD patients with mild to severe LID were submitted to a standardized protocol of 1-minute recordings during rest, talking, stress, and four activities of daily life (ADL). Patients were simultaneously monitored with portable multi-channel accelerometry (four pairs of bi-axial sensors mounted onto the most affected arm, leg, and at the trunk) and recorded by video. LID severity was assessed with a modified Abnormal Involuntary Movement Scale (m-AIMS). The signals were analyzed, and every 1/8-second interval the amplitude was obtained of the dominant frequency within 1-4 Hz and 4-8 Hz frequency bands (Amp1-4 and Amp4-8). For both measures, convergent validity, reproducibility, and responsiveness were determined. In absence of voluntary movements, a significant relation was found between Amp1-4 and Amp4-8 and m-AIMS. Repeated measurements during rest showed a high reproducibility (intraclass correlation coefficient = 0.90 [Amp1-4] and 0.86 [Amp4-8]). The extent to which LID increased with talking and stress correlated significantly (p = 0.02) between the objective and clinical measures (intraclass correlation for differences = 0.67). During ADL, LID occurred in a similar frequency band as voluntary movements and only Amp1-4 and Amp4-8 of the trunk and leg sensor remained highly correlated with m-AIMS. Although objective measures of LID are reliable and responsive, they fail to distinguish LID from voluntary movements. These measures are of value only when obtained during rest (all sensor sites) or during ADL when derived from those body segments that are normally not involved in these ADL tasks (trunk and leg).
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Affiliation(s)
- J I Hoff
- Department of Neurology, Leiden University Medical Center, The Netherlands
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180
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Abstract
OBJECT The authors conducted an evidence-based review of contemporary published articles on pallidotomy to obtain an appraisal of this procedure in the treatment of Parkinson disease (PD). METHODS A search of the Pubmed database performed using the key word "pallidotomy" yielded 263 articles cited between January 1, 1992, and July 1, 1999. Articles that included original, nonduplicated descriptions of patients with PD treated with radiofrequency pallidotomy were selected. In 85 articles identified for critical review, 1959 patients with PD underwent pallidotomies at 40 centers in 12 countries. There were 1735 unilateral (88.6%) and 224 bilateral procedures (11.4%). The mean age of the patients was 61.4+/-3.6 years and the mean duration of PD symptoms in these patients was 12.3+/-1.9 years. Microelectrode recordings were used in 46.2% of cases. Outcomes were objectively documented using the Unified Parkinson Disease Rating Scale (UPDRS) in 501 (25.6%) of the cases at 6 months and in 218 (11.1%) of the cases at 1 year. There was a consensus on the benefits of pallidotomy for off period motor function and on period, drug-induced dyskinesias, with variations in the extent of symptomatic benefit across studies. At the 1-year assessment, the mean improvement in the UPDRS motor score during off periods was 45.3% and the mean improvement in contralateral dyskinesias during on periods was 86.4%. The overall mortality rate was 0.4% and the rate of persistent adverse effects was estimated at 14%. Major adverse events, including intracerebral hemorrhages, contralateral weakness, and visual field defects, occurred in 5.3% of patients reported. CONCLUSIONS Unilateral pallidotomy is effective and relatively safe in the treatment of PD; however, limited data are available on the long-term outcome of this procedure.
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Affiliation(s)
- A Alkhani
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Ontario, Canada
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181
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Merello M, Cammarota A, Cerquetti D, Leiguarda RC. Mismatch between electrophysiologically defined and ventriculography based theoretical targets for posteroventral pallidotomy in Parkinson's disease. J Neurol Neurosurg Psychiatry 2000; 69:787-91. [PMID: 11080233 PMCID: PMC1737191 DOI: 10.1136/jnnp.69.6.787] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Over the past few years many reports have shown that posteroventral pallidotomy is an effective method for treating advanced cases of Parkinson's disease. The main differences with earlier descriptions were the use of standardised evaluation with new high resolution MRI studies and of single cell microrecording which can electrophysiologically define the sensorimotor portion of the internal globus pallidus (GPi). The present study was performed on a consecutive series of 40 patients with Parkinson's disease who underwent posteroventral pallidotomy to determine localisation discrepancies between the ventriculography based theoretical and the electrophysiologically defined target for posteroventral pallidotomy. METHODS The tentative location of the posteroventral GPi portion was defined according to the proportional Talairach system. Single cell recording was performed in all patients. The definitive target was chosen according to the feasibility of recording single cells with GPi cell features, including the presence of motor drive and correct identification of the internal capsule and of the optic tract by activity recording and microstimulation. RESULTS In all 40 patients the electrophysiologically defined sensorimotor portion of the GPi was lesioned, with significantly improved cardinal Parkinson's disease symptoms as well as levodopa induced dyskinesias, without damage to the internal capsule or optic tract. Significant differences between the localisation of the ventriculography based theoretical versus electrophysiological target were found in depth (p<0.0008) and posteriority (p<0.04). No significant differences were found in laterality between both approaches. Difference ranges were 8 mm for laterality, 6.5 mm for depth, and 10 mm for posteriority. CONCLUSIONS Electrophysiologically defined lesion of GPi for posteroventral pallidotomy, shown to be effective for treating Parkinson's disease, is located at a significantly different site from the ventriculography based theoretical target.
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Affiliation(s)
- M Merello
- Movement Disorders Section, Raul Carrea Institute for Neurological Research (FLENI), Montañeses 2325, (1428) Buenos Aires, Argentina.
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182
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Abstract
The aim of current treatment of Parkinson's disease is to ameliorate the symptoms while seeking to lessen the potential development of late levodopa complications. To this end, there is ample evidence that the early use of dopamine agonists is beneficial in younger Parkinsonian patients but monotherapy with dopamine agonists is for only a select few. Nonergot dopamine agonists offer the potential for fewer side effects. Lower dose levodopa therapy delays the onset and reduces severity of dyskinesia and end of dose failure. However levodopa remains the treatment of choice in Parkinson's disease and should not be restricted unnecessarily in patients with disability. There is no evidence that levodopa is toxic to dopaminergic neurons in people with Parkinson's disease. As yet, no drugs are of proven neuroprotective value. Dopamine agonists, catechol-o-methyltransferase inhibitors, amantadine and apomorphine have differing but beneficial roles in the management of levodopa side effects. Ablative surgery and deep brain stimulation of thalamus, globus pallidus and subthalamic nucleus are increasingly available but choice of procedure depends not just on patient symptomatology, but also on local experience and results. Ideally, deep brain stimulation is the treatment of choice as it offers less morbidity than bilateral ablative surgery, the possibility of postoperative adjustments and the potential for reversibility if better treatments become available.
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Affiliation(s)
- M A Hely
- Department of Neurology, Westmead Hospital, Westmead, NSW, 2145, Australia
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183
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Double blinded evaluation of the effects of pallidal and subthalamic nucleus stimulation on daytime activity in advanced Parkinson's disease. Parkinsonism Relat Disord 2000; 7:35-40. [PMID: 11008194 DOI: 10.1016/s1353-8020(00)00046-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The results of a double blinded evaluation of the effects of globus pallidus (GPi; n=7) and subthalamic nucleus (STN; n=11) stimulation in patients with advanced Parkinson's disease are summarized. The patients were evaluated at 6-8months after surgery. In order to determine the benefits afforded by the stimulation to the actual daily activities, the patients were maintained on-medication with optimal doses and schedules. The stimulation was turned off overnight for at least 12h. It was turned on in the morning (or maintained turned off), and the best and worst scores during daytime activity were recorded, as on-period and off-period scores, respectively. A reduction in total motor score on the Unified Parkinson's Disease Rating Scale was clearly elicited by GPi and STN stimulation at both the off-period (-57 and -29%, respectively) and the on-period (-36 and -25%, respectively). The difference in effects between GPi and STN stimulation appeared to be due largely to an unintended difference in the patients' preoperative symptoms. The benefits provided by stimulation to the actual daily activities appears to be limited in patients who have become unresponsive to a large dose of levodopa. Two advantages of GPi and STN stimulation were identified. Firstly, the stimulation can supplement a reduced action of levodopa during the off-period. It thus improves the patient's daily activities through attenuation of the motor fluctuations. Secondly, the stimulation can replace part of the action of levodopa during the on-period. It thus attenuates dopa-induced dyskinesia through a reduced dose of medication. More importantly, the stimulation improves the daily activities in dopa-intolerant patients who are being administered a small dose of levodopa because of unbearable side effects. In addition, GPi stimulation has its own inhibitory effect on dopa-induced dyskinesia. Clinically important improvement was observed in severe gait freezing in 2 patients following unilateral anterodorsal GPi stimulation on the right side alone.
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184
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Graybiel AM, Canales JJ, Capper-Loup C. Levodopa-induced dyskinesias and dopamine-dependent stereotypies: a new hypothesis. Trends Neurosci 2000; 23:S71-7. [PMID: 11052223 DOI: 10.1016/s1471-1931(00)00027-6] [Citation(s) in RCA: 165] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The basal ganglia are thought to modulate the release or inhibition of movements by way of direct and indirect pathways that act as a push-pull system of cortico-basal ganglia circuits. Here we suggest a three-pathway model of the basal ganglia that takes into consideration the fundamental division of the striatum into striosomes and extrastriosomal matrix. We suggest that, in addition to the balance between direct and indirect pathways on which normal release of individual movements depends, the balance of activity between these matrix-based pathways and the striosomal pathway regulates the frequency of release of given behavioral sequences and, thus, modulates behavioral focus. Differential plasticity in these compartmentally organized circuits might contribute to the development of L-dopa-induced dyskinesias under parkinsonian conditions and dopamine-receptor-agonist induced stereotypies under normal conditions.
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Affiliation(s)
- A M Graybiel
- Dept of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge 02139, USA
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185
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Abstract
Parkinson's disease (PD) is an age-related neurodegenerative disorder with an average onset age of 60 years. In the United States, approximately one million persons suffer from PD, and there are 60,000 newly diagnosed cases every year. The estimated cost of PD to society is $27 billion per year. Based on United States Census Bureau projections, it is estimated that the frequency of PD will increase fourfold by the year 2040, making it an even larger burden on patients, their families and society.
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Affiliation(s)
- J A Obeso
- Dept of Neurology and Neurosurgery, Neuroscience Center, Clínica Universitaria and Medical School, Pamplona, Spain
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186
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Obeso JA, Rodríguez-Oroz MC, Rodríguez M, Lanciego JL, Artieda J, Gonzalo N, Olanow CW. Pathophysiology of the basal ganglia in Parkinson's disease. Trends Neurosci 2000; 23:S8-19. [PMID: 11052215 DOI: 10.1016/s1471-1931(00)00028-8] [Citation(s) in RCA: 544] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Insight into the organization of the basal ganglia in the normal, parkinsonian and L-dopa-induced dyskinesia states is critical for the development of newer and more effective therapies for Parkinson's disease. We believe that the basal ganglia can no longer be thought of as a unidirectional linear system that transfers information based solely on a firing-rate code. Rather, we propose that the basal ganglia is a highly organized network, with operational characteristics that simulate a non-linear dynamic system.
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Affiliation(s)
- J A Obeso
- Dept of Neurology, Neuroscience Centre, Clinica Universitaria and Medical School, University of Navarra, Pamplona, Spain
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187
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Olanow W, Schapira AH, Rascol O. Continuous dopamine-receptor stimulation in early Parkinson's disease. Trends Neurosci 2000; 23:S117-26. [PMID: 11052229 DOI: 10.1016/s1471-1931(00)00030-6] [Citation(s) in RCA: 145] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chronic L-dopa therapy is associated with the development of motor complications in the majority of Parkinson's disease (PD) patients. Although the precise mechanism responsible for these events is not known, increasing laboratory and clinical evidence points to a sequence of events that is initiated by abnormal pulsatile stimulation of dopamine receptors by the intermittent administration of agents with short half-lives such as L-dopa. Initiating therapy with a long-acting dopamine agonist has been shown to delay the onset and reduce the severity of motor complications in MPTP monkeys and PD patients. Administering L-dopa with a catechol-O-methyltransferase (COMT) inhibitor to block its peripheral metabolism increases its plasma half-life and might have a similar effect. Thus, a rational strategy for treating PD would be to initiate therapy with a long-acting dopamine-receptor agonist and supplement at the appropriate time with L-dopa combined with a COMT inhibitor.
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Affiliation(s)
- W Olanow
- Dept of Neurology, Mount Sinai School of Medicine, New York, NY 10029, USA
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188
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Pal PK, Samii A, Kishore A, Schulzer M, Mak E, Yardley S, Turnbull IM, Calne DB. Long term outcome of unilateral pallidotomy: follow up of 15 patients for 3 years. J Neurol Neurosurg Psychiatry 2000; 69:337-44. [PMID: 10945808 PMCID: PMC1737095 DOI: 10.1136/jnnp.69.3.337] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES With the advent of new antiparkinsonian drug therapy and promising results from subthalamic and pallidal stimulation, this study evaluated the long term efficacy of unilateral pallidotomy, a technique which has gained popularity over the past decade for the management of advanced Parkinson's disease. METHODS The 15 patients reported here are part of the original cohort of 24 patients who underwent posteroventral pallidotomy for motor fluctuations and disabling dyskinesias 3 years ago as part of a prospective study. Evaluation scales included the unified Parkinson's disease rating scale, the Goetz dyskinesia scale, and the Purdue pegboard test. RESULTS When compared with the prepallidotomy scores, the reduction in the limb dyskinesias and off state tremor scores persisted on the side contralateral to pallidotomy at the end of 3 years (dyskinesias were reduced by 64% (p<0.01) and tremor by 63% (p<0.05). Other measures tended to deteriorate. The dosage of antiparkinsonian medications did not change significantly from 3 months prepallidotomy to 3 years postpallidotomy. CONCLUSIONS Although unilateral pallidotomy is useful in controlling the contralateral dyskinesias and tremor 3 years after surgery, all other early benefits disappear and activities of daily living continue to worsen.
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Affiliation(s)
- P K Pal
- Neurodegenerative Disorders Centre, M 36 Purdy Pavilion, Vancouver Hospital and Health Sciences Centre, 2221 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5
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189
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Abstract
The neuropsychologic evaluation of patients under consideration for movement disorder surgery is recognized as being an essential component of the preoperative process. Patients with early-stage concomitant dementia must be identified and the relative risk of postoperative cognitive decline evaluated. Knowledge of the patterns of an individual's strengths and weaknesses might also be a factor in deciding on a neurosurgical procedure. Although the advent of pallidal deep brain stimulation (DBS) has possibly resulted in reduced risk of induced cognitive impairment, even this procedure has been associated with negative sequelae. DBS within the subthalamic nucleus is becoming the method of choice and this may lead to cognitive and behavioral compromise, especially in the elderly patient. The team considering the establishment of neurosurgical treatment is often at a loss to decide how much neuropsychologic testing is required to determine relative risks of cognitive or behavioral morbidity as a consequence of the procedure. A brief summary of expected outcome and of pertinent family process and psychodynamic issues are addressed. This article is intended to serve as a guide to permit clinicians to choose the appropriate length and depth of neuropsychologic assessment, but also to highlight the confounding factors often present in these patients.
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Affiliation(s)
- J A Saint-Cyr
- Department of Surgery, University of Toronto, Ontario, Canada
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190
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Obwegeser AA, Uitti RJ, Lucas JA, Witte RJ, Turk MF, Wharen RE. Predictors of neuropsychological outcome in patients following microelectrode-guided pallidotomy for Parkinson's disease. J Neurosurg 2000; 93:410-20. [PMID: 10969938 DOI: 10.3171/jns.2000.93.3.0410] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors studied neuropsychological performance following microelectrode-guided posteroventral pallidotomy in patients with Parkinson's disease (PD) and evaluated correlations with presurgical and surgical factors. METHODS Neuropsychological changes 3 months (43 patients) and 12 months (27 patients) after microelectrode-guided pallidotomy for PD are reported in a series of 44 consecutive patients with the disease, who improved neurologically, as measured by the Unified Parkinson's Disease Rating Scale (UPDRS) in both the "off' (p<0.001) and best "on" (p<0.001) states. Findings of the vocabulary subtest of the Wechsler Adult Intelligence Scale-Revised (p<0.01), Letter Fluency (p<0.001), Verbal Fluency for semantic categories (p<0.001), and the Wisconsin Card Sorting Test (p<0.01) showed a significant decline in neuropsychological performance in patients 3 months after undergoing left-sided pallidotomy. Impairment in the language domain (semantic fluency) persisted at the 12-month follow-up examination (p<0.01). Visual memory improved after right-sided pallidotomies (p<0.01 after 3 months), with a nonsignificant trend toward persistent improvement 1 year postsurgery (p<0.02 after 12 months). Preoperative semantic fluency was influenced by patient age (p<0.001) and by the width of the third ventricle (p<0.05), as measured by magnetic resonance imaging. A regression model revealed that semantic fluency 3 months postoperatively was significantly affected by the baseline score (p<0.001), side of surgery (p<0.001), handedness (p<0.01), and patient age (p<0.05). However, postoperative lesion volume, lesion location, number of tracks, number of lesions, distance from anatomical landmarks, or UPDRS score did not significantly contribute to neuropsychological outcome. CONCLUSIONS Neuropsychological changes in a cohort of patients with PD who underwent pallidotomy and experienced excellent clinical benefits and minimum postoperative complications, emphasize the importance of neuropsychological examinations and further investigation of predictive factors.
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Affiliation(s)
- A A Obwegeser
- Department of Neurosurgery, Mayo Clinic Jacksonville, Florida, USA
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191
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Angelini L, Nardocci N, Estienne M, Conti C, Dones I, Broggi G. Life-threatening dystonia-dyskinesias in a child: successful treatment with bilateral pallidal stimulation. Mov Disord 2000; 15:1010-2. [PMID: 11009215 DOI: 10.1002/1531-8257(200009)15:5<1010::aid-mds1039>3.0.co;2-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We report a 13-year-old boy who developed severe, refractory dystonia-dyskinesias as an abrupt worsening of a previously nonprogressive movement disorder. The movements became continuous, requiring artificial respiration and continuous sedation in the intensive-care unit. Various drugs and drug combinations failed to achieve control. The child was then treated successfully with bilateral pallidal (GPi) stimulation as shown in the videotape. Four months later and without medication, the boy regained autonomous gait and audible speech; his neurologic condition continues to improve.
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Affiliation(s)
- L Angelini
- Department of Neuropediatrics, National Neurological Institute C. Besta, Milan, Italy
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192
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Abstract
L-Dopa-induced dyskinesias constitute a challenge to the management of advanced Parkinson's disease. According to recent reports, treatment with the NMDA receptor antagonist amantadine may significantly diminish L-dopa-induced dyskinesias. In the present study, the effect of amantadine on L-dopa-induced dykinesias was assessed in a 5-week, double-blind crossover trial. Dyskinesia severity as assessed following oral L-dopa challenges and by self-scoring dyskinesia diaries were reduced approximately 50% after amantadine treatment compared with baseline or placebo phases. Similarly, dyskinesia assessments on the Unified Parkinson's Disease Rating Scale, part IV (items 32 and 33) also revealed significant improvement after treatment with amantadine. The magnitude of the L-dopa motor response to oral challenges was not different after amantadine or placebo treatment, and there was no significant reduction of daily off-time when patients received active treatment. These results confirm previous observations concerning the antidyskinetic potential of amantadine.
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Affiliation(s)
- E Luginger
- Department of Neurology, University Hospital Innsbruck, Austria
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193
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Aguiar PM, Ferraz HB, Ferraz FP, Saba RA, Hisatugo MK, Andrade LA. Motor performance after posteroventral pallidotomy and VIM-thalamotomy in Parkinson's disease: a 1-year follow-up study. ARQUIVOS DE NEURO-PSIQUIATRIA 2000; 58:830-5. [PMID: 11018819 DOI: 10.1590/s0004-282x2000000500007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Twenty-three patients with Parkinson's disease underwent stereotactic surgery. To study the long-term motor performance, the patients were evaluated at the pre-operative period and at the 1st, 3rd, 6th, and 12th post-operative months, with the following scales: Unified Parkinson's Disease Rating Scale (UPDRS) motor score and Larsen's Scale for Dyskinesias. The patients under levodopa therapy were assessed both in "on" and "off" periods. Fourteen unilateral ventrolateral thalamotomies (VLT), 4 unilateral posteroventral pallidotomies (PVP), 2 bilateral PVP, and 3 VLT with contralateral PVP were performed. The motor improvement was significant and long-lasting in the "off" period, except for 2 patients. The "on" period quality improved, mainly due to the control of dyskinesias. The improvement of dyskinesias was long-lasting for the majority of the patients. There was no significant decrease in the levodopa dose. Three patients showed permanent complications, but none was severe.
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Affiliation(s)
- P M Aguiar
- Department of Neurology and Neurosurgery, Escola Paulista de Medicina, Universidade Federal de São Paulo, Brazil
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194
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Rettig GM, York MK, Lai EC, Jankovic J, Krauss JK, Grossman RG, Levin HS. Neuropsychological outcome after unilateral pallidotomy for the treatment of Parkinson's disease. J Neurol Neurosurg Psychiatry 2000; 69:326-36. [PMID: 10945807 PMCID: PMC1737102 DOI: 10.1136/jnnp.69.3.326] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the long term cognitive outcome of unilateral posteroventral pallidotomy (PVP) and the overall efficacy of the surgery. METHODS Forty two (29 left and 13 right PVP) patients with Parkinson's disease underwent neurological and neuropsychological testing before PVP and at 3 and 12 months after PVP. The neuropsychological testing battery emphasised measures of verbal learning and memory, visuospatial abilities, speed of information processing, executive functioning, and affective functioning. RESULTS All patients demonstrated motor improvements after surgery during their off state, and 86% of patients also showed improvements in motor functioning in their on state. Repeated measures ANOVA showed significant improvements in confrontational naming, visuospatial organisation, and affective functioning 3 months and 12 months after surgery, with inconsistent improvements in executive functioning 12 months post-PVP. Patients demonstrated a transient impairment in verbal memory, with verbal learning performance returning to baseline 12 months post-PVP after a significant decline 3 months after PVP. When three patients with lesions extending outside of the PVP were excluded from the analysis, a decline in verbal fluency performance after PVP was not found to be significant. Differences due to side of lesion placement were not found on any of the cognitive measures. CONCLUSIONS In the largest long term follow up study reported to date, the cognitive changes found up to a year after PVP are minimal compared with the robust improvements in motor function. The findings highlight the need to investigate the relation between the specific fibre tracts affected by the lesions and cognitive outcome.
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Affiliation(s)
- G M Rettig
- Department of Neurosurgery, Baylor College of Medicine and The Methodist Hospital, 6560 Fannin, Suite 944, Houston, Texas 77030, USA
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195
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Guridi J, Ramos E, Linazasoro G, Obeso JA. Excitotoxic ablation. J Neurosurg 2000; 93:364-6. [PMID: 10930028 DOI: 10.3171/jns.2000.93.2.0364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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196
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Honey CR, Nugent RA. A prospective randomized comparison of CT and MRI pre-operative localization for pallidotomy. Can J Neurol Sci 2000; 27:236-40. [PMID: 10975536 DOI: 10.1017/s0317167100000871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE During the pallidotomy procedure, is pre-operative localization with MRI more accurate than CT and does it result in a significant difference in surgical outcome? METHODS Twenty-four Parkinson's Disease patients received a unilateral pallidotomy for their motor symptoms. Dyskinesia was scored pre- and six weeks postoperatively. All patients had a pre-operative CT scan and MRI to calculate the target co-ordinates. Patients were then randomly selected to proceed with either the CT or MRI coordinates. The final position for the lesion was determined with intraoperative macrostimulation and impedance measurements. The percentage improvement of dyskinesia was noted for each patient and the two groups compared by the Mann-Whitney test. The distance from the final target to the MRI and CT pre-operative co-ordinates were calculated for each patient. The mean distance for each modality was then compared by Student's t-test. The number of electrode repositionings was also recorded for each patient and the two groups compared by the nonparametric Mann-Whitney test. RESULTS Although the MRI co-ordinates were significantly (p<0.023) closer to the final target, this did not translate into a significant reduction in electrode repositionings. There was no significant difference in the improvement in dyskinesia between the two groups. CONCLUSIONS The pre-operative MRI co-ordinates were significantly (p=0.023) closer to the final target than those from the CT. The potential advantages and disadvantages of both imaging modalities are reviewed. There was no significant difference in surgical outcome using either MRI or CT for pre-operative localization in pallidotomy.
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Affiliation(s)
- C R Honey
- Department of Radiology, University of British Columbia, Vancouver, Canada
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197
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Uitti RJ, Wharen RE, Duffy JR, Lucas JA, Schneider SL, Rippeth JD, Wszolek ZK, Obwegeser AA, Turk MF, Atkinson EJ. Unilateral pallidotomy for Parkinson's disease: speech, motor, and neuropsychological outcome measurements. Parkinsonism Relat Disord 2000; 6:133-143. [PMID: 10817952 DOI: 10.1016/s1353-8020(00)00008-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We studied the effects of unilateral medial pallidotomy in the first 57 consecutive Parkinson's disease (PD) patients undergoing this MRI/electrophysiologically guided procedure at our institution, obtaining qualitative and quantitative measures of speech, motor function, activities of daily living, and neuropsychological functioning at 3 and 12months post-operatively. Speech intelligibility was typically preserved, declining mildly in one-third of patients post-operatively. Pallidotomy significantly improved motor function similarly in patients >/=65 or <65years (n=20). Cognitive abilities generally remained stable following surgery; however, performance on measures of letter fluency and semantic fluency declined in patients with left pallidotomies. We conclude that in our series mild deterioration in speech may occur with unilateral pallidotomy in patients otherwise responsive to this treatment.
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Affiliation(s)
- RJ Uitti
- Department of Neurology, Mayo Clinic Jacksonville, 4500 San Pablo Road, Jacksonville, FL, USA
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198
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Moro E, Esselink RA, Van Blercom N, Caputo E, Pollak P, Limousin P, Hariz MI. Bilateral subthalamic nucleus stimulation in a parkinsonian patient with previous unilateral pallidotomy and thalamotomy. Mov Disord 2000; 15:753-5. [PMID: 10928596 DOI: 10.1002/1531-8257(200007)15:4<753::aid-mds1031>3.0.co;2-b] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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199
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Fine J, Duff J, Chen R, Chir B, Hutchison W, Lozano AM, Lang AE. Long-term follow-up of unilateral pallidotomy in advanced Parkinson's disease. N Engl J Med 2000; 342:1708-14. [PMID: 10841873 DOI: 10.1056/nejm200006083422304] [Citation(s) in RCA: 180] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although the short-term benefits of posteroventral pallidotomy for patients with advanced Parkinson's disease have been well documented, little is known about the long-term outcome of the procedure. METHODS We conducted a long-term follow-up study of a cohort of 40 patients who had undergone unilateral posteroventral medial pallidotomy between 1993 and 1996. Twenty patients were not evaluated because they had undergone a second surgical procedure (11 patients) or had died (2) or because they had dementia or another debilitating illness (4), lived too far away (1), or had been lost to follow-up (2). We conducted serial postoperative assessments of parkinsonism in the remaining 20 patients while they were taking medications ("on" period) and after overnight withdrawal of the drugs ("off" period). The mean follow-up time was 52 months (range, 41 to 64). RESULTS The combined off-period score for activities of daily living and motor function on the Unified Parkinson's Disease Rating Scale was 18.0 percent better at the last evaluation than at base line (95 percent confidence interval, 4.9 to 31.0 percent; P=0.01). Significant improvements were also evident in the off-period scores for contralateral tremor (65.4 percent improvement, P=0.007), rigidity (43.2 percent, P=0.03), and bradykinesia (18.2 percent, P=0.04) and in the on-period score for contralateral dyskinesia (70.6 percent, P<0.001). Changes in medication did not contribute to the sustained improvement. The 20 patients who could not be included in the long-term analysis had similar base-line characteristics but a worse response to surgery at six months. CONCLUSIONS In the group of patients with advanced Parkinson's disease who could be enrolled in our long-term follow-up study of unilateral posteroventral medial pallidotomy (20 patients from the original cohort of 40), significant early improvements in off-period contralateral signs of parkinsonism were sustained for up to five and a half years. There was a sustained significant improvement in on-period contralateral dyskinesia but not in other on-period signs of parkinsonism.
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Affiliation(s)
- J Fine
- Department of Medicine, Toronto Western Hospital, University of Toronto, ON, Canada
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200
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Abstract
Surgical treatment of Parkinson's disease (PD) can provide gratifying symptomatic improvements for many individuals who suffer from persistent disabling symptoms despite the best available medical management. Current surgical therapies include ablative techniques (thalamotomy and pallidotomy), augmentative techniques (nondestructive) (deep brain stimulation), and restorative techniques (tissue transplantation and gene therapy). Ablative procedures can provide substantial clinical benefit, but the current trend is toward deep brain stimulation, which can provide similar symptomatic improvement in a nondestructive manner. Restorative techniques, such as tissue transplantation and gene therapy, are exciting but have significant obstacles to overcome before their promise can be realized. Until the underlying pathological defect of PD can be identified and treated, surgical intervention is likely to remain important in the symptomatic treatment of this disabling disease.
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Affiliation(s)
- K A Follett
- Division of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City 52242, USA.
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