Surgical treatment of Parkinson disease: past, present, and future

Magnetic Resonance-Guided focused ultrasound surgery for Parkinson's disease: A mini-review and comparison between deep brain stimulation

Magnetic resonance-guided focused ultrasound (MRgFUS) is a new surgical treatment for Parkinson's disease (PD). Previous experience with radiofrequency lesionectomy and deep brain stimulation (DBS) has identified several candidate targets for MRgFUS intended to alleviate the motor symptoms of PD. The main advantage of MRgFUS is that it is incisionless. MRgFUS has certain limitations and is associated with adverse effects. The present study reviews the literature on conventional surgical interventions for PD, discusses recent studies on MRgFUS, and the comparison between DBS and MRgFUS for PD. The reviews aims to provide an essential reference for neurologists to select the appropriate treatments for patients with PD.

An Embedded Multi-Core Real-Time Simulation Platform of Basal Ganglia for Deep Brain Stimulation

Closed-loop deep brain stimulation (DBS) paradigm is gaining tremendous favor due to its potential capability of further and more efficient improvements in neurological diseases. Preclinical validation of closed-loop controller is quite necessary in order to minimize injury risks of clinical trials to patients, which can greatly benefit from real-time computational models and thus potentially reduce research and development costs and time. Here we developed an embedded multi-core real-time simulation platform (EMC-RTP) for a biological-faithful computational network model of basal ganglia (BG). The single neuron model is implemented in a highly real-time manner using a reasonable simplification. A modular mapping architecture with hierarchical routing organization was constructed to mimic the pathological neural activities of BG observed in parkinsonian conditions. A closed-loop simulation testbed for DBS validation was then set up using a host computer as the DBS controller. The availability of EMC-RTP and the testbed system was validated by comparing the performance of open-loop and proportional-integral (PI) controllers. Our experimental results showed that the proposed EMC-RTP reproduces abnormal beta bursts of BG in parkinsonian conditions while meets requirements of both real-time and computational accuracy as well. Closed-loop DBS experiments using the EMC-RTP suggested that the platform could perform reasonable output under different kinds of DBS strategies, indicating the usability of the platform.

High-quality nursing intervention can improve negative emotions, quality of life and activity of daily living of elderly patients with Parkinson's disease

OBJECTIVE

This study was designed to determine the effect of high-quality nursing intervention on negative emotions, quality of life and activities of daily living (ADL) of elderly patients with Parkinson's disease (PD).

METHODS

Totally 115 elderly PD patients treated in our hospital from March 2018 to September 2019 were selected as the research participants. According to different nursing intervention methods, they were divided into two groups. The research group (RG) (65 cases) received high-quality nursing intervention, while the control group (CG) (50 cases) received routine nursing intervention. The adverse reactions, negative emotions, quality of life, ADL, PSQI, MDRSPD scores and nursing satisfaction were compared between the two groups.

RESULTS

After nursing intervention, the incidence of adverse reactions in the RG was dramatically lower than that in the CG. Before nursing intervention, there was no marked difference in the scores of quality of life, ADL and MDRSPD between the two groups. But after nursing, those scores in the RG were markedly higher than those in the CG. Before nursing intervention, there was no remarkable difference in SAS, SDS and PSQI scores between both groups, but after that, the scores of the RG were obviously lower than those of the CG. After nursing intervention, the nursing satisfaction of patients in the RG was dramatically higher than that in the CG.

CONCLUSION

High-quality nursing intervention for elderly PD patients can dramatically improve their negative emotions, quality of life and ADL, and promote recovery of motor function.

Progress in Neuroengineering for brain repair: New challenges and open issues

Background

In recent years, biomedical devices have proven to be able to target also different neurological disorders. Given the rapid ageing of the population and the increase of invalidating diseases affecting the central nervous system, there is a growing demand for biomedical devices of immediate clinical use. However, to reach useful therapeutic results, these tools need a multidisciplinary approach and a continuous dialogue between neuroscience and engineering, a field that is named neuroengineering. This is because it is fundamental to understand how to read and perturb the neural code in order to produce a significant clinical outcome.

Results

In this review, we first highlight the importance of developing novel neurotechnological devices for brain repair and the major challenges expected in the next years. We describe the different types of brain repair strategies being developed in basic and clinical research and provide a brief overview of recent advances in artificial intelligence that have the potential to improve the devices themselves. We conclude by providing our perspective on their implementation to humans and the ethical issues that can arise.

Conclusions

Neuroengineering approaches promise to be at the core of future developments for clinical applications in brain repair, where the boundary between biology and artificial intelligence will become increasingly less pronounced.

The evolution of endovascular electroencephalography: historical perspective and future applications

Current standard practice requires an invasive approach to the recording of electroencephalography (EEG) for epilepsy surgery, deep brain stimulation (DBS), and brain-machine interfaces (BMIs). The development of endovascular techniques offers a minimally invasive route to recording EEG from deep brain structures. This historical perspective aims to describe the technical progress in endovascular EEG by reviewing the first endovascular recordings made using a wire electrode, which was followed by the development of nanowire and catheter recordings and, finally, the most recent progress in stent-electrode recordings. The technical progress in device technology over time and the development of the ability to record chronic intravenous EEG from electrode arrays is described. Future applications for the use of endovascular EEG in the preoperative and operative management of epilepsy surgery are then discussed, followed by the possibility of the technique's future application in minimally invasive operative approaches to DBS and BMI.

Are the Symptoms of Parkinsonism Cortical in Origin?

We present three reasons to suspect that the major deleterious consequence of dopamine loss from the striatum is a cortical malfunction. We suggest that it is cortex, rather than striatum, that should be considered as the source of the debilitating symptoms of Parkinson's disease (PD) since:1.

Cortical synapses onto striatal dendritic spines are lost in PD.

2.

All known treatments of the symptoms of PD disrupt beta oscillations. Oscillations that are also disrupted following antidromic activation of cortical neurons.

3.

The final output of basal ganglia directly modulates thalamic connections to layer I of frontal cortical areas, regions intimately associated with motor behaviour.

These three reasons combined with evidence that the current summary diagram of the basal ganglia involvement in PD is imprecise at best, suggest that a re-orientation of the treatment strategies towards cortical, rather than striatal malfunction, is overdue.

•

Suggested experimental contributions support the proposal of a cortical participation in PD.

•

DBS produces antidromic activation of motor cortex and desynchronizes beta oscillations.

•

Loss of dopamine decreases dendritic spines in the striatal D2 projection neurons.

•

Motor thalamus distributes terminals into frontal cortex layer I.

•

Thalamocortical-layer I activity increases with locomotion.

Deep brain stimulation for Parkinson's disease: current status and future outlook

Parkinson's disease is a neurodegenerative condition secondary to loss of dopaminergic neurons in the substantia nigra pars compacta. Surgical therapy serves as an adjunct when unwanted medication side effects become apparent or additional therapy is needed. Deep brain stimulation emerged into the forefront in the 1990s. Studies have demonstrated improvement in all of the cardinal parkinsonian signs with stimulation. Frameless and ‘mini-frame’ stereotactic systems, improved MRI for anatomic visualization, and intraoperative MRI-guided placement are a few of the surgical advances in deep brain stimulation. Other advances include rechargeable pulse generators, voltage- or current-based stimulation, and enhanced abilities to ‘steer’ stimulation. Work is ongoing investigating closed-loop ‘smart’ stimulation in which stimulation is predicated on neuronal feedback.

Contemporary frameless intracranial biopsy techniques: Might variation in safety and efficacy be expected?

Background

Frameless stereotactic neuronavigation has proven to be a feasible technology to acquire brain biopsies with good accuracy and little morbidity and mortality. New systems are constantly introduced into the neurosurgical armamentarium, although few studies have actually evaluated and compared the diagnostic yield, morbidity, and mortality of various manufacturer’s frameless neuronavigation systems. The present study reports our experience with brain biopsy procedures performed using both the Medtronic Stealth Treon^TM Vertek® and BrainLAB® Varioguide frameless stereotactic brain biopsy systems.

Patients and methods

All 247 consecutive biopsies from January 2008 until May 2013 were evaluated retrospectively. One hundred two biopsies each were performed using the Medtronic (2008–2009) and BrainLAB® system (2011–2013), respectively. The year 2010 was considered a transition year, in which 43 biopsies were performed with either system. Patient demographics, perioperative characteristics, and histological diagnosis were reviewed, and a comparison was made between the two brain biopsy systems.

Results

The overall diagnostic yield was 94.6 %, i.e., 11 biopsies were nondiagnostic, 5 (4.9 %) with the Medtronic and 6 (5.9 %) with the BrainLAB® system. No differences besides the operating time (108 vs 120 min) were found between the two biopsy methods. On average, 6.6 tissue samples were taken with either technique. Peri- and postoperative complications were seen in 5.3 % and 12.9 %, consisting of three symptomatic hemorrhages (1.2 %). Biopsy-related mortality occurred in 0.8 % of all biopsies.

Conclusions

Regarding diagnostic yield, complication rate, and biopsy-related mortality, there seems to be no difference between the frameless biopsy technique from Medtronic and BrainLAB®. In contemporary time, the neurosurgeon has many tools to choose from, all with a relatively fast learning curve and ever improving feasibility. Thus, the issue of choice involves not the results, but the familiarity, end-user friendliness, and overall comfort when operating the system.

Advanced stages of PD: interventional therapies and related patient-centered care

During the last decades, symptomatic treatment of motor symptoms of Parkinson's disease (PD) improved continuously and is reflected by long-range independency of the patient during the disease course. However, advanced stages of PD still represent an important challenge to patients, caregivers and treating physicians. In patients with advanced PD, interventional therapy strategies are increasingly applied. These device-related treatment strategies using pump-based continuous dopaminergic stimulation (CDS) or deep brain stimulation (DBS) opened new treatment options especially if motor complications predominate. Well-designed clinical studies on these interventional therapeutic approaches provided class 1 evidence for the efficacy of DBS and CDS in advanced PD and opened new perspectives for their use in earlier disease stages also. Therefore, careful selection of patients amenable to the (semi)invasive therapy options becomes more and more important and requires an interdisciplinary setting that accounts for (i) optimal patient information and awareness, (ii) selection of best individual treatment modality, (iii) training of relatives and caregivers, (iv) management of complications, and (v) follow-up care. Here, we address these topics by summarizing current state-of-the-art in patient selection, providing specificities of treatment options and troubleshooting, and defining steps towards an optimized patient-centered care. Interventional therapies pioneer in the area of individualized treatment approaches for PD, and may be complemented in the future by biomarker-based improved stratification and by closed-loop systems for adaptive therapeutic strategies. In the present review, we summarize the proceedings of an Expert Workshop on Parkinson's disease held on November 22, 2014 in Frankfurt, Germany.