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Franzini A, Cordella R, Messina G, Marras CE, Romito LM, Albanese A, Rizzi M, Nardocci N, Zorzi G, Zekaj E, Villani F, Leone M, Gambini O, Broggi G. Targeting the brain: considerations in 332 consecutive patients treated by deep brain stimulation (DBS) for severe neurological diseases. Neurol Sci 2012; 33:1285-303. [PMID: 22271259 DOI: 10.1007/s10072-012-0937-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 12/23/2011] [Indexed: 11/28/2022]
Abstract
Deep brain stimulation (DBS) extends the treatment of some severe neurological diseases beyond pharmacological and conservative therapy. Our experience extends the field of DBS beyond the treatment of Parkinson disease and dystonia, including several other diseases such as cluster headache and disruptive behavior. Since 1993, at the Istituto Nazionale Neurologico "Carlo Besta" in Milan, 580 deep brain electrodes were implanted in 332 patients. The DBS targets include Stn, GPi, Voa, Vop, Vim, CM-pf, pHyp, cZi, Nacc, IC, PPN, and Brodmann areas 24 and 25. Three hundred patients are still available for follow-up and therapeutic considerations. DBS gave a new therapeutic chance to these patients affected by severe neurological diseases and in some cases controlled life-threatening pathological conditions, which would otherwise result in the death of the patient such as in status dystonicus, status epilepticus and post-stroke hemiballismus. The balance of DBS in severe neurological disease is strongly positive even if further investigations and studies are needed to search for new applications and refine the selection criteria for the actual indications.
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Affiliation(s)
- Angelo Franzini
- Fondazione IRCCS Istituto Neurologico "C. Besta", Via Celoria 11, 20133, Milan, Italy
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252
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Sankar T, Tierney TS, Hamani C. Novel applications of deep brain stimulation. Surg Neurol Int 2012; 3:S26-33. [PMID: 22826807 PMCID: PMC3400483 DOI: 10.4103/2152-7806.91607] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 12/20/2011] [Indexed: 11/11/2022] Open
Abstract
The success of deep brain stimulation (DBS) surgery in treating medically refractory symptoms of some movement disorders has inspired further investigation into a wide variety of other treatment-resistant conditions. These range from disorders of gait, mood, and memory to problems as diverse as obesity, consciousness, and addiction. We review the emerging indications, rationale, and outcomes for some of the most promising new applications of DBS in the treatment of postural instability associated with Parkinson's disease, depression, obsessive–compulsive disorder, obesity, substance abuse, epilepsy, Alzheimer′s-type dementia, and traumatic brain injury. These studies reveal some of the excitement in a field at the edge of a rapidly expanding frontier. Much work still remains to be done on basic mechanism of DBS, optimal target and patient selection, and long-term durability of this technology in treating new indications.
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Affiliation(s)
- Tejas Sankar
- Department of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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253
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Insola A, Valeriani M, Mazzone P. Targeting the Pedunculopontine Nucleus. Oper Neurosurg (Hagerstown) 2012; 71:96-103. [DOI: 10.1227/neu.0b013e318249c726] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Pedunculopontine tegmental nucleus (PPTg) deep brain stimulation (DBS) has been used in patients with Parkinson disease.
OBJECTIVE:
To verify the position of the DBS lead within the pons during PPTg targeting.
METHODS:
In 10 Parkinson disease patients undergoing electrode implantation in the PPTg, somatosensory evoked potentials were recorded after median nerve stimulation from the 4 DBS electrode contacts and from 2 scalp leads placed in the frontal and parietal regions.
RESULTS:
The DBS electrode recorded a P16 potential (latency at contact 0, 16.33 ± 0.76 ms). There was a P16 latency shift of 0.18 ± 0.07 ms from contact 0 (lower) to contact 3 (upper). The scalp electrodes recorded the P14 far-field response (latency, 15.44 ± 0.63 ms) and the cortical N20 potential (latency, 21.58 ± 1.42 ms). The P16 potentials recorded by the intracranial electrode contacts are generated by the volley traveling along the medial lemniscus, whereas the scalp P14 potential represents a far-field response generated at the Obex level. Considering that the distance between the electrode contacts 0 and 3 is 6 mm, the distance of the electrode contact 0 from the Obex (ΔObex) was calculated by the equation: ΔObex = 6 × Δlatency P14- PPTg0/Δlatency PPTg0-PPTg3. The Obex-to-brainstem electrode distance obtained by the neurophysiological method confirmed that the electrode was located within the pons in all patients. Moreover, this distance was very similar to that issued from the individual brain magnetic resonance imaging.
CONCLUSION:
Somatosensory evoked potentials may be a helpful tool for calculating the macroelectrode position within the pons during PPTg targeting.
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Affiliation(s)
- Angelo Insola
- Unità Operativa di Neurofisiopatologia, CTO, Rome, Italy
| | - Massimiliano Valeriani
- Divisione di Neurologia, Ospedale Pediatrico Bambino Gesù, IRCCS, Rome, Italy
- Center for Sensory-Motor Interaction, Aalborg University, Aalborg, Denmark
| | - Paolo Mazzone
- Unità Operativa di Neurochirurgia Funzionale e Stereotassica, CTO, Rome, Italy
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254
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Thevathasan W, Pogosyan A, Hyam JA, Jenkinson N, Foltynie T, Limousin P, Bogdanovic M, Zrinzo L, Green AL, Aziz TZ, Brown P. Alpha oscillations in the pedunculopontine nucleus correlate with gait performance in parkinsonism. ACTA ACUST UNITED AC 2012; 135:148-60. [PMID: 22232591 PMCID: PMC3267984 DOI: 10.1093/brain/awr315] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The pedunculopontine nucleus, a component of the reticular formation, is topographically organized in animal models and implicated in locomotor control. In Parkinson's disease, pedunculopontine nucleus stimulation is an emerging treatment for gait freezing. Local field potentials recorded from pedunculopontine nucleus electrodes in such patients have demonstrated oscillations in the alpha and beta frequency bands, reactive to self-paced movement. Whether these oscillations are topographically organized or relevant to locomotion is unknown. Here, we recorded local field potentials from the pedunculopontine nucleus in parkinsonian patients during rest and unconstrained walking. Relative gait speed was assessed with trunk accelerometry. Peaks of alpha power were present at rest and during gait, when they correlated with gait speed. Gait freezing was associated with attenuation of alpha activity. Beta peaks were less consistently observed across rest and gait, and did not correlate with gait speed. Alpha power was maximal in the caudal pedunculopontine nucleus region and beta power was maximal rostrally. These results indicate a topographic distribution of neuronal activity in the pedunculopontine nucleus region and concur with animal data suggesting that the caudal subregion has particular relevance to gait. Alpha synchronization, proposed to suppress 'task irrelevant' distraction, has previously been demonstrated to correlate with performance of cognitive tasks. Here, we demonstrate a correlation between alpha oscillations and improved gait performance. The results raise the possibility that stimulation of caudal and rostral pedunculopontine nucleus regions may differ in their clinical effects.
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Affiliation(s)
- Wesley Thevathasan
- Nuffield Department of Clinical Neurosciences, University of Oxford OX3 9DU, UK
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255
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Aviles-Olmos I, Foltynie T, Panicker J, Cowie D, Limousin P, Hariz M, Fowler CJ, Zrinzo L. Urinary incontinence following deep brain stimulation of the pedunculopontine nucleus. Acta Neurochir (Wien) 2011; 153:2357-60. [PMID: 21927820 DOI: 10.1007/s00701-011-1155-6] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Accepted: 08/29/2011] [Indexed: 11/28/2022]
Abstract
Low-frequency deep brain stimulation (DBS) of the pedunculopontine nucleus (PPN) has been reported to improve akinesia and gait difficulties in patients with Parkinson's disease (PD). We report on a patient with PD and L: -dopa refractory gait symptoms who developed detrusor over-activity immediately after right PPN DBS. Proximity between caudal PPN and brainstem structures implicated in control of micturition is a possible explanation.
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256
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Stein JF, Aziz TZ. Basal ganglia output to the PPN, a commentary. Exp Neurol 2011; 233:745-6. [PMID: 22134154 DOI: 10.1016/j.expneurol.2011.11.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 11/08/2011] [Accepted: 11/14/2011] [Indexed: 12/01/2022]
Affiliation(s)
- John F Stein
- Nuffield Department of Surgery, Level 3, The West Wing, John Radcliffe Hospital, Headington, Oxford, OX3 9DU, UK
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257
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Holl EM, Petersen EA, Foltynie T, Martinez-Torres I, Limousin P, Hariz MI, Zrinzo L. Improving targeting in image-guided frame-based deep brain stimulation. Neurosurgery 2011; 67:437-47. [PMID: 21099570 DOI: 10.1227/neu.0b013e3181f7422a] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is commonly used in the treatment of movement disorders such as Parkinson disease (PD), dystonia, and other tremors. OBJECTIVE To examine systematic errors in image-guided DBS electrode placement and to explore a calibration strategy for stereotactic targeting. METHODS Pre- and postoperative stereotactic MR images were analyzed in 165 patients. The perpendicular error between planned target coordinates and electrode trajectory was calculated geometrically for all 312 DBS electrodes implanted. Improvement in motor unified PD rating scale III subscore was calculated for those patients with PD with at least 6 months of follow-up after bilateral subthalamic DBS. RESULTS Mean (standard deviation) scalar error of all electrodes was 1.4(0.9) mm with a significant difference between left and right hemispheres. Targeting error was significantly higher for electrodes with coronal approach angle (ARC) ≥10° (P < .001). Mean vector error was X: -0.6, Y: -0.7, and Z: -0.4 mm (medial, posterior, and superior directions, respectively). Targeting error was significantly improved by using a systematic calibration strategy based on ARC and target hemisphere (mean: 0.6 mm, P < .001) for 47 electrodes implanted in 24 patients. Retrospective theoretical calibration for all 312 electrodes would have reduced the mean (standard deviation) scalar error from 1.4(0.9) mm to 0.9(0.5) mm (36% improvement). With calibration, 97% of all electrodes would be within 2 mm of the intended target as opposed to 81% before calibration. There was no significant correlation between the degree of error and clinical outcome from bilateral subthalamic nucleus DBS (R = 0.07). CONCLUSION After calibration of a systematic targeting error an MR image-guided stereotactic approach would be expected to deliver 97% of all electrodes to within 2 mm of the intended target point with a single brain pass.
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Affiliation(s)
- Etienne M Holl
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, United Kingdom
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258
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c-Fos expression after deep brain stimulation of the pedunculopontine tegmental nucleus in the rat 6-hydroxydopamine Parkinson model. J Chem Neuroanat 2011; 42:210-7. [DOI: 10.1016/j.jchemneu.2011.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 08/03/2011] [Accepted: 08/03/2011] [Indexed: 11/22/2022]
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259
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Jahn K, Dieterich M. Recent advances in the diagnosis and treatment of balance disorders. J Neurol 2011; 258:2305-8. [DOI: 10.1007/s00415-011-6286-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 10/07/2011] [Indexed: 01/07/2023]
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260
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Alam M, Heissler HE, Schwabe K, Krauss JK. Deep brain stimulation of the pedunculopontine tegmental nucleus modulates neuronal hyperactivity and enhanced beta oscillatory activity of the subthalamic nucleus in the rat 6-hydroxydopamine model. Exp Neurol 2011; 233:233-42. [PMID: 22036687 DOI: 10.1016/j.expneurol.2011.10.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 09/28/2011] [Accepted: 10/09/2011] [Indexed: 01/03/2023]
Abstract
Deep brain stimulation (DBS) of the pedunculopontine nucleus (PPN) area has been introduced as a novel surgical therapy for dopamine refractory gait problems, freezing and postural instability in the late stage of Parkinson's disease (PD). Lesions of the pedunculopontine tegmental (PPTg) nucleus, the equivalent of the PPN in rodents, were shown to reduce the elevated discharge rate of the subthalamic nucleus (STN) in the 6-hydroxydopamine (6-OHDA) rat model of PD. In order to further elucidate the modulatory effect of the PPTg on the STN we examined the effect of 25 Hz low frequency PPTg stimulation on neuronal single unit activity and oscillatory local field potentials (LFPs) of the STN, and on the electrocorticogram (ECoG) of the primary motor cortex region in rats with unilateral 6-OHDA induced nigrostriatal lesions. Stimulation of the PPTg reduced the enhanced firing rate in the STN, without affecting the firing pattern or approximate entropy (ApEn). It also reduced the activity in the beta band (15-30 Hz) of the STN, which is elevated in 6-OHDA lesioned rats, without affecting beta activity in the motor cortex. We showed a modulatory effect of PPTg stimulation on altered neuronal STN activity in the PD 6-OHDA rat model, indicating that PPTg DBS may alter activity of the basal ganglia circuitry at least partially. It remains unclear, however, how these changes are exactly mediated and whether they are relevant with regard to the descending PPTg projections in the lower brainstem.
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Affiliation(s)
- Mesbah Alam
- Department of Neurosurgery, Hannover Medical School, Hannover, Germany.
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261
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Abstract
The basal ganglia (BG) are a group of subcortical structures involved in diverse functions, such as motor, cognition and emotion. However, the BG do not control these functions directly, but rather modulate functional processes occurring in structures outside the BG. The BG form multiple functional loops, each of which controls different functions with similar architectures. Accordingly, to understand the modulatory role of the BG, it is strategic to uncover the mechanisms of signal processing within specific functional loops that control simple neural circuits outside the BG, and then extend the knowledge to other BG loops. The saccade control system is one of the best-understood neural circuits in the brain. Furthermore, sophisticated saccade paradigms have been used extensively in clinical research in patients with BG disorders as well as in basic research in behaving monkeys. In this review, we describe recent advances of BG research from the viewpoint of saccade control. Specifically, we account for experimental results from neuroimaging and clinical studies in humans based on the updated knowledge of BG functions derived from neurophysiological experiments in behaving monkeys by taking advantage of homologies in saccade behavior. It has become clear that the traditional BG network model for saccade control is too limited to account for recent evidence emerging from the roles of subcortical nuclei not incorporated in the model. Here, we extend the traditional model and propose a new hypothetical framework to facilitate clinical and basic BG research and dialogue in the future.
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Affiliation(s)
- Masayuki Watanabe
- Department of Physiology, Kansai Medical University, Fumizonocho 10-15, Moriguchi, Osaka 570-8506, Japan
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262
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Weiss D, Wächter T, Meisner C, Fritz M, Gharabaghi A, Plewnia C, Breit S, Krüger R. Combined STN/SNr-DBS for the treatment of refractory gait disturbances in Parkinson's disease: study protocol for a randomized controlled trial. Trials 2011; 12:222. [PMID: 21989388 PMCID: PMC3205029 DOI: 10.1186/1745-6215-12-222] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Accepted: 10/11/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Severe gait disturbances in idiopathic Parkinson's disease (PD) are observed in up to 80% of all patients in advanced disease stages with important impact on quality of life. There is an unmet need for further symptomatic therapeutic strategies, particularly as gait disturbances generally respond unfavourably to dopaminergic medication and conventional deep brain stimulation of the subthalamic nucleus in advanced disease stages. Recent pathophysiological research pointed to nigro-pontine networks entrained to locomotor integration. Stimulation of the pedunculopontine nucleus is currently under investigation, however, hitherto remains controversial. The substantia nigra pars reticulata (SNr)--entrained into integrative locomotor networks--is pathologically overactive in PD. High-frequent stimulation of the substantia nigra pars reticulata preferentially modulated axial symptoms and therefore is suggested as a novel therapeutic candidate target for neuromodulation of refractory gait disturbances in PD. METHODS 12 patients with idiopathic Parkinson's disease and refractory gait disturbances under best individual subthalamic nucleus stimulation and dopaminergic medication will be enroled into this double-blind 2 × 2 cross-over clinical trial. The treatment consists of two different stimulation settings using (i) conventional stimulation of the subthalamic nucleus [STNmono] and (ii) combined stimulation of distant electrode contacts located in the subthalamic nucleus and caudal border zone of STN and substantia nigra pars reticulata [STN+SNr]. The primary outcome measure is the change of the cumulative 'axial score' (UPDRS II items '13-15' and UPRDS III items '27-31') at three weeks of constant stimulation in either condition. Secondary outcome measures include specific scores on freezing of gait, balance function, quality of life, non-motor symptoms, and neuropsychiatric symptoms. The aim of the present trial is to investigate the efficacy and safety of a three week constant combined stimulation on [STN+SNr] compared to [STNmono]. The results will clarify, whether stimulation on nigral contacts additional to subthalamic stimulation will improve therapeutic response of otherwise refractory gait disturbances in PD. TRIAL REGISTRATION The trial was registered with the clinical trials register of http://www.clinicaltrials.gov (NCT01355835).
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Affiliation(s)
- Daniel Weiss
- German Centre of Neurodegenerative Diseases, Tübingen, Germany
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263
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Mazzone P, Scarnati E, Garcia-Rill E. Commentary: the pedunculopontine nucleus: clinical experience, basic questions and future directions. J Neural Transm (Vienna) 2011; 118:1391-6. [PMID: 21188437 PMCID: PMC3654381 DOI: 10.1007/s00702-010-0530-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 11/03/2010] [Indexed: 12/24/2022]
Abstract
This issue is dedicated to a potential new target for the treatment of movement disorders, the pedunculopontine tegmental nucleus (PPTg), or, more simply, the pedunculopontine nucleus, that some authors abbreviate as PPN. We provide an overview of the field as an introduction to the general reader, beginning with the clinical experience to date of Mazzone and co-workers in Rome, some basic questions that need to be addressed, and potential future directions required in order to ensure that the potential benefits of this work are realized.
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Affiliation(s)
- P. Mazzone
- Functional and Stereotactic Neurosurgery, CTO Hospital ASL Roma C, Via San Nemesio 21, 00145 Rome, Italy
| | - E. Scarnati
- Department of Biomedical Sciences and Technologies (STB), University of L’Aquila, Via Vetoio Coppito 2, 67100 L’Aquila, Italy
| | - E. Garcia-Rill
- Center for Translational Neuroscience, Department of Neurobiology & Developmental Sciences College of Medicine University of Arkansas for Medical Sciences, 4301 West Markham St. Little Rock, AR 72205, USA
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264
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Garcia-Rill E, Simon C, Smith K, Kezunovic N, Hyde J. The pedunculopontine tegmental nucleus: from basic neuroscience to neurosurgical applications: arousal from slices to humans: implications for DBS. J Neural Transm (Vienna) 2011; 118:1397-407. [PMID: 20936418 PMCID: PMC3084344 DOI: 10.1007/s00702-010-0500-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Accepted: 09/24/2010] [Indexed: 12/23/2022]
Abstract
One element of the reticular activating system (RAS) is the pedunculopontine nucleus (PPN), which projects to the thalamus to trigger thalamocortical rhythms and the brainstem to modulate muscle tone and locomotion. The PPN is a posterior midbrain site known to induce locomotion in decerebrate animals when activated at 40-60 Hz, and has become a target for DBS in disorders involving gait deficits. We developed a research program using brainstem slices containing the PPN to study the cellular and molecular organization of this region. We showed that PPN neurons preferentially fire at gamma band frequency (30-60 Hz) when maximally activated, accounting for the effects of electrical stimulation. In addition, we developed the P13 midlatency auditory evoked potential, which is generated by PPN outputs, in freely moving rats. This allows the study of PPN cellular and molecular mechanisms in the whole animal. We also study the P50 midlatency auditory evoked potential, which is the human equivalent of the rodent P13 potential, allowing us to study PPN-related processes detected in vitro, confirmed in the whole animal, and tested in humans. Previous findings on the P50 potential in PD suggest that PPN output in this disorder is overactive. This translational research program led to the discovery of a novel mechanism of sleep-wake control based on electrical coupling, pointing the way to a number of new clinical applications in the development of novel stimulants (e.g., modafinil) and anesthetics. In addition, it provides methods for monitoring therapeutic efficacy of DBS in humans and animal models.
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Affiliation(s)
- Edgar Garcia-Rill
- Department of Neurobiology and Developmental Science, Center For Translational Neuroscience, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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265
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Effects of unilateral pedunculopontine stimulation on electromyographic activation patterns during gait in individual patients with Parkinson’s disease. J Neural Transm (Vienna) 2011; 118:1477-86. [DOI: 10.1007/s00702-011-0705-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Accepted: 08/18/2011] [Indexed: 10/17/2022]
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266
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Thevathasan W, Pogosyan A, Hyam JA, Jenkinson N, Bogdanovic M, Coyne TJ, Silburn PA, Aziz TZ, Brown P. A block to pre-prepared movement in gait freezing, relieved by pedunculopontine nucleus stimulation. ACTA ACUST UNITED AC 2011; 134:2085-95. [PMID: 21705424 PMCID: PMC3122373 DOI: 10.1093/brain/awr131] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Gait freezing and postural instability are disabling features of Parkinsonian disorders, treatable with pedunculopontine nucleus stimulation. Both features are considered deficits of proximal and axial musculature, innervated predominantly by reticulospinal pathways and tend to manifest when gait and posture require adjustment. Adjustments to gait and posture are amenable to pre-preparation and rapid triggered release. Experimentally, such accelerated release can be elicited by loud auditory stimuli—a phenomenon known as ‘StartReact’. We observed StartReact in healthy and Parkinsonian controls. However, StartReact was absent in Parkinsonian patients with severe gait freezing and postural instability. Pedunculopontine nucleus stimulation restored StartReact proximally and proximal reaction times to loud stimuli correlated with gait and postural disturbance. These findings suggest a relative block to triggered, pre-prepared movement in gait freezing and postural instability, relieved by pedunculopontine nucleus stimulation.
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267
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Improvement of hand dexterity induced by stimulation of the peduncolopontine nucleus in a patient with advanced Parkinson's disease and previous long-lasting bilateral subthalamic DBS. Acta Neurochir (Wien) 2011; 153:1587-90. [PMID: 21638144 DOI: 10.1007/s00701-011-1051-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 05/12/2011] [Indexed: 12/26/2022]
Abstract
We report the case of a patient already submitted to bilateral deep-brain stimulation (DBS) of the subthalamic nucleus (STN) who started to develop gait impairment, postural imbalance and frequent falls in the course of the disease and who subsequently underwent DBS of the right pedunculopontine nucleus (PPN) at our institute. An immediate clinical benefit in hand dexterity was observed with acute external stimulation and maintained after the definitive implant of the internal pulse generator (IPG) at 6 months' follow-up. The benefit on hand dexterity seemed to be related to the interactions between the PPN low-frequency stimulation and the bilateral STN high-frequency stimulation.
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268
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Tykocki T, Mandat T, Nauman P. Pedunculopontine nucleus deep brain stimulation in Parkinson's disease. Arch Med Sci 2011; 7:555-64. [PMID: 22291786 PMCID: PMC3258764 DOI: 10.5114/aoms.2011.24119] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2010] [Revised: 03/10/2011] [Accepted: 04/14/2011] [Indexed: 11/17/2022] Open
Abstract
Postural instability and gait difficulty (PIGD) are commonly observed in advanced Parkinson's disease. The neuronal mechanism of PIGD is not fully understood. Dysfunction of the pedunculopontine nucleus (PPN) might be a possible cause of these symptoms. The autopsy studies of subjects with PIGD revealed a neurodegenerative process involving mainly PPN cholinergic neurons. The PPN participates in the locomotion processes by initiation, modulation and execution of stereotyped patterns of movement. The standard neurosurgical treatment of PD is subthalamic deep brain stimulation (STN DBS). Clinical results revealed low efficiency of STN DBS on PIGD. Preliminary results of simultaneous PPN and STN DBS are very promising. Only a few reports have been published until now; a significant improvement of PIGD was observed in both ON and OFF L-dopa states.
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Affiliation(s)
- Tomasz Tykocki
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - Tomasz Mandat
- Department of Neurosurgery, Maria Skłodowska-Curie Memorial Oncology Centre, Warsaw, Poland
| | - Paweł Nauman
- Department of Neurosurgery, Institute of Psychiatry and Neurology, Warsaw, Poland
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269
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Amara AW, Watts RL, Walker HC. The effects of deep brain stimulation on sleep in Parkinson's disease. Ther Adv Neurol Disord 2011; 4:15-24. [PMID: 21339905 DOI: 10.1177/1756285610392446] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Sleep dysfunction is a common nonmotor symptom experienced by patients with Parkinson's disease (PD). Symptoms, including excessive daytime sleepiness, sleep fragmentation, rapid eye movement (REM) sleep behavior disorder and others, can significantly affect quality of life and daytime functioning in these patients. Recent studies have evaluated the effects of deep brain stimulation (DBS) at various targets on sleep in patients with advanced PD. Several of these studies have provided evidence that subthalamic nucleus DBS improves subjective and objective measures of sleep, including sleep efficiency, nocturnal mobility, and wake after sleep onset (minutes spent awake after initial sleep onset). Although fewer studies have investigated the effects of bilateral internal globus pallidus and thalamic ventral intermedius DBS on sleep, pallidal stimulation does appear to improve subjective sleep quality. Stimulation of the pedunculopontine nucleus has recently been proposed for selected patients with advanced PD to treat severe gait and postural dysfunction. Owing to the role of the pedunculopontine nucleus in modulating behavioral state, the impact of stimulation at this target on sleep has also been evaluated in a small number of patients, showing that pedunculopontine nucleus DBS increases REM sleep. In this review, we discuss the effects of stimulation at these various targets on sleep in patients with PD. Studying the effects of DBS on sleep can enhance our understanding of the pathophysiology of sleep disorders, provide strategies for optimizing clinical benefit from DBS, and may eventually guide novel therapies for sleep dysfunction.
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Affiliation(s)
- Amy W Amara
- Division of Movement Disorders, Department of Neurology, University of Alabama at Birmingham, SC 360, 1530 3rd Avenue South, Birmingham, AL 35294-0017, USA
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270
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Abstract
The realization that medications used to treat movement disorders and psychiatric conditions of basal ganglia origin have significant shortcomings, as well as advances in the understanding of the functional organization of the brain, has led to a renaissance in functional neurosurgery, and particularly the use of deep brain stimulation (DBS). Movement disorders are now routinely being treated with DBS of 'motor' portions of the basal ganglia output nuclei, specifically the subthalamic nucleus and the internal pallidal segment. These procedures are highly effective and generally safe. Use of DBS is also being explored in the treatment of neuropsychiatric disorders, with targeting of the 'limbic' basal ganglia-thalamocortical circuitry. The results of these procedures are also encouraging, but many unanswered questions remain in this emerging field. This review summarizes the scientific rationale and practical aspects of using DBS for neurologic and neuropsychiatric disorders.
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271
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Thevathasan W, Coyne TJ, Hyam JA, Kerr G, Jenkinson N, Aziz TZ, Silburn PA. Pedunculopontine Nucleus Stimulation Improves Gait Freezing in Parkinson Disease. Neurosurgery 2011; 69:1248-53; discussion 1254. [DOI: 10.1227/neu.0b013e31822b6f71] [Citation(s) in RCA: 132] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Pedunculopontine nucleus (PPN) stimulation is a novel therapy for Parkinson disease. However, controversies remain regarding the clinical application of this new therapy, including patient selection, electrode positioning, and how best to assess outcomes.
OBJECTIVE
To clarify the clinical application of PPN stimulation in Parkinson disease.
METHODS
Five consecutive patients with Parkinson disease complicated by severe gait freezing, postural instability, and frequent falls (all persisting even while the patient was on medication) received bilateral stimulation of the mid-lower PPN without costimulation of other brain targets. Outcomes were assessed prospectively over 2 years with gait-specific questionnaires and the Unified Parkinson Disease Rating Scale (part III).
RESULTS
The primary outcome, the Gait and Falls Questionnaire score, improved significantly with stimulation. Benefits were maintained over 2 years. Unified Parkinson Disease Rating Scale (part III) items assessing gait and posture were relatively insensitive to these treatment effects. Beneficial effects often appeared to outlast stimulation for hours or longer. Thus, single-session on- vs off-stimulation assessments may be susceptible to “delayed washout effects.” Stimulation of the PPN did not change akinesia scores or dopaminergic medication requirements.
CONCLUSION
Bilateral stimulation of the mid-lower PPN (more caudal than previous reports) without costimulation of other brain targets may be beneficial for the subgroup of patients with Parkinson disease who experience severe gait freezing and postural instability with frequent falls, which persist even while on medication. Choosing appropriate outcome measures and accounting for the possibility of prolonged stimulation washout effects appear to be important for detecting the clinical benefits.
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Affiliation(s)
- Wesley Thevathasan
- Nuffield Department of Surgery, University of Oxford, Oxford, United Kingdom
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, London, United Kingdom
| | | | - Jonathan A. Hyam
- Nuffield Department of Surgery, University of Oxford, Oxford, United Kingdom
| | - Graham Kerr
- Movement Neuroscience Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
| | - Ned Jenkinson
- Nuffield Department of Surgery, University of Oxford, Oxford, United Kingdom
| | - Tipu Z. Aziz
- Nuffield Department of Surgery, University of Oxford, Oxford, United Kingdom
| | - Peter A. Silburn
- Movement Neuroscience Program, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia
- University of Queensland, Centre for Clinical Research, Royal Brisbane and Women's Hospital, Queensland, Australia
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272
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Subthalamic nucleus versus pedunculopontine nucleus stimulation in Parkinson disease: synergy or antagonism? J Neural Transm (Vienna) 2011; 118:1469-75. [PMID: 21695419 DOI: 10.1007/s00702-011-0673-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Accepted: 06/05/2011] [Indexed: 01/07/2023]
Abstract
Stimulation of the subthalamic nucleus (STN) improves the cardinal features of Parkinson disease (PD). However, its efficacy on gait disorders is less satisfying in the long term. In recent years, the pedunculopontine (PPN) nucleus has emerged as a possible promising deep brain stimulation target for gait disorders in PD. In this review, we examine whether STN and PPN act synergistically or antagonistically. Results suggest that the combination of STN and PPN stimulations leads to a significant further improvement in gait as compared with STN stimulation alone, but additive effects on the classical motor triad are questionable. Thus, they highlight the specificity of STN stimulation over PPN's for the PD cardinal features and the specificity of PPN stimulation over STN for gait disorders. In addition, low-frequency stimulation of the PPN may improve alertness. The additive rather than potentiating effects of STN and PPN stimulations suggest that they may be mediated by distinct pathways. Nevertheless, considering the inconsistencies in published results regarding the influence of PPN stimulation on gait disorders, work is still needed before one can know whether it will convert into a standard surgical treatment and to decipher its place beside STN stimulation.
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273
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Albanese A, Romito L. Deep brain stimulation for Parkinson's disease: where do we stand? Front Neurol 2011; 2:33. [PMID: 21647412 PMCID: PMC3102887 DOI: 10.3389/fneur.2011.00033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 05/10/2011] [Indexed: 11/13/2022] Open
Affiliation(s)
- Alberto Albanese
- Neurologia I, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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274
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Hickey P, Stacy M. The surgical management of Parkinson’s disease. Neurodegener Dis Manag 2011. [DOI: 10.2217/nmt.11.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY Parkinson’s disease (PD) is one of the most frequently encountered neurodegenerative disorders in terms of worldwide prevalence. Although medications are typically effective at treating motor symptoms in early to moderately advanced stages, the efficacy of these agents often wanes as the disease progresses. With long-term pharmacologic therapy, many PD patients will also experience motor fluctuations, dyskinesias and unpredictable wearing off of the therapeutic benefit. Deep brain stimulation, the preferred surgical treatment for PD, often improves many of these complications. New surgical options are currently under clinical investigation for advanced PD patients including gene and cell-based therapies.
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Affiliation(s)
- Patrick Hickey
- Division of Neurology, Duke University Medical Center, Durham, NC, USA
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275
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Hickey P, Stacy M. Available and emerging treatments for Parkinson's disease: a review. Drug Des Devel Ther 2011; 5:241-54. [PMID: 21607020 PMCID: PMC3096539 DOI: 10.2147/dddt.s11836] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2011] [Indexed: 11/23/2022] Open
Abstract
Parkinson's disease is a commonly encountered neurodegenerative disorder primarily found in aged populations. A number of medications are available to control symptoms, although these are less effective in advanced disease. Deep brain stimulation provides a practicable alternative at this stage, although a minority of patients meet the strict criteria for surgery. Novel medications that provide enhanced symptomatic control remain in developmental demand. Both gene and cell-based therapies have shown promise in early clinical studies. A major unmet need is a treatment that slows or stops disease progression.
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Affiliation(s)
- Patrick Hickey
- Division of Neurology, Duke University Medical Center, Durham, NC, USA
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276
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277
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Profice P, Mazzone P, Pilato F, Dileone M, Insola A, Ranieri F, Di Lazzaro V. Neurophysiological evaluation of the pedunculopontine nucleus in humans. J Neural Transm (Vienna) 2011; 118:1423-9. [PMID: 21479864 DOI: 10.1007/s00702-011-0644-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2011] [Accepted: 03/28/2011] [Indexed: 12/19/2022]
Abstract
The pedunculopontine nucleus (PPTg) is constituted by a heterogeneous cluster of neurons located in caudal mesencephalic tegmentum which projects to the thalamus to trigger thalamocortical rhythms and the brainstem to modulate muscle tone and locomotion. It has been investigated as potential deep brain stimulation (DBS) target for treating Parkinson's disease (PD) symptoms. Neurophysiological studies conducted in humans using DBS electrodes for exploring functional properties of PPTg in vivo, reviewed in this paper, demonstrated that the functional connections between PPTg and cortex, basal ganglia, brainstem network involved in sleep/wake control, and spinal cord can be explored in vivo and provided useful insights about the physiology of this nucleus and pathophysiology of PD.
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Affiliation(s)
- P Profice
- Institute of Neurology, Università Cattolica, L.go A. Gemelli 8, 00168, Rome, Italy
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278
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Zrinzo L, Zrinzo LV, Massey LA, Thornton J, Parkes HG, White M, Yousry TA, Strand C, Revesz T, Limousin P, Hariz MI, Holton JL. Targeting of the pedunculopontine nucleus by an MRI-guided approach: a cadaver study. J Neural Transm (Vienna) 2011; 118:1487-95. [PMID: 21484277 DOI: 10.1007/s00702-011-0639-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Accepted: 03/22/2011] [Indexed: 10/18/2022]
Abstract
Laboratory evidence suggests that the pedunculopontine nucleus (PPN) plays a central role in the initiation and maintenance of gait. Translational research has led to reports on deep brain stimulation (DBS) of the rostral brainstem in parkinsonian patients. However, initial clinical results appear to be rather variable. Possible factors include patient selection and the wide variability in anatomical location of implanted electrodes. Clinical studies on PPN DBS efficacy would, therefore, benefit from an accurate and reproducible method of stereotactic localization of the nucleus. The present study evaluates the anatomical accuracy of a specific protocol for MRI-guided stereotactic targeting of the PPN in a human cadaver. Imaging at 1.5 and 9.4 T confirmed electrode location in the intended region as defined anatomically by the surrounding fiber tracts. The spatial relations of each electrode track to the nucleus were explored by subsequent histological examination. This confirmed that the neuropil surrounding each electrode track contained scattered large neurons morphologically consistent with those of the subnucleus dissipatus and compactus of the PPN. The results support the accuracy of the described specific MR imaging protocol.
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Affiliation(s)
- Ludvic Zrinzo
- Unit of Functional Neurosurgery, Box 146, Institute of Neurology and National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.
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279
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Rolland AS, Karachi C, Muriel MP, Hirsch EC, François C. Internal pallidum and substantia nigra control different parts of the mesopontine reticular formation in primate. Mov Disord 2011; 26:1648-56. [PMID: 21469212 DOI: 10.1002/mds.23705] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Revised: 01/31/2011] [Accepted: 02/10/2011] [Indexed: 11/08/2022] Open
Abstract
The locomotor area has recently emerged as a target for deep brain stimulation to lessen gait disturbances in advanced parkinsonian patients. An important step in choosing this target is to define anatomical limits of its 2 components, the pedunculopontine nucleus and the cuneiform nucleus, their connections with the basal ganglia, and their output descending pathway. Based on the hypothesis that pedunculopontine nucleus controls locomotion whereas cuneiform nucleus controls axial posture, we analyzed whether both nuclei receive inputs from the internal pallidum and substantia nigra using anterograde and retrograde tract tracing in monkeys. We also examined whether these nuclei convey descending projections to the reticulospinal pathway. Pallidal terminals were densely distributed and restricted to the pedunculopontine nucleus, whereas nigral terminals were diffusely observed in the whole extent of both the pedunculopontine nucleus and the cuneiform nucleus. Moreover, nigral terminals formed symmetric synapses with pedunculopontine nucleus and cuneiform nucleus dendrites. Retrograde tracing experiments confirmed these results because labeled cell bodies were observed in both the internal pallidum and substantia nigra after pedunculopontine nucleus injection, but only in the substantia nigra after cuneiform nucleus injection. Furthermore, anterograde tracing experiments revealed that the pedunculopontine nucleus and cuneiform nucleus project to large portions of the pontomedullary reticular formation. This is the first anatomical evidence that the internal pallidum and the substantia nigra control different parts of the brain stem and can modulate the descending reticulospinal pathway in primates. These findings support the functional hypothesis that the nigro-cuneiform nucleus pathway could control axial posture whereas the pallido-pedunculopontine nucleus pathway could modulate locomotion.
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Affiliation(s)
- Anne-Sophie Rolland
- Université Pierre et Marie Curie-Paris 6, CR-ICM, UMR-S975, INSERM, U975, CNRS, UMR 7225, Assistance Publique-Hôpitaux de Paris, Groupe Pitié-Salpêtrière, Paris, France
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280
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Okun MS, Foote KD. Parkinson’s disease DBS: what, when, who and why? The time has come to tailor DBS targets. Expert Rev Neurother 2011; 10:1847-57. [PMID: 21384698 DOI: 10.1586/ern.10.156] [Citation(s) in RCA: 108] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Deep brain stimulation (DBS) has recently been proven to be an effective therapy for medication refractory symptoms of Parkinson's disease. As the evidence base continues to evolve, many important issues have surfaced, including: what operation should be performed (brain target[s],unilateral vs bilateral, simultaneous vs staged); when to operate (how early is too early to intervene?), who should be operated on (disease duration, age, symptom profiles and the use of the interdisciplinary screening team); and finally, why to operate (the rationale of surgery vs medication/apomorphine pumps/duodopa pumps/stem cell trials/gene therapy trials). We will address each of these critical issues, as well make the argument that a tailored approach to DBS and DBS targeting will best serve each potential candidate. We will review the multiple peer reviewed studies and we will emphasize the recently available data from randomized DBS studies.We will argue that moving away from a single DBS target (e.g., subthalamic nucleus DBS) and a single approach to DBS methodology (e.g., bilateral simultaneous operations) is a reasonable next step for the Parkinson's disease community. Following careful interdisciplinary DBS screening, a physician-patient discussion has the potential to establish a patient-centered and symptom-specific outcome for each potential DBS candidate. The interdisciplinary DBS team can function together to formulate and to consider an optimal and tailored approach. A tailored approach will allow for the consideration of the complex and numerous variables that may contribute to a positive or negative overall DBS outcome. We will review and provide expert commentary on a potential interdisciplinary approach to selecting unilateral or alternatively bilateral subthalamic nucleus or globus pallidus internus DBS. Our approach is aimed to maximize benefit(s) and minimize risk(s) in order to best tailor therapy for an individual patient.
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Affiliation(s)
- Michael S Okun
- University of Florida Movement Disorders Center, McKnight Brain Institute, Gainesville, FL USA.
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281
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Khan S, Mooney L, Plaha P, Javed S, White P, Whone AL, Gill SS. Outcomes from stimulation of the caudal zona incerta and pedunculopontine nucleus in patients with Parkinson's disease. Br J Neurosurg 2011; 25:273-80. [PMID: 21344974 DOI: 10.3109/02688697.2010.544790] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Axial symptoms including postural instability, falls and failure of gait initiation are some of the most disabling motor symptoms of Parkinson's disease (PD). We performed bilateral deep brain stimulation (DBS) of the pedunculopontine nucleus (PPN) in combination with the caudal zona incerta (cZi) in order to determine their efficacy in alleviating these symptoms. METHODS Seven patients with predominant axial symptoms in both the 'on' and 'off' medication states underwent bilateral cZi and PPN DBS. Motor outcomes were assessed using the motor component of the Unified Parkinson's Disease Rating Scale (UPDRS 3) and a composite axial subscore was derived from items 27, 28, 29 and 30 (arising from chair, posture, gait and postural stability). Quality of life was measured using the PDQ39. Comparisons were made between scores obtained at baseline and those at a mean follow-up of 12 months. RESULTS In both the off and on medication states, a statistically significant improvement in the UPDRS part 3 score was achieved by stimulation of the PPN, cZi and both in combination. In the off medication state, our composite axial subscore of the UPDRS part 3 improved with stimulation of the PPN, cZi and both in combination. The composite axial subscore, in the 'on' medication state, however, only showed a statistically significant improvement when a combination of cZi and PPN stimulation was used. CONCLUSIONS This study provides evidence that a combination of PPN and cZi stimulation can achieve a significant improvement in the hitherto untreatable 'on' medication axial symptoms of PD.
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Affiliation(s)
- Sadaquate Khan
- Department of Neurosurgery, Institute of Neurosciences, Frenchay Hospital, Bristol, UK
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282
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Fuentes R, Petersson P, Nicolelis MAL. Restoration of locomotive function in Parkinson's disease by spinal cord stimulation: mechanistic approach. Eur J Neurosci 2011; 32:1100-8. [PMID: 21039949 DOI: 10.1111/j.1460-9568.2010.07417.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Specific motor symptoms of Parkinson's disease (PD) can be treated effectively with direct electrical stimulation of deep nuclei in the brain. However, this is an invasive procedure, and the fraction of eligible patients is rather low according to currently used criteria. Spinal cord stimulation (SCS), a minimally invasive method, has more recently been proposed as a therapeutic approach to alleviate PD akinesia, in light of its proven ability to rescue locomotion in rodent models of PD. The mechanisms accounting for this effect are unknown but, from accumulated experience with the use of SCS in the management of chronic pain, it is known that the pathways most probably activated by SCS are the superficial fibers of the dorsal columns. We suggest that the prokinetic effect of SCS results from direct activation of ascending pathways reaching thalamic nuclei and the cerebral cortex. The afferent stimulation may, in addition, activate brainstem nuclei, contributing to the initiation of locomotion. On the basis of the striking change in the corticostriatal oscillatory mode of neuronal activity induced by SCS, we propose that, through activation of lemniscal and brainstem pathways, the locomotive increase is achieved by disruption of antikinetic low-frequency (<30 Hz) oscillatory synchronization in the corticobasal ganglia circuits.
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Affiliation(s)
- Romulo Fuentes
- Department of Neurobiology, Duke Medical Center, 311 Research Drive, Durham, NC 27710, USA.
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283
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Mazzone P, Sposato S, Insola A, Scarnati E. The deep brain stimulation of the pedunculopontine tegmental nucleus: towards a new stereotactic neurosurgery. J Neural Transm (Vienna) 2011; 118:1431-51. [DOI: 10.1007/s00702-011-0593-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 01/24/2011] [Indexed: 10/18/2022]
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284
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Varanese S, Birnbaum Z, Rossi R, Di Rocco A. Treatment of advanced Parkinson's disease. PARKINSONS DISEASE 2011; 2010:480260. [PMID: 21331376 PMCID: PMC3038575 DOI: 10.4061/2010/480260] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Accepted: 12/20/2010] [Indexed: 11/20/2022]
Abstract
Patients at late stage Parkinson's disease (PD) develop several motor and nonmotor complications, which dramatically impair their quality of life. These complications include motor fluctuations, dyskinesia, unpredictable or absent response to medications, falls, dysautonomia, dementia, hallucinations, sleep disorders, depression, and psychosis. The therapeutic management should be driven by the attempt to create a balance between benefit and side effects of the pharmacological treatments available. Supportive care, including physical and rehabilitative interventions, speech therapy, occupational therapy, and nursing care, has a key role in the late stage of disease. In this review we discuss the several complications experienced by advance PD patients and their management. The importance of an integrative approach, including both pharmacological and supportive interventions, is emphasized.
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Affiliation(s)
- Sara Varanese
- New York University School of Medicine, Department of Neurology, Division of Movement Disorders, New York, NY 10016, USA
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285
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Weiss D, Breit S, Wächter T, Plewnia C, Gharabaghi A, Krüger R. Combined stimulation of the substantia nigra pars reticulata and the subthalamic nucleus is effective in hypokinetic gait disturbance in Parkinson’s disease. J Neurol 2011; 258:1183-5. [DOI: 10.1007/s00415-011-5906-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Revised: 01/06/2011] [Accepted: 01/06/2011] [Indexed: 10/18/2022]
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286
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Abstract
IMPORTANCE OF THE FIELD Parkinson's disease (PD) is characterized by a slowly ongoing neuronal death, which affects neurotransmitter metabolism and causes a wide variety of motor and non-motor features. Until now, therapy approaches have predominantly focused on motor behavior associated with dopamine substitution. AREAS COVERED IN THIS REVIEW This review aims to discuss putative reasons for recent failures of investigated treatment approaches, and to introduce currently tested and future compounds. WHAT THE READER WILL GAIN We will describe how development programs of novel molecules now additionally consider non-motor features of PD as promising targets in order to obtain regulatory approval. Regulatory authorities increasingly exert influence on trial designs, demanding therapeutic effects that are not always clinically feasible given the variety of manifestations of the disease entity known as PD. TAKE HOME MESSAGE In the past, research pitfalls have resulted in the failure of promising new compounds. Among the many reasons for this are massive placebo responses; the participation of too many investigators, with consequent wide variations of efficacy assessments; and a misconception of preclinical drug development, with models of PD that do not mimic its clinical nature. A few compounds are now being tested that have modes of action indirectly modulating the dopamine system; however, critical analysis of the preclinical and clinical research concept and drug approval is warranted to prevent further frustration in this field.
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Affiliation(s)
- Thomas Müller
- St. Joseph Hospital Berlin-Weissensee, Department of Neurology, Gartenstrasse 1, 13088 Berlin, Germany.
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287
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Yeh IJ, Tsang EW, Hamani C, Moro E, Mazzella F, Poon YY, Lozano AM, Chen R. Somatosensory evoked potentials recorded from the human pedunculopontine nucleus region. Mov Disord 2011; 25:2076-83. [PMID: 20669321 DOI: 10.1002/mds.23233] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The pedunculopontine nucleus region (PPNR) is an integral component of the midbrain locomotor region and has widespread connections with the cortex, thalamus, brain stem, cerebellum, spinal cord, and especially, the basal ganglia. No previous study examined the somatosensory connection of the PPNR in human. We recorded somatosensory evoked potentials (SEP) from median nerve stimulation through deep brain stimulation (DBS) electrodes implanted in the PPNR in 8 patients (6 with Parkinson's disease, 2 with progressive supranuclear palsy). Monopolar recordings from the PPNR contacts showed triphasic or biphasic potentials. The latency of the largest negative peak was between 16.8 and 18.7 milliseconds. Bipolar derivation revealed phase reversal with median nerve stimulation contralateral to the DBS electrode in 6 patients. There was no difference in SEP amplitude and latency between on and off medication states. We also studied the high frequency oscillations (HFOs) by filtering the signal between 500 and 2,500 Hz. The HFOs could be identified only from contralateral stimulation and had intraburst frequencies of 1061 ± 121 Hz, onset latencies of 13.8 ± 1.2 milliseconds, and burst durations of 7.3 ± 1.1 milliseconds. Among the 10 recordings with HFOs, only 1 had possible phase reversal in the bipolar derivation. Our results suggest that there are direct somatosensory inputs to the PPNR. The slow components and HFOs of the SEP have different origins.
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Affiliation(s)
- I-Jin Yeh
- Toronto Western Research Institute, University Health Network, Toronto, Ontario, Canada
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288
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Tierney TS, Sankar T, Lozano AM. Deep brain stimulation emerging indications. PROGRESS IN BRAIN RESEARCH 2011; 194:83-95. [PMID: 21867796 DOI: 10.1016/b978-0-444-53815-4.00015-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
There are a number of emerging surgical indications for deep brain stimulation. We have shown that modulation of activity within motor, mood, and cognitive circuits has beneficial effects in patients with Parkinson's disease, treatment-resistant depression, and perhaps Alzheimer's type dementia. We review the rationale, safety, and efficacy for each of these indications, focusing on disease mechanisms and relevant data that are necessary to document therapeutic value in each case. The review closes with some thoughts on possible future directions for deep brain stimulation. It is likely that applications for deep brain stimulation will continue to expand as accumulating data establish its safety and efficacy profile in these and other conditions.
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Affiliation(s)
- Travis S Tierney
- Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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289
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Abstract
Medications, psychotherapy, and other treatments are effective for many patients with psychiatric disorders. However, with currently available interventions, a substantial number of patients experience incomplete resolution of symptoms, and relapse rates are high. In the search for better treatments, increasing interest has focused on focal neuromodulation. This focus has been driven by improved neuroanatomical models of mood, thought, and behavior regulation, as well as by more advanced strategies for directly and focally altering neural activity. Deep brain stimulation (DBS) is one of the most invasive focal neuromodulation techniques available; data have supported its safety and efficacy in a number of movement disorders. Investigators have produced preliminary data on the safety and efficacy of DBS for several psychiatric disorders, as well. In this review, we describe the development and justification for testing DBS for various psychiatric disorders, carefully consider the available clinical data, and briefly discuss potential mechanisms of action.
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Affiliation(s)
- Paul E. Holtzheimer
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia 30322
| | - Helen S. Mayberg
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia 30322
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290
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Tass PA, Qin L, Hauptmann C, Dovero S, Bezard E, Boraud T, Meissner WG. The translational value of the MPTP non-human primate model of Parkinsonism for deep brain stimulation research. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2011; 2011:663-666. [PMID: 22254396 DOI: 10.1109/iembs.2011.6090148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Deep brain stimulation (DBS) has been applied in more than 70000 patients worldwide during the last two decades. The main target is the subthalamic nucleus (STN) for the treatment of motor complications in late stage Parkinson's disease (PD). Positive results in 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-treated non-human primates have set the grounds for its successful translation to PD patients. Since then, this model has allowed gaining significant insights in the underlying mechanisms of action of DBS and is currently being used for the development of new stimulation techniques. Altogether, this underpins the high potential of this preclinical model for future translation of DBS research in PD.
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Affiliation(s)
- Peter A Tass
- Institute of Neuroscience and Medicine-Neuromodulation, Research Centre Juelich, Germany.
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291
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The pedunculopontine nucleus as a target for deep brain stimulation. J Neural Transm (Vienna) 2010; 118:1461-8. [PMID: 21194002 DOI: 10.1007/s00702-010-0547-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 11/29/2010] [Indexed: 10/18/2022]
Abstract
The pedunculopontine nucleus (PPN) is a brain stem locomotive center that is also involved in the processing of sensory and behavioral information. The PPN has been recently proposed as a potential target for the treatment of axial symptoms in Parkinson's disease (PD). To date, results of the first series of PD patients treated with PPN deep brain stimulation (DBS) have shown promising results. In this article, we review some of the basic aspects of the PPN as a target and the outcome of the recently published clinical trials.
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292
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Shah RS, Chang SY, Min HK, Cho ZH, Blaha CD, Lee KH. Deep brain stimulation: technology at the cutting edge. J Clin Neurol 2010; 6:167-82. [PMID: 21264197 PMCID: PMC3024521 DOI: 10.3988/jcn.2010.6.4.167] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2010] [Revised: 09/16/2010] [Accepted: 09/16/2010] [Indexed: 01/15/2023] Open
Abstract
Deep brain stimulation (DBS) surgery has been performed in over 75,000 people worldwide, and has been shown to be an effective treatment for Parkinson's disease, tremor, dystonia, epilepsy, depression, Tourette's syndrome, and obsessive compulsive disorder. We review current and emerging evidence for the role of DBS in the management of a range of neurological and psychiatric conditions, and discuss the technical and practical aspects of performing DBS surgery. In the future, evolution of DBS technology may depend on several key areas, including better scientific understanding of its underlying mechanism of action, advances in high-spatial resolution imaging and development of novel electrophysiological and neurotransmitter microsensor systems. Such developments could form the basis of an intelligent closed-loop DBS system with feedback-guided neuromodulation to optimize both electrode placement and therapeutic efficacy.
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Affiliation(s)
- Rahul S Shah
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
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293
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Scarnati E, Florio T, Capozzo A, Confalone G, Mazzone P. The pedunculopontine tegmental nucleus: implications for a role in modulating spinal cord motoneuron excitability. J Neural Transm (Vienna) 2010; 118:1409-21. [PMID: 21161714 DOI: 10.1007/s00702-010-0532-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2010] [Accepted: 11/06/2010] [Indexed: 12/19/2022]
Abstract
There is evidence that deep brain stimulation (DBS) of the pedunculopontine tegmental nucleus (PPTg) improves parkinsonian motor signs. The mechanisms that mediate these effects and the modifications that occur in the PPTg in Parkinson's disease (PD) are not fully known and are the object of current debate. The aim of this paper was to critically review available data with respect to (1) the presence of PPTg neurons linked to reticulospinal projections, (2) the involvement of these neurons in modulating spinal reflexes, and (3) the participation of fibers close to or within the PPTg region in such modulation. The PPTg neurons are distributed in a large pontotegmental region, stimulation of which can evoke activity in hindlimb, shoulder and neck muscles, and potentiate motor responses evoked by stimulation of dorsal roots. This influence seems to be carried out by fast-conducting descending fibers, which likely run in the medial reticulospinal pathway. It is yet unclear which neurotransmitters are involved and on which elements of the gray matter of the spinal cord PPTg fibers synapse. The modulation of spinal cord activity which can be achieved by stimulating the PPTg region seems to be mediated not only by PPTg neurons, but also by tecto-reticular fibers which run in the pontotegmental area, and which likely are activated during PPTg-DBS. The importance of these fibers is discussed taking into account the degeneration of PPTg neurons in PD and the benefits in gait and postural control that PPTg-DBS exerts in PD. The potential usefulness of PPTg-DBS in other neurodegenerative disorders characterized by neuronal loss in the brainstem is also considered.
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Affiliation(s)
- Eugenio Scarnati
- Department of Biomedical Sciences and Technologies (STB), University of L'Aquila, Via Vetoio Coppito 2, 67100, L'Aquila, Italy.
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294
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Alam M, Schwabe K, Krauss JK. The pedunculopontine nucleus area: critical evaluation of interspecies differences relevant for its use as a target for deep brain stimulation. Brain 2010; 134:11-23. [PMID: 21147837 DOI: 10.1093/brain/awq322] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Recently, the pedunculopontine nucleus has been highlighted as a target for deep brain stimulation for the treatment of freezing of postural instability and gait disorders in Parkinson's disease and progressive supranuclear palsy. There is great controversy, however, as to the exact location of the optimal site for stimulation. In this review, we give an overview of anatomy and connectivity of the pedunculopontine nucleus area in rats, cats, non-human primates and humans. Additionally, we report on the behavioural changes after chemical or electrical manipulation of the pedunculopontine nucleus. We discuss the relation to adjacent regions of the pedunculopontine nucleus, such as the cuneiform nucleus and the subcuneiform nucleus, which together with the pedunculopontine nucleus are the main areas of the mesencephalic locomotor region and play a major role in the initiation of gait. This information is discussed with respect to the experimental designs used for research purposes directed to a better understanding of the circuitry pathway of the pedunculopontine nucleus in association with basal ganglia pathology, and with respect to deep brain stimulation of the pedunculopontine nucleus area in humans.
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Affiliation(s)
- Mesbah Alam
- Department of Neurosurgery, Medical University of Hannover, Carl-Neuberg-Str 1, 30625 Hannover, Germany
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295
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Ceravolo R, Brusa L, Galati S, Volterrani D, Peppe A, Siciliano G, Pierantozzi M, Moschella V, Bonuccelli U, Stanzione P, Stefani A. Low frequency stimulation of the nucleus tegmenti pedunculopontini increases cortical metabolism in Parkinsonian patients. Eur J Neurol 2010; 18:842-9. [DOI: 10.1111/j.1468-1331.2010.03254.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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296
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Holtzheimer PE, Mayberg HS. Stuck in a rut: rethinking depression and its treatment. Trends Neurosci 2010; 34:1-9. [PMID: 21067824 DOI: 10.1016/j.tins.2010.10.004] [Citation(s) in RCA: 219] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 10/10/2010] [Accepted: 10/12/2010] [Indexed: 02/09/2023]
Abstract
The current definition of major depressive disorder (MDD) emerged from efforts to create reliable diagnostic criteria for clinical and research use. However, despite decades of research, the neurobiology of MDD is largely unknown, and treatments are no more effective today than they were 50-70 years ago. Here, we propose that the current conception of depression is misguiding basic and clinical research. Redefinition is necessary and could include a focus on a more narrowly defined set of core symptoms. However, we conclude that depression is better defined as the tendency to enter into, and inability to disengage from, a negative mood state rather than the mood state per se. We also discuss the implications of this revised definition for future clinical and basic research.
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Affiliation(s)
- Paul E Holtzheimer
- Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, 101 Woodruff Circle NE, Suite 4000, Atlanta, GA 30322, USA.
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297
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Fuentes R, Petersson P, Nicolelis MAL. Restoration of locomotive function in Parkinson's disease by spinal cord stimulation: mechanistic approach. THE EUROPEAN JOURNAL OF NEUROSCIENCE 2010. [PMID: 21039949 DOI: 10.1111/j.1460-9568.2010.07417.x.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Specific motor symptoms of Parkinson's disease (PD) can be treated effectively with direct electrical stimulation of deep nuclei in the brain. However, this is an invasive procedure, and the fraction of eligible patients is rather low according to currently used criteria. Spinal cord stimulation (SCS), a minimally invasive method, has more recently been proposed as a therapeutic approach to alleviate PD akinesia, in light of its proven ability to rescue locomotion in rodent models of PD. The mechanisms accounting for this effect are unknown but, from accumulated experience with the use of SCS in the management of chronic pain, it is known that the pathways most probably activated by SCS are the superficial fibers of the dorsal columns. We suggest that the prokinetic effect of SCS results from direct activation of ascending pathways reaching thalamic nuclei and the cerebral cortex. The afferent stimulation may, in addition, activate brainstem nuclei, contributing to the initiation of locomotion. On the basis of the striking change in the corticostriatal oscillatory mode of neuronal activity induced by SCS, we propose that, through activation of lemniscal and brainstem pathways, the locomotive increase is achieved by disruption of antikinetic low-frequency (<30 Hz) oscillatory synchronization in the corticobasal ganglia circuits.
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Affiliation(s)
- Romulo Fuentes
- Department of Neurobiology, Duke Medical Center, 311 Research Drive, Durham, NC 27710, USA.
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298
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Management of Motor Complications in Parkinson Disease: Current and Emerging Therapies. Neurol Clin 2010; 28:913-25. [DOI: 10.1016/j.ncl.2010.03.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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299
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Snijders AH, Nonnekes J, Bloem BR. Recent advances in the assessment and treatment of falls in Parkinson's disease. F1000 MEDICINE REPORTS 2010; 2:76. [PMID: 21173838 PMCID: PMC2981191 DOI: 10.3410/m2-76] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Falls are among the most incapacitating features of Parkinson's disease. Prevention of falls requires a systematic assessment of all contributing factors (with emphasis on freezing of gait and frontal executive dysfunction), and a multidisciplinary treatment approach tailored to the specific pathophysiology of falls for each individual patient.
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Affiliation(s)
- Anke H Snijders
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical CentrePO Box 9101, 6500 HB, NijmegenThe Netherlands
| | - Jorik Nonnekes
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical CentrePO Box 9101, 6500 HB, NijmegenThe Netherlands
| | - Bastiaan R Bloem
- Department of Neurology, Donders Institute for Brain, Cognition and Behavior, Radboud University Nijmegen Medical CentrePO Box 9101, 6500 HB, NijmegenThe Netherlands
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300
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Peppe A, Pierantozzi M, Chiavalon C, Marchetti F, Caltagirone C, Musicco M, Stanzione P, Stefani A. Deep brain stimulation of the pedunculopontine tegmentum and subthalamic nucleus: effects on gait in Parkinson's disease. Gait Posture 2010; 32:512-8. [PMID: 20727761 DOI: 10.1016/j.gaitpost.2010.07.012] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2009] [Revised: 07/14/2010] [Accepted: 07/16/2010] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study examines the effects of subthalamic nucleus (STN) deep brain stimulation (DBS) and pedunculopontine tegmentum (PPTg) DBS in advanced Parkinson's disease using gait analysis. METHODS Five people underwent bilateral DBS in both the STN and PPTg. Gait analysis was performed one year after neurosurgery using an optoelectronic system. The effects of DBS (STN, PPTg and STN+PPTg) were studied in two clinical conditions: without (Off) and during (On) antiparkinsonian therapy. RESULTS PPTg and STN DBS were associated with changes in spatio-temporal and kinematics variables. CONCLUSIONS Although experimental data cannot be generalized widely due to the small sample, PPTg DBS appears to affect the neuronal circuits subserving gait.
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Affiliation(s)
- A Peppe
- IRCCS, Santa Lucia Foundation, Via Ardeatina 309, 00179 Rome, Italy.
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