Stereotactic Subthalamic Nucleus Lesioning for the Treatment of Parkinson’s Disease

O, Vilela Filho; Silva, Dionei José da; Ha, Souza; Je, Cavalcante; Jt, Sousa; Fp, Ferraz; Lg, Silva; Lf, Santos

doi:10.1159/000064601

Cited by 20 publications

(24 citation statements)

References 3 publications

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supporting

confidence: 68%

“…Using these models it was possible to demonstrate hyperactivity in the globus pallidus internus (GPi) and subthalamic nucleus (STN) and the presence of tremor-cells in GPi and STN 1,[3][4][5][6][7] , validating previously proposed circuits of the basal ganglia [8][9][10] . Such knowledge made possible the comprehension of the genesis of the cardinal manifestations of PD 1,[3][4][5][6][7] and how to better treat them surgically 1 . Besides, a new hypothesis has been advanced: the excitotoxic effect of STN glutamate on dopaminergic cells of substantia nigra pars compacta (SNC) would act as a perpetuating mechanism of dopaminergic cell death and PD progression 3,4,7,11 .…”

supporting

confidence: 68%

“…Such knowledge made possible the comprehension of the genesis of the cardinal manifestations of PD 1,[3][4][5][6][7] and how to better treat them surgically 1 . Besides, a new hypothesis has been advanced: the excitotoxic effect of STN glutamate on dopaminergic cells of substantia nigra pars compacta (SNC) would act as a perpetuating mechanism of dopaminergic cell death and PD progression 3,4,7,11 .…”

mentioning

confidence: 99%

“…Taking these findings all together, one could suppose that STN would be the most suitable target to treat PD 3,4 . STN deep brain stimulation (STN-DBS) was first performed by Benabid's group in 1993 12,13 .…”

mentioning

confidence: 99%

“…STN lesioning, on the other hand, was first reported by Obeso et al in 1997 26 . Probably due to the fear of producing hemiballismus, this procedure has been reported in only 21 patients all over the world 1,3,4,7,14,17,[26][27][28][29][30] , despite the significant improvement obtained.…”

mentioning

confidence: 99%

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Unilateral subthalamic nucleus lesioning: a safe and effective treatment for Parkinson's disease

Filho

Silva

2002

Arq. Neuro-Psiquiatr.

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-The present study, the largest in the literature, was performed to assess the effectiveness and safety of unilateral subthalamic nucleus (STN) lesioning for Parkinson's disease (PD). From August 1999 to September 2000, 21 consecutive patients evaluated pre-and postoperatively by a single examiner were operated. Levodopa intake and dyskinesia, Hoehn & Yahr, Schwab & England and UPDRS motor scores were recorded. Stereotactic CT and MRI and the effects of macrostimulation were used to determine STN coordinates. A single radiofrequency lesion was made (60-75ºC/60"). Concomitant ipsilateral Vim/VOp lesions were made in 8 patients. Using a new technique, we were able to determine the territory of STN involved by the surgical lesion. The Wilcoxon and Mann-Whitney statistical tests were applied to evaluate the surgical results. All recorded parameters showed stable improvement after a mean follow up of 13.5 months. Recurrence occurred in two patients. Contralateral tremor arrest and decrease of rigidity and bradykinesia should be regarded as STN hallmarks to stimulation. Hyperintense lesions in the early-phase MRI seem to be a poor prognostic factor. Lateral territory lesioning correlates with better results. There was no significant difference between the cohorts with and without a Vim/VOp lesion. Dyskinesias happened in two patients (promptly abolished by a Vim/VOp lesion). Other complications were transient and/or rare. In conclusion, STN lesioning is a safe and very effective procedure to treat PD and probably an underutilized operation for those who can not afford the costs of DBS.KEY WORDS: subthalamic nucleus lesioning, deep brain stimulation, stereotactic surgery, subthalamic nucleotomy, subthalamotomy, Parkinson's disease. Lesão unilateral do núcleo subtalâmico: um tratamento seguro e eficaz para a doença de ParkinsonRESUMO -O presente estudo, o maior da literatura, foi realizado para avaliar a eficácia e segurança da lesão unilateral do NST (núcleo subtalâmico) para o tratamento da DP (doença de Parkinson). Entre agosto de 1999 e setembro de 2000, 21 pacientes consecutivos avaliados pré e pós-operatoriamente por um único examinador foram operados. Os seguintes parâmetros foram avaliados: dose diária de levodopa, discinesia induzida pela levodopa, estadiamento da doença, atividades de vida diária e escores motores da UPDRS. RNM e TC estereotáxicas e os efeitos da estimulação com macroeletrodo foram utilizados na determinação das coordenadas do NST. Uma única lesão por radiofrequência foi realizada (60 -75ºC / 60"). Lesão concomitante de Vim/VOp ipsilateral foi realizada em 8 pacientes. Utilizando-se uma nova técnica, foi possível estabelecer o território do NST lesado cirurgicamente. Os testes estatísticos de Wilcoxon e Mann-Whitney foram aplicados para avaliar os resultados cirúrgicos. Todos os parâmetros avaliados apresentaram melhora sustentada após seguimento médio de 13.5 meses. Recidiva ocorreu em 2 casos. Abolição do tremor e redução da rigidez e bradicinesia contralaterais devem ser considerad...

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supporting

confidence: 68%

supporting

confidence: 68%

mentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Unilateral subthalamic nucleus lesioning: a safe and effective treatment for Parkinson's disease

Filho

Silva

2002

Arq. Neuro-Psiquiatr.

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Lesion therapy for Parkinson's disease and other movement disorders: Update and controversies

2004

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An analysis of the international literature on lesioning for movement disorders was undertaken to review lesion therapy for Parkinson's disease (PD) and other movement disorders and to highlight important controversies surrounding this surgical technique. Lesions have been placed throughout the neuraxis with varying approaches and success. Our understanding of the pathophysiological basis underlying the development of PD and other movement disorders has led to a better understanding of why lesioning certain portions of the nervous system should improve motor function. Advances in imaging technology and electrophysiological techniques used for localization of brain structures, such as microelectrode mapping, have improved the ability to accurately identify and lesion target structures deep in the brain. This improvement has led to an increase in the degree and consistency of clinical benefit. The major controversies in lesion therapy include: (1) which target for which disorder; (2) determination of the optimal lesion site and whether the external globus pallidus (GPe) should be included in the pallidotomy lesion for PD; (3) determination of the size of the lesion; (4) whether bilateral lesions can be placed without the high incidence of side effects reported by some investigators; (5) whether microelectrodes aid in the ability to improve clinical outcomes or increase the risk of side effects by making multiple microelectrode penetrations; (6) whether the subthalamic nucleus (STN) should be explored further as a lesioning target; and (7) whether lesioning should be abandoned entirely in favor of deep brain stimulation (DBS). Many important questions and controversies regarding lesion therapy remain unanswered. It is unlikely given the pro-DBS environment that these questions will be answered in the near future. We should, however, be careful not to abandon an effective therapy before fully exploring through randomized trials the relative effect of different surgical approaches for the treatment of patients with movement disorders.

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Changes induced by levodopa and subthalamic nucleus stimulation on parkinsonian speech

et al. 2005

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Levodopa (L‐dopa) and subthalamic nucleus (STN) stimulation treatments have been associated with both improvement and exacerbation of dysarthria in Parkinson's disease (PD). We report four cases illustrating variant responses of dysarthria to dopaminergic and STN stimulation therapies. Patients' motor disability and dysarthria were perceptually rated by the Unified Parkinson's Disease Rating Scale (UPDRS) in four conditions according to medication and STN stimulation. Dedicated software packages allowed acquisition and analysis of acoustic recordings. Case 1, who had a severe off period aphonia, experienced improvement of speech induced by both levodopa and STN stimulation. In Case 2, both treatments worsened speech due to the appearance of dyskinesias. Case 3 had a dysarthria exacerbation induced by STN stimulation with parameters above optimal levels, interpreted as current diffusion from the STN to corticobulbar fibers. In Case 4, dysarthria exacerbation occurred with stimulation at an electrode contact located caudally to the target, also arguing for current diffusion as a potential mechanism of speech worsening. The presented cases demonstrated variant effects in relation to L‐dopa and STN stimulation on speech. It seems that motor speech subcomponents can be improved like other limb motor aspect, but that complex coordination of all speech anatomical substrates is not responsive to STN stimulation. These hypotheses may be helpful for better understanding and management of STN stimulation effects on motor speech and skeleton–motor subsystems. © 2005 Movement Disorder Society

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Stereotactic Subthalamic Nucleus Lesioning for the Treatment of Parkinson’s Disease

Cited by 20 publications

References 3 publications

Unilateral subthalamic nucleus lesioning: a safe and effective treatment for Parkinson's disease

Unilateral subthalamic nucleus lesioning: a safe and effective treatment for Parkinson's disease

Lesion therapy for Parkinson's disease and other movement disorders: Update and controversies

Changes induced by levodopa and subthalamic nucleus stimulation on parkinsonian speech

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