Maria Gabriela dos Santos Ghilardi

Effects of deep brain stimulation on pain and other nonmotor symptoms in Parkinson disease

Objective: To prospectively evaluate the effect of subthalamic nucleus deep brain stimulation (STN-DBS) on the different characteristics of pain and other nonmotor symptoms (NMS) in patients with Parkinson disease (PD). Methods: Forty-four patients with PD and refractory motor symptoms were screened for STN-DBS. Patients were evaluated before and 1 year after surgery. The primary outcome was change in pain prevalence after surgery. Secondary outcome measures were changes in motor function (Unified Parkinsons Disease Rating Scale), characteristics of pain and other NMS using specific scales and questionnaires, and quality of life. Results: Forty-one patients completed the study. The prevalence of pain changed from 70% to 21% after surgery (p < 0.001). There were also significant improvements in pain intensity, NMS, and quality of life after STN-DBS (p < 0.05). Dystonic and musculoskeletal pain responded well to DBS, while central pain and neuropathic pain were not influenced by surgery. There was a strong correlation between the change in pain intensity and the improvement in quality of life (r = 0.708, p < 0.005). No correlation was found between pain improvement and preoperative response to levodopa or motor improvement during stimulation (r = 0.247, p = 0.197 and r = 0.249, p = 0.193, respectively) or with changes in other NMS. Conclusions: STN-DBS decreased pain after surgery, but had different effects in different types of PD-related pain. Motor and nonmotor symptom improvements after STN-DBS did not correlate with pain relief. Classification of evidence: This study provides Class IV evidence that in patients with idiopathic PD with refractory motor fluctuations, STN-DBS decreases the prevalence of pain and improves quality of life.

Spinal cord stimulation improves gait in patients with Parkinson's disease previously treated with deep brain stimulation

Deep brain stimulation and levodopatherapy ameliorate motor manifestations in Parkinsons disease, but their effects on axial signs are not sustained in the long term.

Spinal cord stimulation for Parkinson's disease: a systematic review

Axial symptoms are a late-developing phenomenon in the course of Parkinson’s disease (PD) and represent a therapeutic challenge given their poor response to levodopa therapy and deep brain stimulation. Spinal cord stimulation (SCS) may be a new therapeutic approach for the alleviation of levodopa-resistant motor symptoms of PD. Our purpose was to systematically review the effectiveness of SCS for the treatment of motor symptoms of PD and to evaluate the technical and pathophysiological mechanisms that may influence the outcome efficacy of SCS. A comprehensive literature search was conducted using electronic databases for the period from January 1966 through April 2014. The methodology utilized in this work follows a review process derived from evidence-based systematic review and meta-analysis of randomized trials described in the PRISMA statement. Reports examining SCS for the treatment of PD are limited. Eight studies with a total of 24 patients were included in this review. The overall motor score of the Unified Parkinson’s Disease Rating Scale in the on/off-stimulation condition remained unchanged in 6 patients and improved in 18 patients after SCS. SCS appears to yield positive results for PD symptoms, especially for impairments in gait function and postural stability. However, evidence is limited and long-term prospective studies will be required to identify the optimal candidates for SCS and the best parameters of stimulation and to fully characterize the effects of stimulation on motor and nonmotor symptoms of PD.

Long-term improvement of tremor and ataxia after bilateral DBS of VoP/zona incerta in FXTAS

Fragile X-associated tremor/ataxia syndrome (FXTAS) is an X-linked adult-onset neurodegenerative disorder that affects carriers of the fragile X mental retardation 1 (FMR1) gene premutation, which is a 55–200 CGG repeat expansion in the 5ʹ untranslated region of the gene.1 The core symptoms of FXTAS are progressive intention tremor and cerebellar ataxia. These symptoms can be disabling and, when combined, severely reduce the patients quality of life. Symptomatic control with medication has limited effects.1 Very few cases have been treated with deep brain stimulation (DBS), mostly in the ventrointermediate thalamic (VIM) nucleus. This treatment results in tremor improvement with either no benefit or worsening of the ataxia and balance.2–4 We present a patient who experienced long-term tremor control and ataxia improvement after chronic bilateral stimulation of the ventro-oralis posterior thalamic nucleus and zona incerta (VoP/ZI), which resulted in significant improvement in daily life activities.

Intraoperative dopamine release during globus pallidus internus stimulation in Parkinson's disease

It is still unclear whether dopamine (DA) levels correlate with Parkinsons disease (PD) severity or play a role in the mechanisms of high‐frequency stimulation (HFS).

Parallel improvement in anxiety and tics after DBS for medically intractable Tourette syndrome: A long-term follow-up

Tourette syndrome (TS) is a movement disorder characterzed by repetitive vocal and motor tics that persist for more han one year. The onset is usually in childhood with alternating eriods of improvement and deterioration in adolescence and a endency to improve after age of 18 years [1]. In addition to the otor features, TS is commonly associated with neuropsychiatric omorbidities including obsessive-compulsive disorder (OCD) and ttention-deficit/hyperactivity disorder (ADHD) with substantial nxiety symptoms. Although the severity and frequency of tics iminish considerably in adulthood, some patients remain very ymptomatic despite behavioral and pharmacological therapies. heir quality of life is significantly impaired. The pathophysiolgy underlying TS remains unknown, but evidence supporting the ole of basal ganglia-thalamocortical circuits in the generation of ics and obsessive-compulsive behaviors has led to stereotactic argeting of key-point structures in these circuits in refractory atients [2]. Here we describe a patient with refractory TS with an

Effects of spinal cord stimulation on postural control in Parkinson's disease patients with freezing of gait

Freezing of gait (FoG) in Parkinson’s disease (PD) is an incapacitating transient phenomenon, followed by continuous postural disorders. Spinal cord stimulation (SCS) is a promising intervention for FoG in patients with PD, however, its effects on distinct domains of postural control is not well known. The aim of this study is to assess the effects of SCS on FoG and distinct domains of postural control. Four patients with FoG were implanted with SCS systems in the upper thoracic spine. Anticipatory postural adjustment (APA), reactive postural responses, gait and FoG were biomechanically assessed. In general, the results showed that SCS improved FoG and APA. However, SCS failed to improve reactive postural responses. SCS seems to influence cortical motor circuits, involving the supplementary motor area. On the other hand, reactive posture control to external perturbation that mainly relies on neuronal circuitries involving the brainstem and spinal cord, is less influenced by SCS.

Double target DBS for essential tremor: 8-contact lead for cZI and vim aligned in the same trajectory

Essential tremor (ET) can be disabling and frequently affects a patients quality of life. Although many patients will benefit from pharmacologic therapy, up to 50% of patients with ET can present unsatisfactory tremor control due to drug adverse effects, comorbidities, or suboptimal response. Those patients may need additional surgical treatment. Bilateral deep brain stimulation (DBS) of the thalamic Vim nucleus has been accepted as the standard treatment, but results are limited by side effects such as speech impairment, ataxia, and stimulation tolerance in the long term1; in extreme cases, reoperation may be required.2 More recently, stimulation of the posterior subthalamic area (PSA) that comprises the prelemniscal radiation and the caudal zona incerta (cZI)3 emerged as a promising target for tremor control with encouraging results. Technology has advanced, providing multiple contact electrodes that can increase possibilities for tremor control and perhaps minimize side effects. We propose bilateral implantation of 8-contact electrodes aligning the Vim and the cZI in the same trajectory, offering multiple stimulation targets with no additional risk. The index case of refractory ET treated with bilateral double-target DBS is presented here.

Dramatic improvement of tardive dyskinesia movements by inline skating

A 25-year-old woman with severe tardive dyskinesia (TD) due to neuroleptics had substantial improvement of movements while inline skating (video at Neurology.org). She received pallidal deep brain stimulation (DBS), and gait and inline skating were assessed before and after DBS; her twin sister served as a control (figures 1 and 2). Possible explanations for her improvement include (1) balance stability required by inline skating provides external cues that are less prominent during gait1; and (2) dystonia consistently responds to geste antagoniste.2 Since TD has variable response to treatments, we propose research into alleviating factors in TD that may advance treatment and rehabilitation in this incapacitating disorder.

Simultaneous bilateral stereotactic procedure for deep brain stimulation implants: a significant step for reducing operation time

OBJECT Currently, bilateral procedures involve 2 sequential implants in each of the hemispheres. The present report demonstrates the feasibility of simultaneous bilateral procedures during the implantation of deep brain stimulation (DBS) leads. METHODS Fifty-seven patients with movement disorders underwent bilateral DBS implantation in the same study period. The authors compared the time required for the surgical implantation of deep brain electrodes in 2 randomly assigned groups. One group of 28 patients underwent traditional sequential electrode implantation, and the other 29 patients underwent simultaneous bilateral implantation. Clinical outcomes of the patients with Parkinsons disease (PD) who had undergone DBS implantation of the subthalamic nucleus using either of the 2 techniques were compared. RESULTS Overall, a reduction of 38.51% in total operating time for the simultaneous bilateral group (136.4 ± 20.93 minutes) as compared with that for the traditional consecutive approach (220.3 ± 27.58 minutes) was observed. Regarding clinical outcomes in the PD patients who underwent subthalamic nucleus DBS implantation, comparing the preoperative off-medication condition with the off-medication/on-stimulation condition 1 year after the surgery in both procedure groups, there was a mean 47.8% ± 9.5% improvement in the Unified Parkinsons Disease Rating Scale Part III (UPDRS-III) score in the simultaneous group, while the sequential group experienced 47.5% ± 15.8% improvement (p = 0.96). Moreover, a marked reduction in the levodopa-equivalent dose from preoperatively to postoperatively was similar in these 2 groups. The simultaneous bilateral procedure presented major advantages over the traditional sequential approach, with a shorter total operating time. CONCLUSIONS A simultaneous stereotactic approach significantly reduces the operation time in bilateral DBS procedures, resulting in decreased microrecording time, contributing to the optimization of functional stereotactic procedures.