[Deep-brain stimulation of the internal pallidum in multiple system atrophy]

Surgical Management of Synucleinopathies

Synucleinopathies represent a diverse set of pathologies with significant morbidity and mortality. In this review, we highlight the surgical management of three synucleinopathies: Parkinson’s disease (PD), dementia with Lewy bodies (DLB), and multiple system atrophy (MSA). After examining underlying molecular mechanisms and the medical management of these diseases, we explore the role of deep brain stimulation (DBS) in the treatment of synuclein pathophysiology. Further, we examine the utility of focused ultrasound (FUS) in the treatment of synucleinopathies such as PD, including its role in blood–brain barrier (BBB) opening for the delivery of novel drug therapeutics and gene therapy vectors. We also discuss other recent advances in the surgical management of MSA and DLB. Together, we give a diverse overview of current techniques in the neurosurgical management of these pathologies.

A 3D Deep Residual Convolutional Neural Network for Differential Diagnosis of Parkinsonian Syndromes on 18F-FDG PET Images

Idiopathic Parkinsons disease and atypical parkinsonian syndromes have similar symptoms at early disease stages, which makes the early differential diagnosis difficult. Positron emission tomography with ¹⁸F-FDG shows the ability to assess early neuronal dysfunction of neurodegenerative diseases and is well established for clinical use. In the past decades, machine learning methods have been widely used for the differential diagnosis of parkinsonism based on metabolic patterns. Unlike these conventional machine learning methods relying on hand-crafted features, the deep convolutional neural networks, which have achieved significant success in medical applications recently, have the advantage of learning salient feature representations automatically and effectively. This advantage may offer more appropriate invisible features extracted from data for the enhancement of the diagnosis accuracy. Therefore, this paper develops a 3D deep convolutional neural network on ¹⁸F-FDG PET images for the automated early diagnosis. Furthermore, we depicted in saliency maps the decision mechanism of the deep learning method to assist the physiological interpretation of deep learning performance. The proposed method was evaluated on a dataset with 920 patients. In addition to improving the accuracy in the differential diagnosis of parkinsonism compared to state-of-the-art approaches, the deep learning methods also discovered saliency features in a number of critical regions (e.g., midbrain), which are widely accepted as characteristic pathological regions for movement disorders but were ignored in the conventional analysis of FDG PET images.

Current Concepts in the Treatment of Multiple System Atrophy

MSA is a progressive neurodegenerative disorder characterized by autonomic failure and a variable combination of poor levodopa-responsive parkinsonism and cerebellar ataxia (CA). Current therapeutic management is based on symptomatic treatment. Almost one third of MSA patients may benefit from l-dopa for the symptomatic treatment of parkinsonism, whereas physiotherapy remains the best therapeutic option for CA. Only midodrine and droxidopa were found to be efficient for neurogenic hypotension in double-blind, controlled studies, whereas other symptoms of autonomic failure may be managed with off-label treatments. To date, no curative treatment is available for MSA. Recent results of neuroprotective and -restorative trials have provided some hope for future advances. Considerations for future clinical trials are also discussed in this review.

Multiple system atrophy: current and future approaches to management

Multiple system atrophy (MSA) is a rare neurodegenerative disorder without any effective treatment in slowing or stopping disease progression. It is characterized by poor levodopa responsive Parkinsonism, cerebellar ataxia, pyramidal signs and autonomic failure in any combination. Current therapeutic strategies are primarily based on dopamine replacement and improvement of autonomic failure. However, symptomatic management remains disappointing and no curative treatment is yet available. Recent experimental evidence has confirmed the key role of alpha-synuclein aggregation in the pathogenesis of MSA. Referring to this hypothesis, transgenic and toxic animal models have been developed to assess candidate drugs for MSA. The standardization of diagnosis criteria and assessment procedures will allow large multicentre clinical trials to be conducted. In this article we review the available symptomatic treatment, recent results of studies investigating potential neuroprotective drugs, and future approaches for the management in MSA.

Deep brain stimulation of the pedunculopontine nucleus in a patient with freezing of gait

CASE PRESENTATION

A 54-year-old male patient presenting probable multiple system atrophy with predominant parkinsonism who underwent bilateral deep brain stimulation (DBS) of the pedunculopontine nucleus (PPN) is presented. The patient had dominant freezing of gait (FOG), levodopa-resistant bradykinesia, and autonomic disturbances, but with a good cognitive condition.

METHODS

The patient underwent bilateral DBS of the PPN, which ended with modest benefits.

RESULTS AND CONCLUSION

Although he had a short postoperative follow-up (6 months), his neurological status remained stable and PPN DBS provided modest improvements in the gait disorder and freezing episodes. This unusual case suggests that the mesencephalic pedunculopontine region may have a role in locomotor symptoms and the potential to provide a limited improvement in FOG.