Joo Pyung Kim

Treatment of secondary dystonia with a combined stereotactic procedure: long-term surgical outcomes

ObjectiveThere is some debate about the effects of pallidal deep brain stimulation (DBS) or lesioning on secondary dystonia. We applied a multimodal method to maximize the treatment effects of deep brain stimulation in patients with secondary dystonia.MethodsBetween March 2003 and January 2009, four patients underwent bilateral globus pallidus internus (GPi) DBS and six patients underwent bilateral GPi DBS plus unilateral thalamotomy for treatment of cerebral palsy (CP). Among the patients with secondary dystonia without CP, five were also treated by DBS. We classified patients with generalized secondary dystonia with cerebral palsy into group I and patients with focal dystonia without CP into group II. Clinical outcome assessments were based on Burke-Fahn-Marsden Dystonia Rating Scale movement and disability scores. Heath-related quality of life was assessed with a 36-item short-form general health survey questionnaire preoperatively and at the last follow-up.ResultsThe movement and disability scores of group I-A had improved by 32.0% (P = 0.285) and 14.3% (P = 0.593), respectively, at the last follow-up compared with baseline. The movement and disability scores of group I-B had improved by 31.5% and 0.18% at the last follow-up compared with baseline, respectively. In comparison with patients in group I-A, patients in group I-B showed a significant improvement in movement scores for the contralateral arm (P = 0.042). Group II patients showed a marked improvement in movement and disability scores of 77.7% (P = 0.039) and 80.0% (P = 0.041), respectively.ConclusionsWe demonstrated that DBS plus unilateral ventralis oralis thalamotomy for CP patients with fixed states in the upper extremities is useful not only to treat secondary dystonic movement but also to improve quality of life. In group II patients with post-traumatic dystonia and tardive dyskinesia, we achieved excellent clinical outcomes using a stereotactic procedure.

A Combination Procedure with Double C-Shaped Skin Incision and Dual-Floor Burr Hole Method to Prevent Skin Erosion on the Scalp and Reduce Postoperative Skin Complications in Deep Brain Stimulation

Background: The purpose of this study was to introduce a combination procedure with double C-shaped skin incision and an adjusted dual-floor burr hole to prevent skin complications on the scalp with deep brain stimulation (DBS) surgery. Methods: Between March 2000 and March 2010, 504 DBS electrodes were implanted in 268 patients. We included both bilateral and unilateral DBS surgery cases for Parkinson’s disease, tremor, pain, obsessive-compulsive disorder and intractable seizure accompanied with cranial and IPG insertion procedure, but excluded motor cortex stimulation, and spinal cord stimulation. We used a straight skin incision in 118 patients, double C-shaped skin incision only in 113 patients since March 2006, and combined a double C-shaped skin incision and dual-floor burr hole in 37 patients since August 2009. We compared scalp wound complications and the height subscale of the Vancouver Scar Scale between previous straight or C-shaped skin incision and the combination procedure. Results: We had eight scalp erosions associated with infection (3.0%) and six disconnection (2.2%) cases among 268 patients. Before the use of the double C- skin incision or adjusted dual-floor burr hole technique, we had 5 (4.2%) scalp erosion cases among 118 patients. With the introduction of the C-shaped incision, only 3 patients (2.7%) developed scalp erosion. However, no patient among 37 patients developed scalp erosion after using both double C-shaped skin incision and dual-floor burr hole technique. Scalp bump measured by the height subscale of the Vancouver Scar Scale was more cosmetic in the combination procedure. Conclusion: The combination procedure prevents skin complications associated with DBS surgery, with tensile strength, less impaired vascular supply and better cosmetic outcome. This promising approach prevents unwanted skin complications associated with DBS surgery and improves patient satisfaction.

Effects of relative low-frequency bilateral globus pallidus internus stimulation for treatment of cervical dystonia.

Objective: To assess the effect of relative lower amplitude and frequency for globus pallidus internus (GPi) deep brain stimulation (DBS) of cervical dystonia (CD). Materials and Methods: Between February 2005 and October 2008, 14 patients diagnosed with CD underwent bilateral GPi DBS and all the patients received low-frequency stimulation and were followed for more than 2 years. We activated the implantable pulse generator 3–4 days postoperatively and initial amplitude, pulse width, and frequency were set at 1.5 V, 120 µs, and 70 Hz. The Toronto Western Spasmodic Torticolis Rating Scale (TWSTRS) was applied preoperatively and at 1, 6, 12 and 24 months postoperatively. Results: The overall TWSTRS scores improved 71.2% 2 years postoperatively (p = 0.001). The mean improvement was 78.4% in severity subscores, 68.4% in disability, and 66.8% in pain scores for the 2-year follow-up period. The TWSTRS scores were significantly reduced (p < 0.05), suggesting that the most significant improvement of the TWSTRS scores occurred within 1 month. The final amplitude was 2.9/2.7 V with the pulse width of 147.9/147.9 µs and the frequency of 101.1/100 Hz. Conclusion: According to our results, the initial settings of low amplitude and especially relatively low frequency are safe and effective for treatment of CD.

The long-term surgical outcomes of secondary hemidystonia associated with post-traumatic brain injury

BackgroundThe aim was to assess the effect of deep brain stimulation for secondary hemidystonias associated with focal post-traumatic brain injuries.MethodsFour patients underwent deep brain stimulation for the treatment of medically refractory secondary hemidystonia associated with post-traumatic brain injury. Clinical outcome assessments were based on Burke-Fahn-Marsden Dystonia Rating Scale movement and disability scores. Health-related quality of life was assessed using a 36-item short-form general health survey questionnaire administered preoperatively and at the last follow-up visit.ResultsBurke-Fahn-Marsden Dystonia Rating Scale movement scores had improved by 73.2% (range, 38.1–94.1) and disability scores had improved by 75% (range, 60–100) at the 2-year follow-up visit. The health-related quality of life assessment revealed satisfactory results at follow-up, such that body pain, general health, vitality, social functioning, as well as emotional and mental health improved significantly.ConclusionsGlobus pallidus internus deep brain stimulation can be used to modulate and ameliorate secondary hemidystonia associated with focal post-traumatic brain injury.

Simultaneous Thalamic and Posterior Subthalamic Electrode Insertion With Single Deep Brain Stimulation Electrode for Essential Tremor

Objectives:  The optimal target location of deep brain stimulation (DBS) is the subject of some controversy. We implanted electrodes that could stimulate both posterior subthalamic area (PSA) and ventralis intermedius nucleus of thalamus (Vim), and examined the benefits of bilateral DBS of Vim, PSA, and Vim + PSA in patients with essential tremor (ET).

Gamma knife radiosurgery for idiopathic trigeminal neuralgia as primary vs. secondary treatment option

OBJECTIVE To enable physicians to remain informed of secondary GKR after multiple surgical choices. This study compares gamma knife radiosurgery (GKR) as a first and a second treatment for the management of medically refractory idiopathic trigeminal neuralgia (TN). METHODS Between May 1998 and May 2008, a total of 86 patients with idiopathic TN underwent GKR, with 62 patients receiving the treatment as a first therapy (primary GKR group) and 24 patients receiving the treatment as a second procedure (secondary GKR group). The median follow-up time was 76.4 months (range 12-161 months). The mean prescription marginal dose delivered to the involved trigeminal nerve root entry zone was 82.4±6.25Gy for the primary GKR group, and 81.0±4.89Gy for the secondary GKR group. In the secondary group, eleven patients underwent percutaneous radiofrequency rhizotomy (PRFR), seven underwent microvascular decompression (MVD), three underwent percutaneous glycerol rhizotomy and another three underwent GKR as their first treatment. We excluded a typical, multiple sclerosis or secondary trigeminal neuralgia. RESULTS No significant differences in radiation dose, time to initial response, recurrence or pain relief were observed between the use of GKR as a primary and a secondary procedure for idiopathic TN. The occurrence of new onset after GKR were the same for the two groups, but overall facial sensory changes was higher in the secondary GKR group. CONCLUSION For pain control, GKR can be offered both as a primary and as a secondary procedure, but shows higher overall facial sensory changes in secondary GKR group. The results of our study enable physicians to remain informed of secondary GKR after multiple surgical choices. GKR would be an alternative treatment modality after other surgical treatments including GKR, MVD, PRFR and Glycerol.

Impact of ventralis caudalis deep brain stimulation combined with stereotactic bilateral cingulotomy for treatment of post-stroke pain.

Stroke is the third leading cause of death worldwide. As the elderly population grows, interest in the quality of life, management and treatment of patients with post-stroke pain has grown. Pharmacological treatment is usually the first line of management in these patients. However, if medications fail to achieve appropriate pain relief, neuroablative or neuromodulating procedures are used as alternative methods to interrupt the transmission of pain. We performed unilateral ventralis caudalis deep brain stimulation combined with stereotactic bilateral cingulotomy to maximize the effects of treatment for 3 patients with intractable post-stroke pain.

Outcomes of surgical treatment for hemifacial spasm associated with the vertebral artery: severity of compression, indentation, and color change

ObjectThe object of surgical treatment for hemifacial spasm (HFS) is the exclusion of pulsatile neurovascular compression of the root exit zone (REZ). However, spasm persists transiently or permanently in some cases even after complete decompression. In particular, we mainly experience these results when the vertebral artery (VA) is the offender. Hence, we verified color changes of the nerve and indentations from within the operative field in HFS patients with the VA as the offender. So, we reviewed retrospectively the records of those patients who were treated with microvascular decompression (MVD) in order to assess the relationship between operative findings and clinical results.MethodsA total of 232 patients with HFS associated with the VA were treated with MVD between January 1994 and January 2009 at our institution. The patients were classified into one of the following three categories based on compression severity: Group I, mild; Group II, moderate; Group III, severe. The patients were also classified into one of the following four categories based on the existence of indentation and discoloration of nerve VII: Group A (−/−), B (+/−), C (−/+), or D (+/+).ResultsA total of 94.2% and 96.6% of the patients in Groups I and II, respectively, had improved to grades I-II at the last follow-up. The surgical outcomes of Group III were slightly poorer than those of Groups I and II. Group A showed the poorest outcomes with 60% of the patients classified as grades III-IV. In Group B, 98.4% of the patients showed a marked improvement and Groups C and D showed relatively poor outcomes compared with those of Group B.ConclusionsSevere deviations and color changes of the facial nerves may be the risk factors for poor surgical outcomes. Future studies with larger sample sizes and investigations of the pathophysiology underlying these findings are needed.

Bilateral Globus Pallidus Internus Deep Brain Stimulation for DYT1+ Generalized Dystonia with Previously Received Bilateral Thalamotomy and Unilateral Pallidotomy

Ablation of the globus pallidus internus (GPi) and thalamotomy have been extensively used in the past. Posteroventral GPi deep brain stimulation has been considered as a treatment for dystonia. However, to date, there is no report in the literature of any dystonia patient who underwent GPi deep brain stimulation who had previously undergone staged bilateral thalamotomy and unilateral pallidotomy. The authors of the present study have acquired relatively good clinical results, even in patients who previously received bilateral thalamotomy and unilateral pallidotomy for DYT1+ primary generalized dystonia.

The effect of bilateral globus pallidus internus deep brain stimulation plus ventralis oralis thalamotomy on patients with cerebral palsy.

Objective: We compared bilateral globus pallidus internus (GPi) deep brain stimulation (DBS) with bilateral GPi DBS plus ventralis oralis (Vo) thalamotomy to analyze the effect of the combined Vo thalamotomy. Methods: Between March 2003 and December 2008, 10 patients underwent DBS and/or Vo thalamotomy for treatment of cerebral palsy in our institute of neurosurgery and rehabilitation medicine. Four patients received bilateral posteroventral GPi DBS as group I and 6 patients received GPi DBS plus unilateral thalamotomy as group II. Results: The movement and disability scores of group I improved by 32 and 14.3%, respectively, at the last follow-up compared with baseline. The movement and disability scores of group II improved by 31.5 and 0.18%. The BFMDRS-movement subscores of group II demonstrated statistically significant improvement in the contralateral arm compared to group I (p = 0.042). Body pain, vitality and mental health seemed to improve in group II, in terms of health-related quality of life. Conclusions: Contrary to our expectations, we were unable to demonstrate clear improvements in overall BFMDRS scores between group I and group II. However, movements of the contralateral upper extremities improved and health-related quality of life in group II showed satisfactory results.