Marcin Tutaj

Thalamic deep brain stimulation for tremor among multiple sclerosis patients

BACKGROUND AND PURPOSE Disabling tremor might be the main cause of disability of multiple sclerosis (MS) patients. Neuromodulation with deep brain stimulation of the thalamic nucleus ventralis intermedius (Vim DBS) is a well accepted method of neurosurgical treatment of tremor related to essential tremor or Parkinson disease. Vim DBS is not widely used to control MS tremor. MATERIAL AND METHODS Five MS patients with tremor (3 females and 2 males) were treated with Vim DBS. Age at implantation was 37 ± 5 years. MS lasted from 5 to 12 years (mean 6) and tremor was the main cause of disability of those patients from 2 to 5 years (mean 3) before surgery. Clinical condition of the group was evaluated with spirography, the modified Fahn scale and the modified Activity of Daily Living (ADL) scale. Evaluations were performed before surgery and 3 months after surgery. MRI exclusion criteria were the presence of a thalamic hyperintense signal in T2-weight-ed images or ventricular enlargement. The procedures of implantation were performed under local and general anaesthesia. RESULTS Intensity of contralateral limb tremor during intraoperative macrostimulation was reduced in the whole group. The therapeutic effect of DBS was maintained at three-month follow-up. Mean contralateral limb tremor reduction was 40%. Mean ADL score improved by 18%. No mortality or morbidity was reported in the group. CONCLUSIONS The study confirms the value and safety of Vim DBS for treatment of MS-related tremor. Further study on a larger population and introduction of a qualification protocol might increase efficacy of the treatment.

Deep brain stimulation in the treatment of Holmes tremor - a long-term case observation.

We present the patient with Holmes tremor secondary to the infarction of thalamus, successfully treated with the deep brain stimulation (DBS) of the area between ventralis oralis anterior and zona incerta for a long time, in whom the severe tremor reappeared after removal of the DBS lead. This is the first presentation of the effective DBS on this location. Our case does not support the hypothesis that the DBS treatment could lead to sustained relief of symptoms after cessation of stimulation.

Cardiac responses to orthostatic stress deteriorate in Parkinson disease patients who begin to fall

BACKGROUND AND PURPOSE It is not clear how cardiovascular autonomic nervous system dysfunction can affect falls in Parkinson disease (PD) patients. The aim of the study was to evaluate cardiovascular autonomic responses to orthostatic stress and occurrence of falls in PD patients over a period of 1-2 years. MATERIAL AND METHODS In 53 patients, who either experienced at least one fall during 12 months preceding the study onset (fallers) or did not fall (non-fallers), we monitored RR intervals (RRI), heart rate (HR) and systolic (SBP) and diastolic (DBP) blood pressure, and calculated the coefficient of variation of RRI (RRI-CoV) and the ratio of low to high frequency spectral powers of RRI oscillations (LF/HF) at rest and upon tilting at study entry and after at least 12 months. Based on the number of falls at study closure, we identified three subgroups: non-fallers, chronic fallers, and new fallers. RESULTS At study entry, RR-CoV, SBP, or DBP did not differ between fallers and non-fallers, while LF/HF ratios were lower in fallers than non-fallers at rest and upon tilting. After the follow-up period, HR and RRI-CoV responses to head-up tilt were reduced in new fallers as compared to study entry, whereas these variables remained unchanged during the study in non-fallers and chronic fallers. Prevalence of orthostatic hypotension did not differ between subgroups of patients. CONCLUSIONS Cardiac responses to orthostatic stress deteriorate in PD patients who begin to fall. Orthostatic blood pressure responses remain unchanged over time and are not associated with falls in PD.

Subthalamic nucleus deep brain stimulation after bilateral pallidotomy in the treatment of generalized dystonia

Although it is pallidal (globus pallidus pars interna, GPi) deep brain stimulation (DBS) that has been most consistently employed in treating medically refractory dystonia, the effectiveness of the thalamus, zona incerta, or subthalamic nucleus (STN) stimulation has also been demonstrated. However, there is very little data on how DBS in the STN affects dystonia treatment. Therefore, we report a case of a patient after STN DBS and prior pallidotomy. A 27-year-old female patient complaining about disabling movements of the neck, trunk and limbswas admitted to theMovement Disorder division of the Department of Neurology (Jagiellonian University Medical College, Kraków, Poland). The patient was unable to walk, even when assisted, and was bedridden. She required constant help in basic activities of daily living. The patient had no history of birth trauma or serious neonatal illness, her family history was unremarkable. Her past medical history revealed the following: at the age of 12, she experienced clumsiness due to cramps of the right hand while writing; subsequently, over the next years, she developed sustained twisting and repetitivemovements of both upper limbs as well as of the neck, shoulder girdle and the trunk. Postural and rest tremor of both arms was also intermittently present. At the age of 19, the patient was admitted to the Department of Genetics at the Institute of Psychiatry and Neurology inWarszawa, Poland. At that time, dysarthria, torticollis with head rotation to the right and backwards, adduction of the right shoulder, dystonic movements, sometimes with postural and rest tremor of the upper limbs, and abnormal excessive lordosis in the supine position were found on neurological examination. Further clinical evaluation and laboratory testing for primary dystonia, Huntington’s disease, Wilson’s disease, other types of heredodegenerative dystonia and psychogenic dystonia yielded negative results and she was finally diagnosed with DYT1 negative primary generalized dystonia. Within the next two years, the symptoms deteriorated; moreover, progressive gait disturbances and frequent falling appeared. As the pharmacological treatment (levodopa, MAO-B inhibitor, tetrazepam, diazepam,

Optimizing Final Electrode Placement Based on Intraoperative Neurophysiological Evaluation during Subthalamic Deep Brain Stimulation for ParkinsonâÂÂs Disease

Background and purpose: Target point identification based solely on MRI and CT of subthalamic nucleus (STN) in deep brain stimulation procedures (DBS) for Parkinson’s disease (PD) might have suboptimal clinical effects. The authors analyse alterations of permanent electrode location depending on neurophysiological evaluation compared to an anatomically based calculated target. Materials and methods: The group comprised 66 patients (32 females and 34 males) aged 57.6 (38–76) years, in whom 131 electrodes were implanted. The patients were qualified for the surgery according to the CAPSIT-PD criteria. STN was identified using the direct and indirect methods, based on 1.5 T MRI and CT. The surgery was performed under local anesthesia. Two to 5 microelectrodes were used for microrecording and macrostimulation. Results: Anterior (49.2%), central (35.6%) and lateral (13.6%) trajectories were most frequently used for permanent electrode placement. The electrode was most frequently placed at a depth of +2/+3 (58.3%) or +1 and +5 mm (36.4%) with regard to the planned target point. Differences in selecting the trajectory and depth of the final electrode position were statistically significant (p<0.05). Conclusion: DBS implantation based only on anatomical identification of STN can lead to suboptimal results. Additional application of intrasurgical neurophysiological analysis may increase the effectiveness of the STN DBS therapy for PD.

Dynamic cerebral autoregulation is compromised in ischaemic stroke of undetermined aetiology only in the non-affected hemisphere

BACKGROUND AND PURPOSE To assess dynamic cerebral autoregulation (CA) in patients with acute ischaemic stroke of undetermined aetiology, within 72h of stroke onset. MATERIALS AND METHODS In 6 patients with ischaemic stroke of undetermined aetiology (aged 66±9 years, National Institutes of Health Stroke Scale [NIHSS] score on admission: 4.0, range: 4-11), selected based on screening of 118 consecutive ischaemic stroke patients and in 14 volunteers (aged 62±10 years), we continuously monitored RR intervals (RRI), mean arterial pressure (MAP) by means of photoplethysmography, mean cerebral blood flow velocity (CBFV) using transcranial Doppler ultrasonography, end-tidal CO2 (ETCO2) and respiration during 2-min deep breathing paced at 6min(-1) (0.1Hz). To assess CA, we evaluated the impact of breathing-induced MAP oscillations on fluctuations of CBFV in the hemispheres with stroke, the non-involved hemispheres and randomly selected hemispheres of controls by applying cross-spectral analysis and calculating coherence, transfer function gain (CBFV-MAP gain) and phase shift angle between the two oscillating signals. RESULTS Phase shift angle between MAP and CBFV oscillations showed values >0 and was significantly reduced in the hemispheres without stroke as compared to controls (0.39±0.95 vs. -1.59±0.33rad, p=0.015), whereas in the hemispheres with stroke, phase shift angle did not differ significantly from that observed in the control hemispheres. Clinical status of stroke patients significantly improved at discharge from the hospital (NIHSS: 2.0, range: 1-8, p=0.028). CONCLUSIONS During the first days of ischaemic stroke of undetermined aetiology, dynamic cerebral autoregulation is compromised in the non-affected hemisphere, but not in the hemisphere with ischaemic lesion.