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Query: UMLS:C0040822 (tremor)
 18,428 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Deep brain stimulation (DBS) is a new and promising technique for the treatment of movement disorders. Medically intractable Parkinson's disease (PD) is one of the most common indications for DBS. There are three possible subcortical targets for PD, depending on the symptomatology (i.e., the motor subdivision of the thalamus, the globus pallidus internus, the subthalamic nucleus [STN]). Thalamic stimulation has been well established as a safe and effective treatment for essential tremor and the tremor associated with PD. Globus pallidus internus and STN DBS are being investigated for the treatment of all the cardinal signs of PD. This article describes the pathophysiology of PD, the surgical treatment history of PD, surgical techniques used for DBS implants, and the role the perioperative nurse has in the care of the patients undergoing these procedures.
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PMID:Deep brain stimulation for advanced Parkinson's disease. 1100 60

Positron emission tomography allows a quantitative assessment of the impact of functional neurosurgery in Parkinson's disease (PD) by measuring regional cerebral flow and glucose and oxygen consumption as indicators of metabolic activity of specific brain regions. PET can also be used to study the dopaminergic nigrostriatal system, and therefore serves as a surrogate marker of the evolution of striatal grafts for PD. Pallidotomy has been associated with increased activation of premotor areas (supplementary motor area and dorsolateral prefrontal cortex) and reduced hyperactivity of the lentiform nucleus (augmented preoperatively). Pallidal (GPi) and subthalamic (STN) stimulation also increase activation of premotor areas but decrease activation of primary motor area. Suppression of unilateral tremor with thalamic stimulation is associated with a reduction in cerebellar blood flow. These main findings are in keeping with the general notion that increased activity in the STN GPi projection is directly implicated in the pathophysiology of PD. Surgical blockage of these output nuclei leads to partial restoration of cortical physiology.
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PMID:The effects of surgical treatment of Parkinson's disease on brain function: PET findings. 1118 76

This study was performed to evaluate the effectiveness and safety of unilateral STN lesioning in 23 patients with PD. L-Dopa intake and dyskinesia, Hoehn & Yahr, Schwab & England, and UPDRS motor scores were recorded pre- and postoperatively. Stereotactic MRI and CT and macrostimulation were used to establish target coordinates. A single RF lesion was performed. All patients underwent postoperative MRI. Contralateral tremor arrest and decrease of rigidity and bradykinesia should be regarded as hallmarks to STN stimulation. All recorded parameters were significantly improved after a mean follow-up of 13.5 months. Patients with STN lateral territory lesioning (alpha <0.05), younger than 61 years and with a duration of the disease between 6 and 9 years (alpha >0.05) did better than the others. The recurrence rate was 10%. Two patients developed dyskinesias which were completely resolved by a Vim/VOp lesion. Other significant complications were rare. The authors conclude that unilateral STN lesioning is a safe and very effective procedure to treat PD.
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PMID:Stereotactic subthalamic nucleus lesioning for the treatment of Parkinson's disease. 1237 61

Parkinson's disease (PD) is a progressive disturbances of movement that affects mainly the motor system. Prolonged pharmacological administration may result in insufficient control of symptoms and significant side effects. Deep brain stimulation (DBS), targeted at the STN, is a recent surgical procedure that, according to the symptoms response, allows modification of stimulation parameters; its effects are also reversible. In this paper management of surgical patients is reported. It includes patient selection, inclusion and exclusion criteria, postoperative clinical protocol. The evaluation rating scale such as UPDRS, Dyskinesias Rating Scale and Self-Reporting Questionnaire usually administrated on PD patients are analyzed. Surgical inclusion criteria are (1) idiopathic PD, (2) IV or V Hoehn-Yahr stage, (3) severe motor disability, and (4) no dementia or psychiatric abnormalities. Postoperative clinical protocol is analyzed and parameter of stimulation after surgery and at the follow up are reported. Generally DBS allows an improvement of rigidity and tremor; bradykinesia also improves with high frequency stimulation. Results obtained by continuous stimulation show a mean improvement of UPDRS of about 60% and a significant reduction in the drug intake.
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PMID:Surgery of Parkinson's disease: inclusion criteria and follow-up. 1277 12

To determine whether the degree to which a patient with Parkinson's disease expects therapeutic benefit from subthalamic nucleus-deep brain stimulation (STN-DBS) influences the magnitude of his or her improved motor response, 10 patients with idiopathic Parkinson's and bilateral STN-DBS were tested after a 12-hour period off medication and stimulation. Four consecutive UPDRS III scores were performed in the following conditions: (a) stimulation OFF, patient aware; (b) stimulation OFF, patient blind; (c) stimulation ON, patient aware; and (d) stimulation ON, patient blind. Statistical significance (P = 0.0001) was observed when comparing main effect ON versus OFF (mean ON: 32.55; mean OFF: 49.15). When the stimulation was OFF, patients aware of this condition had higher UPDRS motor scores than when they were blinded (mean: 50.7 vs. 47.6). With the stimulation ON, UPDRS motor scores were lower when the patients were aware of the stimulation compared with when they were blinded (mean: 30.6 vs. 34.5). The interaction between these levels was significant (P = 0.049). This variation was important for bradykinesia and was not significant for tremor and rigidity. The authors conclude that the information about the condition of the stimulation enhanced the final clinical effect in opposite directions. The results presented support the role of expectation and placebo effects in STN-DBS in Parkinson's disease patients.
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PMID:Expectation and the placebo effect in Parkinson's disease patients with subthalamic nucleus deep brain stimulation. 1672 50

In patients with Parkinson's disease (PD), tetrapolar electrodes were implanted in the prelemniscal radiations (RAPRL) to treat tremor, rigidity and bradykinesia. Fifteen patients were implanted unilaterally and five patients bilaterally and followed-up for one year. The selection criteria included the presence of unilateral pronounced tremor and rigidity in patients implanted unilaterally or bilateral symptoms including severe bradykinesia in patients implanted bilaterally. In the operating room, the tremor decreased significantly or was abolished following the insertion of the electrode in the RAPRL. This effect was temporary and subsided when the stimulation was off. However, when the stimulator was turned on, the severity of the symptoms and signs decreased significantly. The post-implantation MRI confirmed that the electrode contacts used for stimulation were inserted in RAPRL, a group of fibers located between the red nucleus and subthalamic nucleus, above the substantia nigra, medially to the zona incerta and below the thalamus. The patients were evaluated using the UPDRS part III, before implantation and every 3 months during the first year. Global scores decreased significantly. The pre- and postoperative median values (range in round brackets) were as follows: tremor improved from 3 (2-16) to 1 (2-3) (p<0.001); rigidity was either abolished or decreased markedly from 2 (1-16) to 0 (0-4) (p< 0.001); bradykinesia improved from 2 (0-4) to 1 (0-2) (p<0.001). We conclude that RAPRL, an area anatomically different from STN, is a good target for electrical stimulation in order to treat effectively all the main symptoms of PD.
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PMID:Neuromodulation of prelemniscal radiations in the treatment of Parkinson's disease. 1769 3

The majority of patients with Parkinson's disease suffer from freezing of gait (FOG), which responds more or less to levodopa. Thalamic stimulation, mainly used in the treatment of tremor dominant Parkinson's disease is ineffective in FOG. GPi stimulation moderately improves FOG, but this effect may abate in the long term. STN stimulation was reported to improve levodopa-responsive FOG. In some patients, the benefit from levodopa is greater than that from STN stimulation, and levodopa and STN stimulation can have additive effects. On the contrary, STN stimulation is ineffective on levodopa-resistant FOG. In the few cases of levodopa-induced FOG, STN stimulation can indirectly be effective, thanks to a great decrease or arrest of levodopa. Stimulation of the pedunculopontine nucleus has recently been performed in small groups of patients suffering from both off- and on-levodopa gait impairments. The first results appear encouraging, but they need to be confirmed by controlled studies in larger series of patients.
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PMID:Deep brain stimulation effect on freezing of gait. 1866 17

The intra-laminar (IL) thalamic complex, composed of centromedian (CM) and parafascicular (Pf) nucleus, is a strategic crossroad for the activity of the basal ganglia and is recently regaining its position has a putative neurosurgical target for Parkinsonian syndromes. The multi-target approach we have encouraged since the late nineties has allowed the combined implantation of a standard target (the subthalamic nucleus-STN or the internal pallidus-GPi) plus an innovative one (CM/Pf) in well-identified Parkinson's disease (PD) patients; hence, it is possible to study, in the same PD patients, the specific target-mediated effects on different clinical signs. Here, we focus on the potential usefulness of implanting the CM/Pf complex when required in the management of contra-lateral tremor (resistant to standard deep brain stimulation-DBS - in STN - , n=2) and disabling involuntary movements, partially responsive to GPi-DBS (n=6). When considering global UPDRS scores, CM/Pf-DBS ameliorate extra-pyramidal symptoms but not as strongly as STN (or GPi) does. Yet, CM/Pf acts very powerfully on tremor and contributes to the long-term management of l-Dopa-induced involuntary movements. The lack of cognitive deficits and psychic impairment associated with the improvement of their quality of life, in our small cohort of CM/Pf implanted patients, reinforces the notion of CM/Pf as a safe and attractive area for surgical treatment of advanced PD, possibly affecting not only motor but also associative functions.
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PMID:Multi-target strategy for Parkinsonian patients: the role of deep brain stimulation in the centromedian-parafascicularis complex. 1881 14

Whether patients with genetically defined Parkinson's disease (PD) may be particularly eligible to benefit from deep brain stimulation of the nucleus subthalamicus (STN-DBS) is currently the subject of debate. We report on a patient with advanced PD due to R793M missense mutation in the LRRK2 gene successfully treated by STN-DBS. Disease onset was at age 42 with bradykinesia, rigidity and rest tremor. During the course of the disease he developed severe motor fluctuations, dyskinesias, postural instability with falls, but preserved levodopa responsiveness. At age 60 the patient was treated by bilateral DBS of the STN. At one year after surgery a 66% improvement of the UPDRS motor score in the off-medication state was determined. During the long-term follow-up there was sustained benefit with 56% improvement of motor score after 8 years. Our report adds evidence that patients with LRRK2 monogenetic Parkinsonism are well suited candidates for DBS treatment and may indicate a potential genetic predictor for positive long-term effect of STN-DBS treatment.
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PMID:Effective long-term subthalamic stimulation in PARK8 positive Parkinson's disease. 2017 95

There is a consensus that in Parkinson's disease, the extent of preoperative levodopa responsiveness predicts the efficacy of subthalamic nucleus deep brain stimulation (STN DBS). However, this may be the result of statistical methods and primary assumptions. We were able to reproduce previously published correlation results on our data (N = 49 patients). Yet, these same results were demonstrated even after random shuffling of our data. Notably, we did not observe a correlation between STN DBS efficacy and preoperative levodopa responsiveness when using their respective baselines and fractional scores of motor improvement. Furthermore, postoperative responses were not limited by preoperative scores, with tremor demonstrating the greatest discrepancy. We conclude that preoperative levodopa responsiveness does not predict or limit the outcome of STN DBS. These results imply different therapeutic mechanisms for levodopa and STN DBS and therefore question the validity of using substantial preoperative levodopa responsiveness as a selection criterion for STN DBS.
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PMID:Levodopa and subthalamic deep brain stimulation responses are not congruent. 2082 33


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