[Deep brain stimulation: 12 years' experience and 150 patients treated with a follow-up of over a year]

INTRODUCTION

Deep brain stimulation (DBS) is a widely accepted clinical technique. The main motor symptoms are significantly reduced. The success of the technique depends on the experience of the neurosurgeon, neurologist and neurophysiologist who carry it out. The presentation of extensive series is needed to confirm and further currently held knowledge.

AIM

To demonstrate the clinical benefits of a long series of patients treated by a single group with a minimum follow-up of one year and to report new neurophysiological data.

PATIENTS AND METHODS

The study examined a total of 250 patients with different diagnoses: most of them with Parkinson's disease, tremor and dystonia. The nuclei that were chosen were located by magnetic resonance imaging, computerised axial tomography and neurophysiological registers. Neurophysiological exclusion criteria, such as reflex control of heart rate, sympathetic skin response and auditory startle reflex, are employed in order to exclude patients with Parkinson-plus.

RESULTS

The motor sub-scale (part III) of the Unified Parkinson's Disease Rating Scale improves by 64% in the off-medication status with sub-thalamic stimulation at one year after surgery. One year after DBS, patients with dystonia show a significant decrease on the Burke-Fahn-Marsden dystonia scale. The improvement on the scales continues, with a mean descent of 65% in the second year after surgery.

CONCLUSIONS

DBS is a suitable technique for the treatment of movement disorders. The neuronal activity of the sub-thalamus and the internal globus pallidus presents its own characteristics that reflect the motor symptoms of the patients. Surface electromyography proves to be useful for quantifying the patients' improvement.

High-frequency stimulation of the subthalamic nucleus silences subthalamic neurons: a possible cellular mechanism in Parkinson's disease

The subthalamic nucleus participates in the control of movement and is considered a surgical target in the treatment of parkinsonian symptoms. Using the rat brain in vitro slice technique we show that sustained high-frequency (>100 Hz) electrical stimulation (i.e., 'tetanic stimulation') of the nucleus, as used in humans to treat Parkinson's disease, silenced subthalamic neurons. Two main cell types were identified. 'Tonic cells' (68%) showed delayed inward rectification, fired continuously, switched to bursting and stopped firing when strongly depolarized with injected current. Tetanic stimulation of the nucleus induced a steady depolarization (approximately 18 mV) that triggered action potentials at a high rate followed by bursts and finally (approximately 25 s) totally silenced tonic cells. The control tonic activity was recovered rapidly (<10 s) after ending stimulation. 'Phasic cells' (25%) discharged a single initial brief burst of action potentials both when depolarized by prolonged current injection and tetanic stimulation and did not show inward rectification. An infrequent cell type called 'phasic-tonic' (7%) showed a mixed discharge. We suggest that the silencing effect of tetanic stimulation is not a frequency-dependent presynaptic depression and could result from the gradual inactivation of Na+-mediated action potentials. These findings suggest that the remission of parkinsonian symptoms by treatment with high-frequency electrical stimulation of the subthalamic nucleus in humans may primarily reside on its capacity to suppress the action potential activity of subthalamic neurons.

Frequency potentiation in the medial cortex of young turtle brains in vitro

Turtle brains have a relatively primitive cortex. Glutamate receptors in the cortex of turtles include N-methyl-D-aspartate (NMDA) and DL-alpha-amino-3-hydroxy-5-methylisoxazole-propionic acid (AMPA). Our aim was to determine whether the medial cortex in turtles, like the cortex and hippocampus in mammals exhibits frequency potentiation, a non-lasting form of synaptic plasticity, and, if so, to identify the involved receptors. Our results indicate that (1) the medial cortex exhibits this phenomenon with septal stimulation at 2 Hz, the frequency with maximum power spectral density in the electrocorticogram of turtles, showing an increase in both the excitatory postsynaptic potential and the evoked potential amplitudes; (2) the frequency potentiation of the medial cortex in turtles is mediated by AMPA type glutamate receptors; (3) the dynamics of frequency potentiation development in turtles show a number of differences from that in mammals. In summary, the cortex in this group of reptiles exhibits a functional trait of the cortex in mammals that is related to learning and memory; this trait, frequency potentiation, may have appeared as an independent specialization in both groups.

[Neuronal activity in the subthalamic nucleus in Parkinson disease]

INTRODUCTION

The subthalamic nucleus has been demonstrated to be involved in Parkinson's disease. Electrical stimulation of this nucleus at high frequency was proved to revert most symptoms and is used as the most advanced alternative therapy. The technique requires the recording of single cell activity as an important step in locating spatially the limits of the nucleus together with magnetic resonance imaging and ventriculography.

OBJECTIVES

To study the electrophysiological properties of single cells in the subthalamus. This information is important to recognize the nucleus in the operating room so as to implant the definitive stimulating electrode.

PATIENTS AND METHODS

Twelve patients with Parkinson's disease were implanted with bilateral electrodes in the subthalamic nucleus. Several neurological tests were applied during one year to study the clinical results.

RESULTS

Single cell activity was recorded in both hemispheres. Three types of cells were recognized based on the mode of discharge: tonic, phasic and rhythmic. The track chosen to implant the definitive electrode was based on the higher number of cells recorded and on the response to tremor and passive or voluntary movements. The neurological tests applied demonstrated a diminution of the symptoms.

CONCLUSION

The subthalamic nucleus plays an important role in handling motor and sensory information. Stimulation of the nucleus at high frequency reveals an amelioration of Parkinson's symptoms during the one year period of study.

Different discharge properties of rat facial nucleus motoneurons

In this paper, we describe two types of putative facial motoneuron based on their electrophysiological properties and on their firing frequency adaptation as recorded in rat brainstem slices. Type I motoneurons (n = 33, 61%) were characterized by a sustained spike firing during depolarizing current injections and a marked depolarizing sag (inward rectification) during hyperpolarizing pulses. The time-course and voltage-dependence of the inward rectification together with the finding that it was blocked by Cs+ are consistent with the involvement of a Na+ -and K+ -mediated Q current. Type II motoneurons (n = 21, 39%) were identified by a fast spike firing adaptation. Type II cells showed a less pronounced inward rectification with hyperpolarizing current pulses and a higher discharge rate than type I cells during depolarizing current pulses. These distinct discharge properties imply the activation of a Ca2+ -dependent K+ current, because when carbachol was added to the bath, or the slice was exposed to a Ca2+ -free solution, a decrease was noticed in the firing frequency adaptation. The two types of motoneuron were further differentiated by the initial delay of the first spike, observed only in type I cells, which was blocked by bath application of 4-aminopyridine, indicating the presence of a K+ -mediated A current. The addition of 4-aminopyridine to the bath also increased the firing rate due to a decrease of the post-spike afterhyperpolarization. However, the two types of motoneuron were not morphologically differentiated. Facial motoneurons exhibited rhythmic membrane potential oscillations (8-20 Hz) at depolarized membrane potentials or during the silence following spike frequency adaptation. It is suggested that the intrinsic properties of these two types of facial motoneuron may be relevant in the government of distinct facial muscle activities. The fact that their discharge rate and the level of spike frequency adaptation were modified by altering some K+ currents suggests a potential plasticity in the modulation of motoneuron firing activities depending upon functional motor needs.

Polymodal sensory and motor convergence in substantia nigra neurons of the awake monkey

Responses of substantia nigra (SN) pars compacta (SNc) and reticulata (SNr) neurons to sensory stimulation and movement were investigated in awake Macaca fascicularis. Concern was assigned to polysensory and sensory/motor convergence on the same cell, which were found in 12% and 9% of the neurons, respectively. Others were modality specific (35%) or unresponsive (44%). The convergence lends support to the notion that SN plays an important role in sensory-motor integration.

Activity in monkey substantia nigra neurons related to a simple learned movement

Single cell activity was recorded in the pars compacta (SNc) and pars reticulata (SNr) of the substantia nigra (SN) in 4 unanesthetized Macaca fascicularis to determine the motor role of the nucleus. Animals were trained to perform a simple task that involved moving a lever by elbow flexion-extensions, in the horizontal plane using the hand contralateral to the recording site. Two monkeys learnt to execute the task on both sides. Electromyograms (EMG) of limb muscles were recorded simultaneously with SN neurons. Discharge rate modulation related to specific movement phases was present in 35% of the neurons. A significant positive correlation of the discharge rate with movement velocity and amplitude was found in SNc and SNr neurons. Some SNr cells discharged in anticipation of the EMG, suggesting a participation of the nucleus in the preparation of movement. The activity of SNr neurons was also related to movement of the left and right upper limb. In conclusion, the SN seems to play an important role in the control of specific motor mechanisms, probably modulating movement velocity, amplitude and direction, with little participation of somatosensory feedback. The involvement of the SNr in the coordination of bilateral arm activity is discussed.

Monkey pulvinar units related to motor activity and sensory response

Single neuron activity in the pulvinar (Pu) was recorded in unanesthetized Macaca irus to investigate the sensory-motor role of this nucleus. A cylinder cemented to the skull allowed microelectrode penetrations. The head was immobilized during recording. Animals were trained to move a lever (push-pull). Electromyographs (EMGs) of several limb muscles were recorded together with Pu unit activity. The effect of active and passive limb movements was studied. Pu responses were also recorded during stimulation with flashes and clicks. A high percentage of units (65%) modified their discharge rate with limb movements. Firings showed a rate modulation in relation to specified movement phases, which were characteristic of each individual unit. Firing rates correlated with movement parameters, strongly with velocity and amplitude, and less with force. Firing rate modulation depth correlated better than mean rate changes with movement parameters, implying that dynamic information is well represented while static parameters are less important. Most of the movement-related units showed visual or auditory responses. A visuo-auditory and motor response was demonstrated in a few cells. The results suggest a participation of the Pu in motor-control.