1
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Huh R, Chung M, Jang I. Outcome of pallidal deep brain stimulation for treating isolated orofacial dystonia. Acta Neurochir (Wien) 2022; 164:2287-2298. [PMID: 35896828 DOI: 10.1007/s00701-022-05320-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 07/15/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Isolated orofacial dystonia is a rare segmental neurological disorder that affects the eye, mouth, face, and jaws. Current literature on pallidal surgery for orofacial dystonia is limited to case reports and small-scale studies. This study was to investigate clinical outcomes of deep brain stimulation (DBS) of the globus pallidus internus (GPi) in patients with isolated orofacial dystonia. METHODS Thirty-six patients who underwent GPi DBS at Incheon St. Mary's Hospital, The Catholic University of Korea, between 2014 and 2019 were included in this study. Burke-Fahn-Marsden Dystonia Rating Scale, Unified Dystonia Rating Scale, and Global Dystonia Severity Rating Scale were retrospectively retrieved for analysis before surgery, at 6-month follow-up as short-term outcome, and at follow-up over 1 year (12 months to 69 months) as long-term results. RESULTS Mean total BFMDRS-M scores at the three time points (baseline, 6 months, and over 1 year follow-up) were 11.6 ± 4.9, 6.1 ± 5.2 (50.3 ± 29.9% improvement, p < 0.05), and 4.3 ± 4.2 (65.0 ± 24.2% improvement, p < 0.05), respectively. In terms of UDRS and GDS, improvement rates were 45.1% (p < 0.001) and 47.7% (p < 0.001) at 6 months, and 63.8% (p < 0.001) and 65.7% (p < 0.001) at over 1 year after surgery, respectively. CONCLUSIONS Bilateral GPi DBS in isolated orofacial dystonia can be effective if conservative treatment option fails. Its benefit is not only observed in a short term, but also maintained in a long-term follow-up.
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Affiliation(s)
- Ryoong Huh
- Department of Neurosurgery, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-Gu, Incheon, 21431, Republic of Korea
| | - Moonyoung Chung
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Soonchunhyang University, 170 Jomaru-ro, Wonmi-gu, Bucheon-si, Gyeonggi-do, 14585, Republic of Korea
| | - Il Jang
- Department of Neurosurgery, College of Medicine, Incheon St. Mary's Hospital, The Catholic University of Korea, 56, Dongsu-ro, Bupyeong-Gu, Incheon, 21431, Republic of Korea.
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2
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Lucas J, Kusyk D, Whiting D. Bilateral pallidal DBS for blepharospasm: A case report and review of the literature. Surg Neurol Int 2022; 13:200. [PMID: 35673639 PMCID: PMC9168297 DOI: 10.25259/sni_1234_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 04/21/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Deep brain stimulation (DBS) of the globus pallidus internus (GPi) in the treatment of craniocervical dystonia often requires an extended period of stimulation parameter manipulations.
Case Description:
We present a patient suffering from debilitating blepharospasm treated with bilateral DBS of the GPi alongside 7 years of stimulation parameter manipulations and a literature review of comparable patients.
Conclusion:
Our literature review suggests that a patient’s specific dystonic symptoms can guide stimulation parameter manipulations. Further research regarding trends in stimulation parameters being used in the field for different dystonic symptoms may expedite the stimulation parameter manipulation process.
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Affiliation(s)
- Joshua Lucas
- MD Program, Drexel University College of Medicine, Philadelphia,
| | - Dorian Kusyk
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, United States
| | - Donald Whiting
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania, United States
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3
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Liu J, Ding H, Xu K, Liu R, Wang D, Ouyang J, Liu Z, Miao Z. Pallidal versus subthalamic deep-brain stimulation for meige syndrome: a retrospective study. Sci Rep 2021; 11:8742. [PMID: 33888857 PMCID: PMC8062505 DOI: 10.1038/s41598-021-88384-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/12/2021] [Indexed: 11/09/2022] Open
Abstract
Deep-brain stimulation (DBS) is an effective treatment for patients with Meige syndrome. The globus pallidus interna (GPi) and the subthalamic nucleus (STN) are accepted targets for this treatment. We compared 12-month outcomes for patients who had undergone bilateral stimulation of the GPi or STN. Forty-two Asian patients with primary Meige syndrome who underwent GPi or STN neurostimulation were recruited between September 2017 and September 2019 at the Department of Neurosurgery, Peking University People's Hospital. The primary outcome was the change in motor function, including the Burke-Fahn-Marsden Dystonia Rating Scale movement (BFMDRS-M) and disability subscale (BFMDRS-D) at 3 days before DBS (baseline) surgery and 1, 3, 6, and 12 months after surgery. Secondary outcomes included health-related quality of life, sleep quality status, depression severity, and anxiety severity at 3 days before and 12 months after DBS surgery. Adverse events during the 12 months were also recorded. Changes in BFMDRS-M and BFMDRS-D scores at 1, 3, 6, and 12 months with DBS and without medication did not significantly differ based on the stimulation target. There were also no significant differences in the changes in health-related quality of life (36-Item Short-Form General Health Survey) and sleep quality status (Pittsburgh Sleep Quality Index) at 12 months. However, there were larger improvements in the STN than the GPi group in mean score changes on the 17-item Hamilton depression rating scale (- 3.38 vs. - 0.33 points; P = 0.014) and 14-item Hamilton anxiety rating scale (- 3.43 vs. - 0.19 points; P < 0.001). There were no significant between-group differences in the frequency or type of serious adverse events. Patients with Meige syndrome had similar improvements in motor function, quality of life and sleep after either pallidal or subthalamic stimulation. Depression and anxiety factors may reasonably be included during the selection of DBS targets for Meige syndrome.
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Affiliation(s)
- Jiayu Liu
- Department of Neurosurgery, Peking University People's Hospital, 11th Xizhimen South St., Beijing, 100044, China
| | - Hu Ding
- Department of Neurosurgery, Peking University People's Hospital, 11th Xizhimen South St., Beijing, 100044, China
| | - Ke Xu
- Department of Neurosurgery, Peking University People's Hospital, 11th Xizhimen South St., Beijing, 100044, China
| | - Ruen Liu
- Department of Neurosurgery, Peking University People's Hospital, 11th Xizhimen South St., Beijing, 100044, China.
| | - Dongliang Wang
- Department of Neurosurgery, Peking University People's Hospital, 11th Xizhimen South St., Beijing, 100044, China
| | - Jia Ouyang
- Department of Neurosurgery, Peking University People's Hospital, 11th Xizhimen South St., Beijing, 100044, China
| | - Zhi Liu
- Department of Neurosurgery, Peking University People's Hospital, 11th Xizhimen South St., Beijing, 100044, China
| | - Zeyu Miao
- Department of Neurosurgery, Peking University People's Hospital, 11th Xizhimen South St., Beijing, 100044, China
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4
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Ma H, Qu J, Ye L, Shu Y, Qu Q. Blepharospasm, Oromandibular Dystonia, and Meige Syndrome: Clinical and Genetic Update. Front Neurol 2021; 12:630221. [PMID: 33854473 PMCID: PMC8039296 DOI: 10.3389/fneur.2021.630221] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/08/2021] [Indexed: 12/14/2022] Open
Abstract
Meige syndrome (MS) is cranial dystonia characterized by the combination of upper and lower cranial involvement and including binocular eyelid spasms (blepharospasm; BSP) and involuntary movements of the jaw muscles (oromandibular dystonia; OMD). The etiology and pathogenesis of this disorder of the extrapyramidal system are not well-understood. Neurologic and ophthalmic examinations often reveal no abnormalities, making diagnosis difficult and often resulting in misdiagnosis. A small proportion of patients have a family history of the disease, but to date no causative genes have been identified to date and no cure is available, although botulinum toxin A therapy effectively mitigates the symptoms and deep brain stimulation is gaining increasing attention as a viable alternative treatment option. Here we review the history and progress of research on MS, BSP, and OMD, as well as the etiology, pathology, diagnosis, and treatment.
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Affiliation(s)
- Hongying Ma
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Institute for Rational and Safe Medication Practices, Xiangya Hospital, Central South University, Changsha, China
| | - Jian Qu
- Department of Pharmacy, The Second Xiangya Hospital, Central South University, Changsha, China
- Institute of Clinical Pharmacy, Central South University, Changsha, China
| | - Liangjun Ye
- Department of Pharmacy, Hunan Provincial Corps Hospital of Chinese People's Armed Police Force, Changsha, China
| | - Yi Shu
- Department of Neurology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiang Qu
- Department of Pharmacy, Xiangya Hospital, Central South University, Changsha, China
- National Clinical Research Center for Geriatric Disorders, Institute for Rational and Safe Medication Practices, Xiangya Hospital, Central South University, Changsha, China
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5
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Honkanen EA, Korpela J, Pekkonen E, Kaasinen V, Reich MM, Joutsa J. Reappearance of Symptoms after GPi-DBS Discontinuation in Cervical Dystonia. Mov Disord Clin Pract 2021; 8:406-411. [PMID: 33816670 PMCID: PMC8015900 DOI: 10.1002/mdc3.13162] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 01/11/2021] [Accepted: 01/24/2021] [Indexed: 11/11/2022] Open
Abstract
Background Deep brain stimulation of the globus pallidus interna (GPi‐DBS) is a highly efficacious treatment for cervical dystonia. Typically, the treatment response is delayed, appearing and increasing even months after implantation. However, it is not known how fast the symptoms reappear and whether there is a long‐term therapeutic effect after the stimulation is discontinued. Objectives To study symptom reappearance after switching GPi‐DBS off in cervical dystonia. Methods Twelve patients with bilateral GPi‐DBS were included in the study. The Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) was evaluated during the study with DBS stimulation on, after switching the stimulation off and 2 days after the stimulation was switched off. Presurgical symptom severity and best postsurgical response were extracted from the hospital records. Results At the time of the investigation, GPi‐DBS was associated with 67 (SD 39)% symptom improvement of presurgical symptoms severity (P = 0.001). Symptom improvement decreased to 27 (53)% (P = 0.046) (n = 12) acutely after switching the stimulation off and was further reduced to 4 (56)% 2 days after discontinuation (P = 0.01) (n = 11), reaching the presurgical level (P = 0.42). In descriptive analyses, older age was associated with faster worsening of symptoms (P < 0.05). Presurgical symptoms severity, stimulation parameters or magnitude of treatment response did not predict symptom worsening. All but one patient tolerated 2 days DBS switched off. Conclusions The results provide novel information about the time frame and severity of symptom worsening after discontinuing GPi‐DBS in cervical dystonia. Symptoms partially reappear immediately after discontinuing GPi‐DBS and full presurgical symptom severity is reached within 2 days.
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Affiliation(s)
- Emma A Honkanen
- Clinical Neurosciences University of Turku Turku Finland.,Division of Clinical Neurosciences Turku University Hospital Turku Finland.,Department of Neurology Satasairaala Central Hospital Pori Finland.,Turku PET Centre Turku University Hospital Turku Finland
| | - Jaana Korpela
- Clinical Neurosciences University of Turku Turku Finland.,Division of Clinical Neurosciences Turku University Hospital Turku Finland
| | - Eero Pekkonen
- Department of Neurology, Helsinki University Hospital and Department of Clinical Neurosciences (Neurology) University of Helsinki Helsinki Finland
| | - Valtteri Kaasinen
- Clinical Neurosciences University of Turku Turku Finland.,Division of Clinical Neurosciences Turku University Hospital Turku Finland
| | - Martin M Reich
- Department of Neurology University Hospital and Julius Maximilian University Würzburg Germany
| | - Juho Joutsa
- Clinical Neurosciences University of Turku Turku Finland.,Division of Clinical Neurosciences Turku University Hospital Turku Finland.,Turku PET Centre Turku University Hospital Turku Finland.,Turku Brain and Mind Center University of Turku Turku Finland
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6
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The impact of deep brain stimulation on health related quality of life and disease-specific disability in Meige Syndrome (MS). Clin Neurol Neurosurg 2018; 171:53-57. [DOI: 10.1016/j.clineuro.2018.05.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/06/2018] [Accepted: 05/10/2018] [Indexed: 12/21/2022]
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7
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Jung NY, Chang JW. Surgical Management of Hemifacial Spasm and Meige Syndrome. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00078-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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8
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Bilateral pallidotomy for Meige syndrome. Acta Neurochir (Wien) 2017; 159:1359-1363. [PMID: 28424916 DOI: 10.1007/s00701-017-3178-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 03/30/2017] [Indexed: 10/19/2022]
Abstract
Meige syndrome (MS) is usually described as a combination of blepharospasm with oromandibular dystonia. There are a large number of case reports of deep brain stimulation (DBS) of the globus pallidus internus (GPI) for MS and only one report of unilateral pallidotomy (PT). We report the first case of staged bilateral PT for treatment of a patient with MS using intraoperative high-frequency stimulation in order to predict and prevent postoperative deficit. There was a significant improvement of the Burk-Fahn-Marsden dystonia rating scale from 26 to 3. There were no adverse postoperative neurological and neuropsychological events.
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9
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Defazio G, Hallett M, Jinnah HA, Conte A, Berardelli A. Blepharospasm 40 years later. Mov Disord 2017; 32:498-509. [PMID: 28186662 DOI: 10.1002/mds.26934] [Citation(s) in RCA: 114] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/15/2016] [Accepted: 12/19/2016] [Indexed: 01/04/2023] Open
Abstract
Forty years ago, C.D. Marsden proposed that blepharospasm should be considered a form of adult-onset focal dystonia. In the present paper, we provide a comprehensive overview of the findings regarding blepharospasm reported in the past 40 years. Although prolonged spasms of the orbicularis oculi muscles remain the clinical hallmark of blepharospasm, patients with blepharospasm may be characterized by various types of involuntary activation of periocular muscles. In addition to motor features, blepharospasm patients may also have nonmotor manifestations, including psychiatric, mild cognitive, and sensory disturbances. The various motor and nonmotor symptoms are not present in all patients, suggesting that blepharospasm is phenomenologically a heterogeneous condition. This emphasizes the need for tools for severity assessment that take into account both motor and nonmotor manifestations. The cause of blepharospasm remains elusive, but several lines of evidence indicate that blepharospasm is a multifactorial condition in which one, or several, as yet unknown genes together with epigenetic and environmental factors combine to reach the threshold of the disease. Although blepharospasm was originally believed to be solely a basal ganglia disorder, neurophysiological and neuroimaging evidence point to anatomical and functional involvement of several brain regions. The contribution of multiple areas has led to the hypothesis that blepharospasm should be considered as a network disorder, and this might reflect the varying occurrence of motor and nonmotor manifestations in blepharospasm patients. Despite advances in the aetiology and pathophysiology, treatment remains symptomatic. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Giovanni Defazio
- Department of Basic Medical Sciences, Neurosciences and Sensory Organs, "Aldo Moro", University of Bari, Bari, Italy
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Hyder A Jinnah
- Departments of Neurology, Human Genetics and Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Antonella Conte
- Department of Neurology and Psychiatry, Sapienza, University of Rome, Rome, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Neuromed, Pozzilli, IS, Italy
| | - Alfredo Berardelli
- Department of Neurology and Psychiatry, Sapienza, University of Rome, Rome, Italy.,Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Neuromed, Pozzilli, IS, Italy
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10
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Pandey S, Sharma S. Meige's syndrome: History, epidemiology, clinical features, pathogenesis and treatment. J Neurol Sci 2017; 372:162-170. [DOI: 10.1016/j.jns.2016.11.053] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/31/2016] [Accepted: 11/21/2016] [Indexed: 10/20/2022]
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11
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Baizabal-Carvallo JF, Alonso-Juarez M. Low-frequency deep brain stimulation for movement disorders. Parkinsonism Relat Disord 2016; 31:14-22. [DOI: 10.1016/j.parkreldis.2016.07.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/21/2016] [Accepted: 07/28/2016] [Indexed: 12/24/2022]
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12
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Abstract
Surgical procedures for dystonia and tremor have evolved over the past few decades, and our understanding of risk, benefit, and predictive factors has increased substantially in that time. Deep brain stimulation (DBS) is the most utilized surgical treatment for dystonia and tremor, though lesioning remains an effective option in appropriate patients. Dystonic syndromes that have shown a substantial reduction in severity secondary to DBS are isolated dystonia, including generalized, cervical, and segmental, as well as acquired dystonia such as tardive dystonia. Essential tremor is quite amenable to DBS, though the response of other forms of postural and kinetic tremor is not nearly as robust or consistent based on available evidence. Regarding targeting, DBS lead placement in the globus pallidus internus has shown marked efficacy in dystonia reduction. The subthalamic nucleus is an emerging target, and increasing evidence suggests that this may be a viable target in dystonia as well. The ventralis intermedius nucleus of the thalamus is the preferred target for essential tremor, though targeting the subthalamic zone/caudal zona incerta has shown promise and may emerge as another option in essential tremor and possibly other tremor disorders. In the carefully selected patient, DBS and lesioning procedures are relatively safe and effective for the management of dystonia and tremor.
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Affiliation(s)
- Jason L Crowell
- Department of Neurology, University of Virginia, PO Box 800394, Charlottesville, VA, 22908, USA
| | - Binit B Shah
- Department of Neurology, University of Virginia, PO Box 800394, Charlottesville, VA, 22908, USA.
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13
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Wang X, Zhang C, Wang Y, Liu C, Zhao B, Zhang JG, Hu W, Shao X, Zhang K. Deep Brain Stimulation for Craniocervical Dystonia (Meige Syndrome): A Report of Four Patients and a Literature-Based Analysis of Its Treatment Effects. Neuromodulation 2015; 19:818-823. [DOI: 10.1111/ner.12345] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 06/20/2015] [Accepted: 07/16/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Xiu Wang
- Department of Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Neurostimulation; Beijing China
| | - Chao Zhang
- Department of Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Neurostimulation; Beijing China
| | - Yao Wang
- Department of Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Neurostimulation; Beijing China
| | - Chang Liu
- Department of Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Neurostimulation; Beijing China
| | - Baotian Zhao
- Department of Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Neurostimulation; Beijing China
| | - Jian-guo Zhang
- Department of Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Neurostimulation; Beijing China
| | - Wenhan Hu
- Beijing Key Laboratory of Neurostimulation; Beijing China
- Beijing Neurosurgical Institute; Beijing China
| | - Xiaoqiu Shao
- Beijing Key Laboratory of Neurostimulation; Beijing China
- Department of Neurology; Beijing Tiantan Hospital; Capital Medical University; Beijing China
| | - Kai Zhang
- Department of Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing China
- Beijing Key Laboratory of Neurostimulation; Beijing China
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14
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Pellicciari R, Defazio G. Current and investigated alternatives to botulinum toxin for managing blepharospasm. Expert Opin Orphan Drugs 2015. [DOI: 10.1517/21678707.2015.1062363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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15
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Hu W, Stead M. Deep brain stimulation for dystonia. Transl Neurodegener 2014; 3:2. [PMID: 24444300 PMCID: PMC3902434 DOI: 10.1186/2047-9158-3-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 01/19/2014] [Indexed: 12/27/2022] Open
Abstract
Deep brain stimulation (DBS) is an effective surgical treatment for medication-refractory movement disorders, and has been approved by the United States Food and Drug Administration for treatment of dystonia. The success of DBS in the treatment of dystonia depends on our understanding of the anatomy and physiology of this disorder and close collaboration between neurosurgeons, neurologists, clinical neurophysiologists, neuroradiologists and neuropsychologists. Currently, pallidal DBS is an established treatment option for medically refractive dystonia. This review is intended to provide a comprehensive review of the use of DBS for dystonia, focusing mainly on the surgical aspects, clinical outcome, MRI findings and side effects of DBS.
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Affiliation(s)
- Wei Hu
- Department of Neurology, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55901, USA.
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16
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Abstract
Dystonia is a movement disorder characterized by involuntary muscular contractions that generate twisting and repetitive movements and/or abnormal postures. It can affect a few muscle groups (focal dystonia) or spread to most muscles in the body (generalized dystonia). While botulinum toxin injections can be successfully used to treat focal dystonias, medical options for generalized dystonia are very limited. Surgical therapies--and in particular deep brain stimulation (DBS)--are becoming the standard of care for medically intractable, disabling dystonias. Advantages of DBS include reversibility, adjustability and continued access to the therapeutic target. Initial reports describing the use of DBS in generalized dystonia have been very encouraging and experience in the use of DBS to treat various forms of dystonia is continuously growing. This article reviews the issues related to DBS treatment of dystonia, including proper patient selection, surgical approaches to target choice and device implant, a description of the stimulating device and its programming principles, clinical results - with a focus on different outcomes for primary versus secondary and generalized versus cervical dystonia - and complications.
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Affiliation(s)
- Michele Tagliati
- Beth Israel Medical Center, 10 Union Square East, Suite 2R, New York, NY 1003, USA.
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17
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Abstract
The few controlled studies that have been carried out have shown that bilateral internal globus pallidum stimulation is a safe and long-term effective treatment for hyperkinetic disorders. However, most recent published data on deep brain stimulation (DBS) for dystonia, applied to different targets and patients, are still mainly from uncontrolled case reports (especially for secondary dystonia). This precludes clear determination of the efficacy of this procedure and the choice of the 'good' target for the 'good' patient. We performed a literature analysis on DBS for dystonia according to the expected outcome. We separated those with good evidence of favourable outcome from those with less predictable outcome. In the former group, we review the main results for primary dystonia (generalised/focal) and highlight recent data on myoclonus-dystonia and tardive dystonia (as they share, with primary dystonia, a marked beneficial effect from pallidal stimulation with good risk/benefit ratio). In the latter group, poor or variable results have been obtained for secondary dystonia (with a focus on heredodegenerative and metabolic disorders). From this overview, the main results and limits for each subgroup of patients that may help in the selection of dystonic patients who will benefit from DBS are discussed.
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Affiliation(s)
- Marie Vidailhet
- AP-HP, Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
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18
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Cheung T, Zhang C, Rudolph J, Alterman RL, Tagliati M. Sustained relief of generalized dystonia despite prolonged interruption of deep brain stimulation. Mov Disord 2013; 28:1431-4. [DOI: 10.1002/mds.25353] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 11/01/2012] [Accepted: 12/03/2012] [Indexed: 11/10/2022] Open
Affiliation(s)
- Tyler Cheung
- Department of Neurology; Cedars-Sinai Medical Center; Los Angeles California USA
| | - Cen Zhang
- Department of Neurology; Hospital of the University of Pennsylvania; Philadelphia Pennsylvania USA
| | - Joseph Rudolph
- Department of Neurology; Cleveland Clinic; Cleveland Ohio USA
| | - Ron L. Alterman
- Department of Neurosurgery; Beth Israel Deaconess; Boston Massachusetts USA
| | - Michele Tagliati
- Department of Neurology; Cedars-Sinai Medical Center; Los Angeles California USA
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19
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Vidailhet M, Jutras MF, Roze E, Grabli D. Deep brain stimulation for dystonia. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:167-187. [PMID: 24112893 DOI: 10.1016/b978-0-444-53497-2.00014-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The few reported controlled studies show that bilateral stimulation of the globus pallidus interna (GPi) is a safe and effective long-term treatment for hyperkinetic disorders. However, the recently published data on deep brain stimulation (DBS) applied to different targets or patients (especially those with secondary dystonia) are mainly uncontrolled case reports, precluding a clear determination of its efficacy, and providing little guidance as to the choice of a "good" target in a "good" patient. This chapter reviews the literature on DBS in primary dystonia, paying particular attention to the risk:benefit ratio in focal and segmental dystonias (cervical dystonia, cranial dystonia) and to the predictive factors for a good outcome. The chapter also highlights recent data on the marked benefits of the technique in myoclonus dystonia (in which pallidal, as opposed to thalamic, stimulation is more effective) and in tardive dystonia-dyskinesia. Although, the decision to treat appears relatively straightforward in patients with primary dystonia, myoclonus-dystonia, and tardive dystonia who have a normal findings on magnetic resonance imaging and normal cognitive function, there are still no reliable tools to help predict the timescale of postoperative benefit. This chapter provides a comprehensive analysis of the use of the treatment in various types of secondary dystonia, with little to moderate benefit in most cases, based on single cases or small series. Beyond the reduction in the severity of dystonia, the global motor and functional outcome is difficult to determine owing to the paucity of adequate evaluation tools. Because of the large interpatient variability, different targets may be effective depending on the symptoms in each individual.
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Affiliation(s)
- Marie Vidailhet
- Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Research Center of the Brain and Spinal Cord Institute, Université Paris 6/Inserm UMR S975, Paris, France; Pierre et Marie Curie Paris-6 University, Paris, France
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Abstract
Dystonia is a neurological condition characterised by abnormal muscle contractions, often causing repetitive twisting movements or abnormal postures. Varying forms of surgical intervention, for dystonia unresponsive to medical therapy, have evolved over the years and have often been associated with poor outcomes and high morbidity. The advent of stereotactic neurosurgery and the success of Deep Brain Stimulation (DBS) in treating a number of movement disorders has revolutionized the surgical treatment for dystonia. This chapter reviews the literature concerning the surgical treatment dystonic conditions, from historical origins to the current use of modern functional neurosurgical techniques.
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Schiefer TK, Matsumoto JY, Lee KH. Moving forward: advances in the treatment of movement disorders with deep brain stimulation. Front Integr Neurosci 2011; 5:69. [PMID: 22084629 PMCID: PMC3211039 DOI: 10.3389/fnint.2011.00069] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 10/07/2011] [Indexed: 11/13/2022] Open
Abstract
The modern era of stereotactic and functional neurosurgery has ushered in state of the art technologies for the treatment of movement disorders, particularly Parkinson's disease (PD), tremor, and dystonia. After years of experience with various surgical therapies, the eventual shortcomings of both medical and surgical treatments, and several serendipitous discoveries, deep brain stimulation (DBS) has risen to the forefront as a highly effective, safe, and reversible treatment for these conditions. Idiopathic advanced PD can be treated with thalamic, globus pallidus internus (GPi), or subthalamic nucleus (STN) DBS. Thalamic DBS primarily relieves tremor while GPi and STN DBS alleviate a wide range of Parkinsonian symptoms. Thalamic DBS is also used in the treatment of other types of tremor, particularly essential tremor, with excellent results. Both primary and various types of secondary dystonia can be treated very effectively with GPi DBS. The variety of anatomical targets for these movement disorders is indicative of the network-level dysfunction mediating these movement disturbances. Despite an increasing understanding of the clinical benefits of DBS, little is known about how DBS can create such wide sweeping neuromodulatory effects. The key to improving this therapeutic modality and discovering new ways to treat these and other neurologic conditions lies in better understanding the intricacies of DBS. Here we review the history and pertinent clinical data for DBS treatment of PD, tremor, and dystonia. While multiple regions of the brain have been targeted for DBS in the treatment of these movement disorders, this review article focuses on those that are most commonly used in current clinical practice. Our search criteria for PubMed included combinations of the following terms: DBS, neuromodulation, movement disorders, PD, tremor, dystonia, and history. Dates were not restricted.
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Affiliation(s)
| | | | - Kendall H. Lee
- Department of Neurologic Surgery, Mayo ClinicRochester, MN, USA
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Kupsch A, Tagliati M, Vidailhet M, Aziz T, Krack P, Moro E, Krauss JK. Early postoperative management of DBS in dystonia: programming, response to stimulation, adverse events, medication changes, evaluations, and troubleshooting. Mov Disord 2011; 26 Suppl 1:S37-53. [PMID: 21692111 DOI: 10.1002/mds.23624] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Early postoperative management in deep brain stimulation-treated patients with dystonia differs from that of patients with essential tremor and Parkinson's disease, mainly due to the usually delayed effects of deep brain stimulation and the heterogenous clinical manifestation and etiologies of dystonia. The present chapter summarizes the available data about and concentrates on practical clinical aspects of early postoperative management in deep brain stimulation-treated patients with dystonia.
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Affiliation(s)
- Andreas Kupsch
- Division of Neurology, Charité, Campus Virchow, Berlin, Germany.
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Tagliati M, Krack P, Volkmann J, Aziz T, Krauss JK, Kupsch A, Vidailhet AM. Long-Term management of DBS in dystonia: response to stimulation, adverse events, battery changes, and special considerations. Mov Disord 2011; 26 Suppl 1:S54-62. [PMID: 21692113 DOI: 10.1002/mds.23535] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Multiple independent case series have documented sustained benefit of bilateral pallidal deep brain stimulation (DBS) up to 3 years in patients with primary dystonia. Growing evidence exists for positive outcomes extending up to 10 years. The beneficial effects from DBS are usually reported to be stable, thus requiring little long-term modifications of the parameters of stimulation. Speech and swallowing abnormalities are less responsive than other dystonic symptoms. Symptom exacerbation after initial benefit has been reported in a few cases. It is not known whether this is related to potential tolerance or habituation to stimulation or to progression of the underlying disease. Failures of pallidal DBS, at least in primary dystonia patients, should not be accepted without further re-evaluation of each individual case, including possible revisions of the electrode location. Both hardware- and stimulation-related adverse effects, including insufficient relief of speech function, have been reported in the long-term. Despite early reports suggesting that hardware problems might be more frequent in dystonia, more recent studies did not confirm these observations. In patients with severe segmental (e.g., axial) or generalized dystonia, sudden cessation of stimulation may become a medical emergency and should be anticipated changing the neurostimulator before its natural end of life.
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Affiliation(s)
- Michele Tagliati
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California 90048, USA.
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Bronte-Stewart H, Taira T, Valldeoriola F, Merello M, Marks WJ, Albanese A, Bressman S, Moro E. Inclusion and exclusion criteria for DBS in dystonia. Mov Disord 2011; 26 Suppl 1:S5-16. [PMID: 21692112 DOI: 10.1002/mds.23482] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
When considering a patient with dystonia for deep brain stimulation (DBS) surgery several factors need to be considered. Level B evidence has shown that all motor features and associated pain in primary generalized and segmental dystonia are potentially responsive to globus pallidus internus (GPi) DBS. However, improvements in clinical series of ≥ 90% may reflect methods that need improvement, and larger prospective studies are needed to address these factors. Nevertheless, to date the selection criteria for DBS-specifically in terms of patient features (severity and nature of symptoms, age, time of evolution, or any other demographic or disease aspects)--have not been assessed in a systematic fashion. In general, dystonia patients are not considered for DBS unless medical therapies have been previously and extensively tested. The vast majority of reported patients have had DBS surgery when the disease was provoking important disability, with loss of independence and impaired quality of life. There does not appear to be an upper age limit or a minimum age limit, although there are no published data regarding the outcome of GPi DBS for dystonia in children younger than 7 years of age. There is currently no enough evidence to prove that subjects with primary--generalized dystonia who undergo DBS at an early age and sooner rather than later after disease onset may gain more benefit from DBS than those undergoing DBS after the development of fixed skeletal deformities. There is no enough evidence to refuse or support consideration of DBS in patients with previous ablative procedures.
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Affiliation(s)
- Helen Bronte-Stewart
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, California 94305, USA.
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Thobois S, Taira T, Comella C, Moro E, Bressman S, Albanese AA. Pre-operative evaluations for DBS in dystonia. Mov Disord 2011; 26 Suppl 1:S17-22. [DOI: 10.1002/mds.23481] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Mixed results for GPi-DBS in the treatment of cranio-facial and cranio-cervical dystonia symptoms. J Neurol 2011; 258:2069-74. [DOI: 10.1007/s00415-011-6075-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 04/20/2011] [Indexed: 10/18/2022]
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Valálik I, Jobbágy A, Bognár L, Csókay A. Effectiveness of unilateral pallidotomy for meige syndrome confirmed by motion analysis. Stereotact Funct Neurosurg 2011; 89:157-61. [PMID: 21494067 DOI: 10.1159/000323341] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2010] [Accepted: 12/02/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND We report the case of a 64-year-old woman with bilateral manifestation of Meige syndrome (MS) successfully treated with left-side unilateral ventroposterolateral pallidotomy. METHODS Symptoms were evaluated according to the Burke-Fahn-Marsden dystonia rating scale. Head tremor, blepharospasm and orofacial dyskinesia were measured with an infrared, video-based, computerized, real-time passive marker-based analyzer of motions (RTPAM). RESULTS The Burke-Fahn-Marsden score showed a 90.2% reduction (from 25.5 to 2.5) at 6 months, and an 88.2% long-lasting benefit (to 3.0) at the 3-year follow-up with good bilateral control of the blepharospasm and orofacial movements. The RTPAM showed a substantial regression of acceleration for all markers, and abolishment of the 4.8-Hz head tremor. The correlation between symmetrical markers, and between markers within the right and left sides, was significantly decreased. CONCLUSIONS Pallidotomy with staged procedure is recommended for the treatment of MS in patients on whom deep brain stimulation could not be performed. In case of good bilateral benefits from the unilateral procedure, contralateral surgery is not needed. The RTPAM is a useful tool for the mapping of facial involuntary movements.
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Affiliation(s)
- István Valálik
- Department of Neurosurgery, St. John's Hospital, Budapest, Hungary.
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Sako W, Morigaki R, Mizobuchi Y, Tsuzuki T, Ima H, Ushio Y, Nagahiro S, Kaji R, Goto S. Bilateral pallidal deep brain stimulation in primary Meige syndrome. Parkinsonism Relat Disord 2011; 17:123-5. [DOI: 10.1016/j.parkreldis.2010.11.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Revised: 11/16/2010] [Accepted: 11/18/2010] [Indexed: 10/18/2022]
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Sobstyl M, Ząbek M. Głęboka stymulacja mózgu w leczeniu kręczu karku i zespołu Meige'a. Neurol Neurochir Pol 2011; 45:590-9. [DOI: 10.1016/s0028-3843(14)60127-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Michał Sobstyl
- Klinika Neurochirurgii, Centrum Medycznego Kształcenia Podyplomowego, Warszawa.
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Romito LM, Elia AE, Franzini A, Bugiani O, Albanese A. Low-voltage bilateral pallidal stimulation for severe meige syndrome in a patient with primary segmental dystonia: case report. Neurosurgery 2010; 67:onsE308; discussion onsE308. [PMID: 20729656 DOI: 10.1227/01.neu.0000381768.04640.46] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Meige syndrome (MS) is an adult-onset segmental dystonia characterized by the combination of upper and lower cranial involvement. Its treatment is challenging and the use of oral medication or of botulinum neurotoxin treatment is not decisive. Deep brain stimulation of the globus pallidus internum (GPi DBS) has been used occasionally in severe cases. CLINICAL PRESENTATION We report the long-term efficacy of low-voltage chronic bilateral GPi DBS in a patient with segmental dystonia featuring severe MS and cervical brachial involvement. The patient received a bilateral ventroposterolateral GPi implant. Postoperative 3-dimensional reconstruction allowed checking of the definitive position of the electrode and contacts within the targeted nucleus. Following implant, the patient received bilateral low-voltage stimulation, consisting in amplitude of 1.3 V with a pulse width of 90 microseconds and a frequency of 130 Hz, yielding a current of 23 microA. Clinical follow-up for 38 months showed a progressive and sustained improvement of dystonia with unchanged electrical settings throughout the observation period. The patient again undertook normal life activities. CONCLUSION Bilateral low-voltage GPi stimulation allowed efficient control of MS symptoms and the associated brachial cervical dystonia.
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Affiliation(s)
- Luigi M Romito
- Department of Neurology, Fondazione I.R.C.C.S. Istituto Neurologico Carlo Besta, Università Cattolica del Sacro Cuore, Milan, Italy.
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Lyons MK, Birch BD, Hillman RA, Boucher OK, Evidente VGH. Long-term follow-up of deep brain stimulation for Meige syndrome. Neurosurg Focus 2010; 29:E5. [PMID: 20672922 DOI: 10.3171/2010.4.focus1067] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Meige syndrome is characterized by blepharospasm, cervical dystonia, and facial oromandibular dystonia. The medical treatment of this condition is largely unsuccessful over time and is a major source of decreased quality of life in those patients suffering from this disease. Recent advances in the application of deep brain stimulation (DBS) surgery techniques for many disorders have prompted several recent reports of DBS for medically refractory cases of Meige syndrome. While the etiology for this disorder is unknown, it is considered by many investigators to be a form of idiopathic torsion dystonia. Pallidal stimulation is widely considered to be effective for dystonia. METHODS The authors report the long-term results of bilateral globus pallidus internus (GPi) or subthalamic nucleus (STN) stimulation in 3 patients with Meige syndrome and 1 patient with Parkinson disease and associated craniofacial dystonia treated at their center. RESULTS Initial 12-month and long-term follow-up Burke-Fahn-Marsden scores were substantially improved in all 4 patients compared with preoperative scores. CONCLUSIONS Bilateral GPi DBS may be an effective and safe treatment for medically refractory Meige syndrome. The results are comparable with those reported in the literature. Sustained and long-term improvement in symptoms does appear to be reproducible across reports. The authors' patient with Parkinson disease and associated craniofacial dystonia syndrome undergoing bilateral STN DBS noted immediate and sustained improvement in his symptoms. Further study is required, but these results, along with the other reports, suggest that bilateral GPi DBS is an effective treatment for medically refractory Meige syndrome.
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Affiliation(s)
- Mark K Lyons
- Department of Neurological Surgery, Mayo Clinic Arizona, Phoenix, Arizona 85054, USA.
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Markaki E, Kefalopoulou Z, Georgiopoulos M, Paschali A, Constantoyannis C. Meige's syndrome: A cranial dystonia treated with bilateral pallidal deep brain stimulation. Clin Neurol Neurosurg 2010; 112:344-6. [PMID: 20061080 DOI: 10.1016/j.clineuro.2009.12.005] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2009] [Revised: 11/16/2009] [Accepted: 12/07/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Meige's syndrome is a rare form of segmental dystonia characterized by blepharospasm and oromandibular dystonia. Medical treatment including botulinum toxin injections usually present disappointing results. The experience on Deep Brain Stimulation (DBS) in the treatment of Meige's syndrome and other segmental dystonias is still limited. At the moment, only a few cases of pallidal DBS have been reported to improve this rare form of dystonia. CASE DESCRIPTION We report on a case of a woman with a 7-year history of Meige's syndrome, which rendered her functionally blind. The treatment with botulinum toxin injections failed to improve her symptoms, whereas stereotactic bilateral DBS of the pallidum led to a dramatic clinical improvement. Clinical assessment using the Burke-Fahn-Mardsen Dystonia Rating Scale (BFMDRS) in a double-blind manner, showed an improvement of 70% in the Movement score and 93.33% in the Disability score (84% reduction of the total score) on the 3 and 6 month follow-up. CONCLUSIONS Stereotactic pallidal DBS might be considered as a potential treatment in the management of Meige's syndrome.
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Affiliation(s)
- Elli Markaki
- Functional Neurosurgery Unit, Department of Neurosurgery, Medical School of Patras, Patras 26500, Greece
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Capelle HH, Krauss JK. Neuromodulation in Dystonia: Current Aspects of Deep Brain Stimulation. Neuromodulation 2009; 12:8-21. [DOI: 10.1111/j.1525-1403.2009.00183.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Hamasaki T, Yamada K, Kuratsu JI. Hemidystonia secondary to thalamic hemorrhage treated with GPi stimulation. Mov Disord 2008; 23:1762-6. [DOI: 10.1002/mds.22183] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Blomstedt P, Tisch S, Hariz MI. Pallidal deep brain stimulation in the treatment of Meige syndrome. Acta Neurol Scand 2008; 118:198-202. [PMID: 18336624 DOI: 10.1111/j.1600-0404.2008.00999.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Pallidal deep brain stimulation (DBS) of globus pallidus internus (Gpi) has emerged as an effective treatment for dystonia. The experience is however limited concerning focal dystonias and to date only a few cases of pallidal DBS in the treatment of Meige syndrome have been published. METHODS/RESULTS We here present a patient with Meige syndrome in whom unilateral pallidal DBS failed to improve the axial symptoms, but bilateral stimulation resulted in a major improvement. The Burke-Fahn-Marsden score (BFM) improved by 71.5% and the patient's blepharospasm was abolished. CONCLUSIONS The results suggest bilateral pallidal DBS may be an effective treatment for Meige syndrome.
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Affiliation(s)
- P Blomstedt
- Department of Neurosurgery, University Hospital of Northern Sweden, Umeå, Sweden.
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Pong M, Horn KM, Gibson AR. Pathways for control of face and neck musculature by the basal ganglia and cerebellum. ACTA ACUST UNITED AC 2008; 58:249-64. [DOI: 10.1016/j.brainresrev.2007.11.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 11/20/2007] [Accepted: 11/27/2007] [Indexed: 11/16/2022]
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Johnson MD, Miocinovic S, McIntyre CC, Vitek JL. Mechanisms and targets of deep brain stimulation in movement disorders. Neurotherapeutics 2008; 5:294-308. [PMID: 18394571 PMCID: PMC2517242 DOI: 10.1016/j.nurt.2008.01.010] [Citation(s) in RCA: 217] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Chronic electrical stimulation of the brain, known as deep brain stimulation (DBS), has become a preferred surgical treatment for medication-refractory movement disorders. Despite its remarkable clinical success, the therapeutic mechanisms of DBS are still not completely understood, limiting opportunities to improve treatment efficacy and simplify selection of stimulation parameters. This review addresses three questions essential to understanding the mechanisms of DBS. 1) How does DBS affect neuronal tissue in the vicinity of the active electrode or electrodes? 2) How do these changes translate into therapeutic benefit on motor symptoms? 3) How do these effects depend on the particular site of stimulation? Early hypotheses proposed that stimulation inhibited neuronal activity at the site of stimulation, mimicking the outcome of ablative surgeries. Recent studies have challenged that view, suggesting that although somatic activity near the DBS electrode may exhibit substantial inhibition or complex modulation patterns, the output from the stimulated nucleus follows the DBS pulse train by direct axonal excitation. The intrinsic activity is thus replaced by high-frequency activity that is time-locked to the stimulus and more regular in pattern. These changes in firing pattern are thought to prevent transmission of pathologic bursting and oscillatory activity, resulting in the reduction of disease symptoms through compensatory processing of sensorimotor information. Although promising, this theory does not entirely explain why DBS improves motor symptoms at different latencies. Understanding these processes on a physiological level will be critically important if we are to reach the full potential of this powerful tool.
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Affiliation(s)
- Matthew D. Johnson
- grid.239578.20000000106754725Department of Biomedical Engineering, Cleveland Clinic Foundation, 44195 Cleveland, Ohio
| | - Svjetlana Miocinovic
- grid.67105.350000000121643847School of Medicine, Case Western Reserve University, 44106 Cleveland, Ohio
| | - Cameron C. McIntyre
- grid.239578.20000000106754725Department of Biomedical Engineering, Cleveland Clinic Foundation, 44195 Cleveland, Ohio
| | - Jerrold L. Vitek
- grid.239578.20000000106754725Department of Neurosciences, Cleveland Clinic Foundation, 9500 Euclid Ave, NC30, 44195 Cleveland, OH
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Abstract
Pallidal deep brain stimulation (DBS) is an established treatment option for medically refractive dystonia. The mechanism by which globus pallidus pars interna (GPi) DBS improves dystonia is still unclear. Primary generalized dystonia usually responds well to this therapy, as recently confirmed in two well-designed, double-blind, controlled trials; however, predictors of outcome within this population are not well known. The role of GPi DBS in idiopathic cervical dystonia resistant to treatment with botulinum toxin, in tardive dystonia, and in some types of secondary dystonia are emerging as populations of patients who may also benefit, but outcomes are not well documented. Serious complications from this therapy are rare. Future research will likely continue to address the most appropriate programming settings for various populations of dystonia, the mechanism by which DBS affects dystonia, and the possibility of alternative brain targets that might have less associated side effects or greater efficacy than the GPi.
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Affiliation(s)
- Jill L Ostrem
- Department of Neurology, University of California, San Francisco, California 94143, USA.
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Abstract
It has been understood, for some time, that modulation of deep brain nuclei within the basal ganglia and thalamus can have a therapeutic effect in patients with movement disorders. Because of its reversibility and adjustability, deep brain stimulation (DBS) has largely come to replace traditional ablation procedures. The clinical effects of DBS vary, depending both on the target being stimulated and on the parameters of stimulation. Both aspects are currently the subject of substantial research and discovery. The most common targets for DBS treatment include the subthalamic nucleus for the treatment of advanced Parkinson's disease, the ventral intermediate nucleus of the thalamus for the treatment of medically refractory essential tremor, and the globus pallidus interna for the treatment of both cervical and generalized dystonias and Parkinson's disease. We review the current indications, targets, outcomes, and general procedure of DBS for essential tremor, Parkinson's disease, and dystonia.
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Affiliation(s)
- Hong Yu
- grid.152326.10000000122647217Department of Neurological Surgery, Vanderbilt University, MCN T-4224, 37232 Nashville, TN
| | - Joseph S. Neimat
- grid.152326.10000000122647217Department of Neurological Surgery, Vanderbilt University, MCN T-4224, 37232 Nashville, TN
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Ostrem JL, Marks WJ, Volz MM, Heath SL, Starr PA. Pallidal deep brain stimulation in patients with cranial-cervical dystonia (Meige syndrome). Mov Disord 2007; 22:1885-91. [PMID: 17618522 DOI: 10.1002/mds.21580] [Citation(s) in RCA: 150] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Idiopathic cranial-cervical dystonia (ICCD) is an adult-onset dystonia syndrome affecting orbicularis oculi, facial, oromandibular, and cervical musculature. ICCD is frequently difficult to treat medically. Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is a highly effective treatment for idiopathic generalized dystonia, however less is known about the effect of GPi DBS on ICCD. In this article, we present the results from a pilot study assessing the effect of GPi DBS in a series of patients with ICCD. Six patients underwent bilateral stereotactic implantation of DBS leads into the sensorimotor GPi. Patients were evaluated with the Burke-Fahn-Marsden dystonia rating scale (BFMDRS) and Toronto western spamodic torticollis rating scale (TWSTRS) before surgery and 6 months postoperatively. At 6 months, patients showed a 72% mean improvement in the BFMDRS total movement score (P < 0.028, Wilcoxin signed rank test). The mean BFMDRS disability score showed a trend toward improvement (P < 0.06). The total TWSTRS score improved 54% (P < 0.043). Despite improvement in dystonia, mild worsening of motor function was reported in previously nondystonic body regions with stimulation in 4 patients. Although GPi DBS was effective in these patients, the influence of GPi DBS on nondystonic body regions deserves further investigation.
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Affiliation(s)
- Jill L Ostrem
- Department of Neurology, University of California, San Francisco, California 94143, USA.
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Vercueil L, Houeto JL, Krystkowiak P, Lagrange C, Cassim F, Benazzouz A, Pidoux B, Destée A, Agid Y, Cornu P, Blond S, Benabid AL, Pollak P, Vidailhet M. Effects of pulse width variations in pallidal stimulation for primary generalized dystonia. J Neurol 2007; 254:1533-7. [PMID: 17597333 DOI: 10.1007/s00415-007-0578-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2006] [Revised: 02/15/2007] [Accepted: 02/28/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Various pulse widths (from 60-450 mus) have been used for bilateral pallidal stimulation in generalized dystonia but, to date, no comparison of this parameter's effects is available. OBJECTIVE To provide an analysis of the differential effects of bilateral short, medium and long stimulus pulse width (PW) on clinical improvement in primary generalized dystonia. METHODS The most effective therapeutic stimulation parameters were recorded in 22 patients using bilateral pallidal stimulation. Six months after surgery, the effects of bilateral pallidal short (60-90 micros), medium (120-150 micros) and long (450 micros) PWs were studied in 20 of those patients. The effect of the stimulation was assessed by reviewing videotaped sessions by an observer blinded to treatment status (Burke-Fahn-Marsden movement score). Patients were tested on separate days, in random order, for the stimulation conditions (acute effect with the stimulation condition lasting 10 hours). The same contact was used for each stimulation condition. All the electrodes were set at 130 Hz (monopolar stimulation) and the intensity was set individually 10% below the side effect threshold. RESULTS Median PWs of 60 (short), 120 (medium) and 450 micros (long) were compared,with a mean intensity of 4.46, 3.45 and 2.47 V, respectively. This study failed to demonstrate any significant difference in the movement scale dystonia mean scores depending on PW. CONCLUSION According to our findings, short duration stimulus PWs are as effective as longer ones during a 10 hour period of observation. Confirmation of this finding for chronic use could be of importance in saving stimulator energy. Moreover, the use of smaller stimulus pulse widths are said to reduce charge injection and increase the therapeutic window between therapeutic effects and side effects.
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Affiliation(s)
- Laurent Vercueil
- Neurology and Neurosurgery, CHU Grenoble, 38043 Grenoble, France.
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Roze E, Navarro S, Cornu P, Welter ML, Vidailhet M. Deep brain stimulation of the globus pallidus for generalized dystonia in GM1 Type 3 gangliosidosis: technical case report. Neurosurgery 2007; 59:E1340; discussion E1340. [PMID: 17277672 DOI: 10.1227/01.neu.0000245620.24603.1b] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE GM1 Type 3 gangliosidosis is a lysosomal storage disorder for which no specific treatment is available. It is characterized by progressive generalized dystonia, which is refractory to pharmacological treatment and results in severe disability and life-threatening complications. We performed bilateral pallidal stimulation in a patient with GM1 gangliosidosis and report the 12-month postoperative course. CLINICAL PRESENTATION A 24-year old woman presented with genetically confirmed GM1 gangliosidosis, resulting in severe progressive generalized dystonia. INTERVENTION Leads were implanted bilaterally into the internal part of the globus pallidus under stereotactic guidance. At follow-up visits, both the patient and the neurologists who performed the assessment were unaware of whether the neurostimulator was on or off. The patient was videotaped with a standardized protocol and scored by an independent expert. CONCLUSION After 1 year of follow-up, double-blind comparison of the patient's status with and without neurostimulation showed a 20% improvement, with a significant functional benefit, but no change in disease progression. Although further studies are needed to evaluate this therapeutic approach, this report suggests that pallidal stimulation might be a promising treatment for dystonia caused by GM1 Type 3 gangliosidosis.
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Affiliation(s)
- Emmanuel Roze
- Department of Neurology, Saint-Antoine Hospital, Paris, France.
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Goto S, Yamada K, Shimazu H, Murase N, Matsuzaki K, Tamura T, Nagahiro S, Kuratsu JI, Kaji R. Impact of bilateral pallidal stimulation on DYT1-generalized dystonia in Japanese patients. Mov Disord 2006; 21:1785-7. [PMID: 16830314 DOI: 10.1002/mds.21021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Early-onset generalized dystonia attributable to a DYT1 gene mutation is a hyperkinetic movement disorder that responds poorly to pharmacotherapy. In this video brief, we show that continuous bilateral stimulation of the globus pallidus internus produced sustained and marked improvements in the motor symptoms and functional disabilities of Japanese patients with DYT1-generalized dystonia.
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Affiliation(s)
- Satoshi Goto
- Department of Neurosurgery, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan.
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Yamada K, Goto S, Soyama N, Shimoda O, Kudo M, Kuratsu JI, Murase N, Kaji R. Complete suppression of paroxysmal nonkinesigenic dyskinesia by globus pallidus internus pallidal stimulation. Mov Disord 2006; 21:576-9. [PMID: 16267844 DOI: 10.1002/mds.20762] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Stereotactic functional surgery is being explored as potential therapies for medically intractable paroxysmal dyskinesias (PxD). We report on a 59-year-old man in whom stimulation of globus pallidus internus produced immediate and sustained relief of paroxysmal non-kinesigenic dyskinesia secondary to a rotator cuff tears on the left shoulder. Our finding strongly suggests that altered function of neuronal circuits of the basal ganglia underlies the manifestation of PxD.
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Affiliation(s)
- Kazumichi Yamada
- Department of Neurosurgery, Graduate School of Medical Sciences, Kumamoto University, Japan.
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Holloway KL, Baron MS, Brown R, Cifu DX, Carne W, Ramakrishnan V. Deep Brain Stimulation for Dystonia: A Meta-Analysis. Neuromodulation 2006; 9:253-61. [DOI: 10.1111/j.1525-1403.2006.00067.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Starr PA, Turner RS, Rau G, Lindsey N, Heath S, Volz M, Ostrem JL, Marks WJ. Microelectrode-guided implantation of deep brain stimulators into the globus pallidus internus for dystonia: techniques, electrode locations, and outcomes. J Neurosurg 2006; 104:488-501. [PMID: 16619651 DOI: 10.3171/jns.2006.104.4.488] [Citation(s) in RCA: 188] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Deep brain stimulation (DBS) of the globus pallidus internus (GPI) is a promising new procedure for the treatment of dystonia. The authors describe their technical approach for placing electrodes into the GPI in awake patients with dystonia, including methodology for electrophysiological mapping of the GPI in the dystonic state, clinical outcomes and complications, and the location of electrodes associated with optimal benefit. METHODS Twenty-three adult and pediatric patients with various forms of dystonia were included in this study. Baseline neurological status and DBS-related improvement in motor function were measured using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). The implantation of DBS leads was performed using magnetic resonance (MR) imaging-based stereotaxy, single-cell microelectrode recording, and intraoperative test stimulation to determine thresholds for stimulation-induced adverse effects. Electrode locations were measured on computationally reformatted postoperative MR images according to a prospective protocol. CONCLUSIONS Physiologically guided implantation of DBS electrodes in patients with dystonia was technically feasible in the awake state in most patients, and the morbidity rate was low. Spontaneous discharge rates of GPI neurons in dystonia were similar to those of globus pallidus externus neurons, such that the two nuclei must be distinguished by neuronal discharge patterns rather than rates. Active electrode locations associated with robust improvement (> 70% decrease in BFMDRS score) were located near the intercommissural plane, at a mean distance from the pallidocapsular border of 3.6 mm.
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Affiliation(s)
- Philip A Starr
- Department of Neurosurgery, University of California, San Francisco 94143, USA.
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Bhidayasiri R, Cardoso F, Truong DD. Botulinum toxin in blepharospasm and oromandibular dystonia: comparing different botulinum toxin preparations. Eur J Neurol 2006; 13 Suppl 1:21-9. [PMID: 16417594 DOI: 10.1111/j.1468-1331.2006.01441.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Amongst all regions of the body, the craniocervical region is the one most frequently affected by dystonia. Whilst blepharospasm--involuntary bilateral eye closure--is produced by spasmodic contractions of the orbicularis oculi muscles, oromandibular dystonia may cause jaw closure with trismus and bruxism, or involuntary jaw opening or deviation, interfering with speaking and chewing. Both forms of dystonia can be effectively treated with botulinum toxin injection. This article summarizes injection techniques in both forms of dystonia and compares doses, potency and efficacy of different commercially available toxins, including Botox, Dysport, Xeomin and Myobloc/NeuroBloc.
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Affiliation(s)
- R Bhidayasiri
- Division of Neurology, Chulalongkorn University Hospital, Bangkok, Thailand
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Abstract
The cause of primary Meige syndrome is unknown, and although gender and age predilections are different from idiopathic torsion dystonia, most investigators consider Meige syndrome a variant of that disorder. Interest in the use of stereotactic brain surgery for refractory forms of dystonia is thus increasing. There is little experience with the use of deep brain stimulation (DBS) in focal dystonias, and reports of its use in Meige syndrome are very rare. We report on a case of Meige syndrome successfully treated with bilateral pallidal DBS.
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Affiliation(s)
- Melissa Houser
- Department of Neurology, Scripps Clinic, San Diego, California 92037, USA.
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Diamond A, Jankovic J. The effect of deep brain stimulation on quality of life in movement disorders. J Neurol Neurosurg Psychiatry 2005; 76:1188-93. [PMID: 16107348 PMCID: PMC1739801 DOI: 10.1136/jnnp.2005.065334] [Citation(s) in RCA: 109] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Deep brain stimulation (DBS) is a viable treatment alternative for patients with Parkinson's disease (PD), essential tremor (ET), dystonia, and cerebellar outflow tremors. When poorly controlled, these disorders have detrimental effects on the patient's health related quality of life (HRQoL). Instruments that measure HRQoL are useful tools to assess burden of disease and the impact of therapeutic interventions on activities of daily living, employment, and other functions. We systematically and critically reviewed the literature on the effects of DBS on HRQoL in PD, ET, dystonia, and cerebellar outflow tremor related to multiple sclerosis.
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Affiliation(s)
- A Diamond
- Department of Neurology, Parkinson's Disease Center and Movement Disorders Clinic, Baylor College of Medicine, 6550 Fannin Street, Suite 1801, Houston, TX 77030, USA
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