- Email: [email protected]
2.337 TREATMENT OF STATUS DYSTONICUS WITH PALLIDAL DEEP BRAIN STIMULATION — CASE REPORT
S150
Tuesday, 13 December 2011 / Parkinsonism and Related Disorders 18S2 (2012) S81–S159
2.334 EFFICACY OF SUBTHALAMIC NUCLEUS DEEP BRAIN STIMULATION FOR LEG TREMOR CONTROL IN PARKINSON’S DISEASE P. Hedera1 , F.T. Phibbs1 , D.P. Charles1 , P.E. Konrad2 , J. Neimat2 , T.L. Davis1 . 1 Neurology, 2 Neurosurgery, Vanderbilt University, Nashville, TN, USA
2.336 PSYCHOGENIC LEVODOPA-INDUCED DYSKINESIA EMERGING AFTER SUCCESSFUL SUBTHALAMIC NUCLEUS DEEP BRAIN STIMULATION (STN-DBS): CASE REPORT AND VIDEO
Objective: To analyze clinical outcome of Parkinson’s disease patients with prominent leg tremor who underwent deep brain stimulation (DBS) surgery with targeting of the subthalamic nucleus (STN). Background: STN DBS is well established surgical therapy for motor fluctuations and tremor in PD. Previous studies reported a high efficacy of STN DBS for the control of upper extremity tremor but there is relative paucity of data regarding its ability to control of leg tremor Methods: We reviewed the records of those with idiopathic PD who underwent STN DBS surgery for motor fluctuations or medically refractory tremor. Only patients with coexisting ipsilateral arm and leg rest tremor were analyzed. Postoperative analysis included UPRDS scores on/off stimulation and on/off medications. Results: Eleven patients met the inclusion criteria. We were able to improve both arm and leg tremor control by at least one point on UPDRS. In 9 patients the best possible control of arm tremor resulted from activation of a different contact than that which produced optimal control of leg tremor. Conclusions: STN DBS surgery is also very effective for the control of the lower extremity tremor. The differences in active electrodes between the most efficacious arm and leg tremor control is consistent with the known somatopy of the STN.
Objective: To describe a case of functional levodopa-induced dyskinesia after STN-DBS. Case report: A 55 year-old man with right-sided resting tremor initially responding to levodopa later developed motor fluctuation and peak-levodopa-dose dyskinesia. After failing multiple medications, he was referred for DBS at an age of 65 years. Preoperative psychiatric evaluation revealed no comorbid psychiatric diagnoses. Three months after undergoing bilateral STNDBS the patient’s medication-off UPDRS score fell from 30 to 13, nearly equaling the preoperative medication-on score of 12; accordingly his levodopa dose was reduced from 250 mg every 3 hours to 100 mg every 4 hours. Six months after surgery, he described return of dyskinesia occurring 30 minutes after each levodopa dose. These remained despite a self-directed reduction of levodopa to only 25 mg twice daily. Videotaped examination confirmed these movements to be functional by their bizarre semi-patterned appearance, distractibility, and entrainment. The patient was informed these were atypical for levodopa-induced dyskinesia, though as they were time-locked to his levodopa doses the medication was fully withdrawn for 2 months. After a slow reintroduction of levodopa therapy, the movements did not return and the patient attained his prior level of benefit. Conclusion: Our patient presented with functional dyskinesialike movements after an otherwise successful STN-DBS procedure; likewise, the emergence of functional tremor has previously been reported after successful thalamic DBS for essential tremor. It may be that some patients have difficulty adjusting to rapid symptom improvements afforded by DBS. Functional movement disorders should be considered in cases of apparent DBS failure.
2.335 LONG TERM EFFECT OF SUBTHALAMIC NUCLEUS STIMULATION (STN) IN PARKINSON’S DISEASE K.J. Lee. Neurosurgery, Yeouido St. Mary’s Hospital, Seoul, Republic of Korea Deep brain stimulation of subthalamic nucleus stimulation is alternative treatment for disabling form of Parkinson’s disease when on-off fluctuations and levodopa-induced dyskinesia compromise patient’s quality of life. The efficacy and safety of STN stimulation have been well documented in short-term studies. A few data are available concerning the long-term. From 2000 to 2004, We have treated many advanved Parkinson’s disease patients with STN DBS. As compared with other literatures, we analyzed and summarized our results. Among them, we studied 18 patients who received implants at our hospital for STN DBS. • Male:Female = 2:16 • Age at surgery: 47–78 (mean: 64.24) • Pre OP Dopa dose: mean 1043.7 mg/day • Mean disease duration before surgery: 8–260 month (mean: 90.84 month) • Follow up availability until 2009: 9 patients. Tremor, rigidity, and bradkinesia are relative well response symptoms to STN DBS. Gait, postural instability, speech, and are relative poor response symptoms to STN DBS. The deterioration of gait, postural instability, speech, and dyskinesia is the characteristic natural course of Parkinson’s disease. STN DBS is relative safe and effective treatment method to Parkinson’s disease, especially at short-term period. But The longterm outcome of STN DBS is considered. Age, Disease duartion, Dopa responsiveness is the prognostic factor of good outcome. There are no major complication.
W. Hu, B. Klassen, M. Stead. Neurology, Mayo Clinic, Rochester, MN, USA
2.337 TREATMENT OF STATUS DYSTONICUS WITH PALLIDAL DEEP BRAIN STIMULATION – CASE REPORT T. Mandat1,2 , H. Koziara1 , R. Rola3 , T. Tykocki1 , W. Bonicki2 , P. Nauman1 . 1 Neurosurgery, IPiN, 2 Neurosurgery, Maria SklodowskaCurie Memorial Oncology Center, 3 Neurology, Institute of Psychiatry and Neurology, Warszawa, Poland Background and purpose: Life-threatening, status dystonicus (SD) may lead to use pallidal deep brain stimulation (GPi DBS) in an urgent manner. The authors present a patient with generalized dystonia (GD), treated with GPi DBS because of SD. Case presentation: An 11-year-old girl was qualified for GPi DBS because of SD. The patient suffered from disabling dystonic movements since she was born and was diagnosed with primary GD. The effects of medical treatment, including intrathecal baclofen, have gradually failed to provide improvement. Since age 9 she developed recurrent episodes of SD, when sedation and mechanical ventilation was required at ICU. At shallowed sedation FahnMarsden Movement Scale (BFM) was 100. In course of the following SD the patient was treated with DBS GPi. The target was identified with direct and indirect method. Intrasurgical macrostimulation and microrecording were used for neurophysiological evaluation of the target. Significant persistent suppression of the dystonic movements was observed at 16 months of the follow-up-BFM 40 (60% reduction) with stimulation at left side: C+ 1-2- 3.8/190/90, right side C+ 1-2- 3.4/190/90. No complications related to the surgery were reported. Conclusions: GPi DBS is believed to be the optimal neuromodulative treatment modality for GD. Life threatening conditions like SD can be safely and effectively treated with GPi DBS as well.
Tuesday, 13 December 2011 / Parkinsonism and Related Disorders 18S2 (2012) S81–S159
2.334 EFFICACY OF SUBTHALAMIC NUCLEUS DEEP BRAIN STIMULATION FOR LEG TREMOR CONTROL IN PARKINSON’S DISEASE P. Hedera1 , F.T. Phibbs1 , D.P. Charles1 , P.E. Konrad2 , J. Neimat2 , T.L. Davis1 . 1 Neurology, 2 Neurosurgery, Vanderbilt University, Nashville, TN, USA
2.336 PSYCHOGENIC LEVODOPA-INDUCED DYSKINESIA EMERGING AFTER SUCCESSFUL SUBTHALAMIC NUCLEUS DEEP BRAIN STIMULATION (STN-DBS): CASE REPORT AND VIDEO
Objective: To analyze clinical outcome of Parkinson’s disease patients with prominent leg tremor who underwent deep brain stimulation (DBS) surgery with targeting of the subthalamic nucleus (STN). Background: STN DBS is well established surgical therapy for motor fluctuations and tremor in PD. Previous studies reported a high efficacy of STN DBS for the control of upper extremity tremor but there is relative paucity of data regarding its ability to control of leg tremor Methods: We reviewed the records of those with idiopathic PD who underwent STN DBS surgery for motor fluctuations or medically refractory tremor. Only patients with coexisting ipsilateral arm and leg rest tremor were analyzed. Postoperative analysis included UPRDS scores on/off stimulation and on/off medications. Results: Eleven patients met the inclusion criteria. We were able to improve both arm and leg tremor control by at least one point on UPDRS. In 9 patients the best possible control of arm tremor resulted from activation of a different contact than that which produced optimal control of leg tremor. Conclusions: STN DBS surgery is also very effective for the control of the lower extremity tremor. The differences in active electrodes between the most efficacious arm and leg tremor control is consistent with the known somatopy of the STN.
Objective: To describe a case of functional levodopa-induced dyskinesia after STN-DBS. Case report: A 55 year-old man with right-sided resting tremor initially responding to levodopa later developed motor fluctuation and peak-levodopa-dose dyskinesia. After failing multiple medications, he was referred for DBS at an age of 65 years. Preoperative psychiatric evaluation revealed no comorbid psychiatric diagnoses. Three months after undergoing bilateral STNDBS the patient’s medication-off UPDRS score fell from 30 to 13, nearly equaling the preoperative medication-on score of 12; accordingly his levodopa dose was reduced from 250 mg every 3 hours to 100 mg every 4 hours. Six months after surgery, he described return of dyskinesia occurring 30 minutes after each levodopa dose. These remained despite a self-directed reduction of levodopa to only 25 mg twice daily. Videotaped examination confirmed these movements to be functional by their bizarre semi-patterned appearance, distractibility, and entrainment. The patient was informed these were atypical for levodopa-induced dyskinesia, though as they were time-locked to his levodopa doses the medication was fully withdrawn for 2 months. After a slow reintroduction of levodopa therapy, the movements did not return and the patient attained his prior level of benefit. Conclusion: Our patient presented with functional dyskinesialike movements after an otherwise successful STN-DBS procedure; likewise, the emergence of functional tremor has previously been reported after successful thalamic DBS for essential tremor. It may be that some patients have difficulty adjusting to rapid symptom improvements afforded by DBS. Functional movement disorders should be considered in cases of apparent DBS failure.
2.335 LONG TERM EFFECT OF SUBTHALAMIC NUCLEUS STIMULATION (STN) IN PARKINSON’S DISEASE K.J. Lee. Neurosurgery, Yeouido St. Mary’s Hospital, Seoul, Republic of Korea Deep brain stimulation of subthalamic nucleus stimulation is alternative treatment for disabling form of Parkinson’s disease when on-off fluctuations and levodopa-induced dyskinesia compromise patient’s quality of life. The efficacy and safety of STN stimulation have been well documented in short-term studies. A few data are available concerning the long-term. From 2000 to 2004, We have treated many advanved Parkinson’s disease patients with STN DBS. As compared with other literatures, we analyzed and summarized our results. Among them, we studied 18 patients who received implants at our hospital for STN DBS. • Male:Female = 2:16 • Age at surgery: 47–78 (mean: 64.24) • Pre OP Dopa dose: mean 1043.7 mg/day • Mean disease duration before surgery: 8–260 month (mean: 90.84 month) • Follow up availability until 2009: 9 patients. Tremor, rigidity, and bradkinesia are relative well response symptoms to STN DBS. Gait, postural instability, speech, and are relative poor response symptoms to STN DBS. The deterioration of gait, postural instability, speech, and dyskinesia is the characteristic natural course of Parkinson’s disease. STN DBS is relative safe and effective treatment method to Parkinson’s disease, especially at short-term period. But The longterm outcome of STN DBS is considered. Age, Disease duartion, Dopa responsiveness is the prognostic factor of good outcome. There are no major complication.
W. Hu, B. Klassen, M. Stead. Neurology, Mayo Clinic, Rochester, MN, USA
2.337 TREATMENT OF STATUS DYSTONICUS WITH PALLIDAL DEEP BRAIN STIMULATION – CASE REPORT T. Mandat1,2 , H. Koziara1 , R. Rola3 , T. Tykocki1 , W. Bonicki2 , P. Nauman1 . 1 Neurosurgery, IPiN, 2 Neurosurgery, Maria SklodowskaCurie Memorial Oncology Center, 3 Neurology, Institute of Psychiatry and Neurology, Warszawa, Poland Background and purpose: Life-threatening, status dystonicus (SD) may lead to use pallidal deep brain stimulation (GPi DBS) in an urgent manner. The authors present a patient with generalized dystonia (GD), treated with GPi DBS because of SD. Case presentation: An 11-year-old girl was qualified for GPi DBS because of SD. The patient suffered from disabling dystonic movements since she was born and was diagnosed with primary GD. The effects of medical treatment, including intrathecal baclofen, have gradually failed to provide improvement. Since age 9 she developed recurrent episodes of SD, when sedation and mechanical ventilation was required at ICU. At shallowed sedation FahnMarsden Movement Scale (BFM) was 100. In course of the following SD the patient was treated with DBS GPi. The target was identified with direct and indirect method. Intrasurgical macrostimulation and microrecording were used for neurophysiological evaluation of the target. Significant persistent suppression of the dystonic movements was observed at 16 months of the follow-up-BFM 40 (60% reduction) with stimulation at left side: C+ 1-2- 3.8/190/90, right side C+ 1-2- 3.4/190/90. No complications related to the surgery were reported. Conclusions: GPi DBS is believed to be the optimal neuromodulative treatment modality for GD. Life threatening conditions like SD can be safely and effectively treated with GPi DBS as well.