Ineffective subthalamic nucleus stimulation in levodopa-resistant postischemic parkinsonism

Abstract

Article abstract-The authors report a patient with postischemic parkinsonism who responded neither to levodopa nor to bilateral subthalamic nucleus (STN) stimulation. MRI revealed bilateral lesions of the substantia nigra, the striatum, the external pallidum, and part of the internal pallidum. PET showed reduced striatal dopa-decarboxylase activity, D 2 receptor binding, and glucose metabolism. 2,3 A single case report indicates a positive effect of pallidotomy in a patient with postischemic parkinsonism, in whom the lesions involved the putamen and the globus pallidus externus bilaterally but spared the globus pallidus internus. 4 Another patient with levodopa-resistant parkinsonism with a normal preoperative MRI and mildly reduced 18 F-fluorodopa PET improved after pallidotomy. 5 We report the case of a patient with a postischemic akineto-rigid parkinsonian syndrome, unresponsive to L-dopa, who showed only a minor response to bilateral STN stimulation.Case report. A 63-year-old man experienced syncope. He was immediately diagnosed with cardiac arrest and received cardiac massage and mouth-to-mouth respiration. Ventricular fibrillation was diagnosed on arrival at the hospital 25 minutes later. Electrical defibrillation restored a sinus rhythm. He regained consciousness, but had generalized tonic-clonic seizures, which were treated with high doses of barbiturates. A barbiturate coma was maintained over 10 days and ventilation was prolonged because of pulmonary infection. Although cognitive functions were quickly recovered, he was left with a severe postischemic akinetic-rigid syndrome that was stable over time. There was no subjective or objective improvement under levodopa (600 mg ϩ decarboxylase inhibitor per day) for 18 months and no deterioration when levodopa was stopped. Administration of subcutaneous apomorphine up to 8 mg as a bolus did not induce any change in the motor state. Before surgery, the parkinsonian syndrome was rated 65/ 108 on the motor part of the Unified Parkinson's Disease Rating Scale (UPDRS). He had severe generalized akinesia and rigidity, mild action tremor of the upper limbs, severe hypophonic speech, frequent choking when swallowing liquids, and loss of postural reflexes. He was able to get out of a chair and walk unassisted, but gait was greatly impaired by initiation difficulties, festination, and freezing. There were no motor fluctuations or dyskinesias. There was no dementia, but neuropsychological examination revealed mild difficulties in tests sensitive to frontal lobe scoring. No definite signs of pyramidal, sensory, or cerebellar involvement were found. MRI revealed bilateral lesions of the basal ganglia with a hypointense signal on T2-and a hyperintense signal on T1-weighted sequences, mainly of the putamen and caudate but also involving the globus pallidus, sparing its most internal part. Mild hyperintense signals were also seen lateral to the interpeduncular cistern in the substantia nigra (figure). Striatal measurements of dopa-decarboxylase activity (fluorodopa PET), D ...

Treatment results: Parkinson's disease

“…Krack and colleagues suggest that parkinsonian patients who do not have a good response to levodopa or in whom a postsynaptic dopaminergic lesion can be shown may not be good candidates for STN surgery. 33 Actually, mainly off-motor symptoms responded to STN stimulation, proportionally to their presurgical response to levodopa or apomorphine. 34,35 Operative complications are more common in aged patients.…”

“…In our group, of 150 parkinsonian patients operated on from STN stimulation, 2 suffered from parkinsonism and dementia, 2 from multiple system atrophy, and 1 from postanoxic parkinsonism. 33 The benefit they drew from surgery was moderate or nil, did not prevent from the subsequent worsening of nonmotor impairment, and did not eventually justify the risk of surgery. Krack and colleagues suggest that parkinsonian patients who do not have a good response to levodopa or in whom a postsynaptic dopaminergic lesion can be shown may not be good candidates for STN surgery.…”

Bilateral Stimulation of the Subthalamic Nucleus in Parkinson’s Disease: Surgical Efficacy and Prediction of Outcome

“…Moreover, preoperative levodopa responsiveness generally confirms the clinical diagnosis of idiopathic PD. Krack et al [36] reported a case of postischemic PD who responded neither to levodopa nor to bilateral STN DBS. They emphasize that the effect of surgery can be predicted by the response to levodopa.…”

Deep brain stimulation of the subthalamic nucleus in Parkinson's Disease 1993 – 2003: where are we 10 years on?

“…73 -75 Thus, patients with atypical Parkinsonism, multisystem atrophy or progressive supranuclear palsy who usually have levodopa-resistant symptoms are unlikely to be as good surgical candidates as patients with idiopathic PD. 76 Even in the latter group, the more levodopa sensitive a symptom is, the more likely it will respond to STN HFS surgery. Thus, the majority of authors recommend performing a preoperative levodopa challenge test that will not only help to predict the potential surgical response, but also help to rationalize patient's expectations.…”