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Analysis of deep brain stimulation and ablative lesions in surgical treatment of movement disorders: with emphasis on safety aspects
Umeå University, Faculty of Medicine, Department of Pharmacology and Clinical Neuroscience.
2007 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background The last decade has witnessed a renaissance of functional stereotactic neurosurgery in the treatment of patients with movement disorders, especially advanced Parkinson’s disease (PD), essential tremor (ET) and dystonia. Ablative lesions such as thalamotomy and pallidotomy have been gradually replaced by the technique of chronic deep brain stimulation (DBS) applied to targets in the basal ganglia and thalamus, and assumed to be more lenient to the brain than stereotactic radiofrequency lesions. Since the aim of functional neurosurgery is to alleviate symptoms of these chronic, progressive, non-fatal diseases, and to improve life quality of the patients, it is imperative that the surgical procedures remain safe and do not result in complications mitigating any anticipated positive effect of the surgery on the symptoms of the disease.

Aim The aim of this thesis is to evaluate, compare and analyse the safety of various surgical procedures used to treat patients with movement disorders, and to document side effects and complications both peri operatively and in a long term follow-up. Further to compare the effects of pallidotomy and pallidal DBS, and to evaluate the longterm efficacy of Vim-DBS.

Method 256 consecutive surgical procedures, 129 DBS and 127 stereotactic lesions, were reviewed with respect to complications in 197 treated patients. In a series of 119 patients operated on with DBS during a 10 year period, the occurrence of hardware related complications (infection, breakage, erosion etc) was documented and analysed. Additionally, the interference of external magnetic field with the stimulation was documented. In one patient operated on with subthalamic nucleus DBS, a highly unusual and unexpected psychiatric side effect was carefully analysed. In 5 patients operated on with both methods (lesion and DBS) on each hemisphere, respectively, the effect and side effects of each method were compared. The long term effect and side effects of thalamic DBS was analysed in a series of patients with ET followed for 7 years.

Results There were no deaths and few severe neurological complications in this material. Unilateral ablative lesions in the pallidum were well tolerated by patients with advanced PD, while for tremor, thalamic DBS was much safer than thalamotomy, even if its effect on certain aspects of tremor could show some decrease of efficacy over time. Some of the side effects of lesioning are transient while most but not all side effects of DBS are reversible. Hardware-related complications were not uncommon especially in the early “learning curve” period, and the DBS technique, being a life-long therapy, will necessitate a life long follow up of patients. Provided safety protocols are followed and provided patient’s and carer’s education and awareness, external electromagnetic interference should not constitute a risk for patients with DBS. PD patients undergoing STN DBS should be carefully selected to avoid psychiatric or cognitive side effects, due to this brain target´s proximity to, and involvment in, non-motor associative and limbic circuitry.

Conclusions In terms of mortality and morbidity, modern stereotactic neurosurgery for movement disorders, both ablation and DBS, is a safe procedure even in advanced stages of disease. Symptoms of PD, ET and dystonia can be alleviated mainly with DBS and even unilaterally with pallidal lesions, at the expense of, in most cases, minor side-effects.

Place, publisher, year, edition, pages
Umeå: Farmakologi och klinisk neurovetenskap , 2007. , 96 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1066
Keyword [en]
deep brain stimulation, pallidotomy, thalamotomy, complications, Parkinson's disease, essential tremor
National Category
Neurology
Research subject
Clinical Neurophysiology
Identifiers
URN: urn:nbn:se:umu:diva-1072ISBN: 91-7264-210-6 (print)OAI: oai:DiVA.org:umu-1072DiVA: diva2:140113
Public defence
2007-04-20, sal D, 9 tr, Tandläkarhögskolan, NUS, Umeå, 09:00 (English)
Opponent
Available from: 2007-04-02 Created: 2007-04-02 Last updated: 2012-06-04Bibliographically approved
List of papers
1. Are complications less common in deep brain stimulation than in ablative procedures for movement disorders?
Open this publication in new window or tab >>Are complications less common in deep brain stimulation than in ablative procedures for movement disorders?
2006 (English)In: Stereotactic and Functional Neurosurgery, ISSN 1011-6125, E-ISSN 1423-0372, Vol. 84, no 2-3, 72-81 p.Article in journal (Refereed) Published
Abstract [en]

The side effects and complications of deep brain stimulation (DBS) and ablative lesions for tremor and Parkinson’s disease were recorded in 256 procedures (129 DBS and 127 lesions). Perioperative complications (seizures, haemorrhage, confusion) were rare and did not differ between the two groups. The rate of hardware-related complications was 17.8%. In ventral intermediate (Vim) thalamotomies, the rate of side effects was 74.5%, in unilateral Vim-DBS 47.3%, while in 7 bilateral Vim-DBS 13 side effects occurred. Most of the side effects of Vim-DBS were reversible upon switching off, or altering, stimulation parameters. In unilateral pallidotomy, the frequency of side effects was 21.9%, while in bilateral staged pallidotomies it was 33.3%. Eight side effects occurred in 11 procedures with pallidal DBS. In 22 subthalamic nucleus DBS procedures, 23 side effects occurred, of which 8 were psychiatric or cognitive. Unilateral ablative surgery may not harbour more postoperative complications or side effects than DBS. Some of the side effects following lesioning are transient and most but not all DBS side effects are reversible. In the Vim DBS is safer than lesioning, while in the pallidum, unilateral lesions are well tolerated.

Copyright © 2006 S. Karger AG, Basel

Keyword
Cerebral Hemorrhage/epidemiology, Deep Brain Stimulation/adverse effects/statistics & numerical data, Functional Laterality, Humans, Movement Disorders/surgery/*therapy, Parkinson Disease/complications/surgery/*therapy, Retrospective Studies, Treatment Outcome
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-6170 (URN)10.1159/000094035 (DOI)16790989 (PubMedID)
Available from: 2008-01-11 Created: 2008-01-11 Last updated: 2017-12-14Bibliographically approved
2. Hardware-related complications of deep brain stimulation: a ten year experience.
Open this publication in new window or tab >>Hardware-related complications of deep brain stimulation: a ten year experience.
2005 (English)In: Acta Neurochirurgica, ISSN 0001-6268, E-ISSN 0942-0940, Vol. 147, no 10, 1061-1064 p.Article in journal (Refereed) Published
Keyword
Adult, Aged, Aged; 80 and over, Craniotomy/adverse effects, Deep Brain Stimulation/*adverse effects/*instrumentation, Electrodes; Implanted/adverse effects, Female, Follow-Up Studies, Humans, Male, Middle Aged, Postoperative Complications/*etiology/physiopathology/prevention & control, Skull/injuries/physiopathology, Stereotaxic Techniques/*adverse effects/*instrumentation, Surgical Wound Infection/physiopathology/prevention & control, Treatment Outcome
Identifiers
urn:nbn:se:umu:diva-5755 (URN)10.1007/s00701-005-0576-5 (DOI)16041470 (PubMedID)
Available from: 2008-01-11 Created: 2008-01-11 Last updated: 2017-12-14Bibliographically approved
3. Electromagnetic environmental influences on implanted deep brain stimulators
Open this publication in new window or tab >>Electromagnetic environmental influences on implanted deep brain stimulators
2006 (English)In: Neuromodulation (Malden, Mass.), ISSN 1094-7159, E-ISSN 1525-1403, Vol. 9, no 4, 262-269 p.Article in journal (Refereed) Published
Abstract [en]

Objective.  The objective of this study was to report our observations on the external electromagnetic field influences on deep brain stimulation (DBS) in our patient population and how these influences affected our patients’ lives and other healthcare-related conditions.

Materials and Methods.  We have retrospectively analyzed data concerning the effects of external electromagnetic fields on 172 of our patients implanted with DBS.

Results.  Identifiable electromagnetic sources turned the implantable pulse generator (IPG) off in 20 patients. In two patients, these episodes necessitated replacement of the Itrel II IPG (Medtronic Inc., Minneapolis, MN, USA) with the magnetically shielded Kinetra IPG (Medtronic Inc.). Six patients received cardiac pacemakers, leading, in two patients, to interference between the systems. Our experience concerning magnetic resonance imaging, electrocardiogram (ECG), heart defibrillation, electro-cautery, and other sources of electromagnetic interference also is described.

Conclusions.  External electromagnetic interference may, in rare cases, constitute a severe threat to the well-being of the patient implanted with a DBS system. Also, malfunction of a DBS system may constitute a medical emergency. Nevertheless, in spite of these external electromagnetic influences, we consider DBS to be a safe method, provided safety protocols are followed, and provided that provider awareness about potential hazards is present.

Keyword
complications, deep barin stimulation, environmental influence, external interference, hardware
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-7173 (URN)10.1111/j.1525-1403.2006.00068.x (DOI)
Available from: 2008-01-04 Created: 2008-01-04 Last updated: 2017-12-14Bibliographically approved
4. Acute severe depression induced by intraoperative stimulation of the Substatia Nigra: a case-report
Open this publication in new window or tab >>Acute severe depression induced by intraoperative stimulation of the Substatia Nigra: a case-report
Show others...
2008 (English)In: Parkinsonism & Related Disorders, ISSN 1353-8020, E-ISSN 1873-5126, Vol. 14, no 3, 253-256 p.Article in journal (Other academic) Published
Abstract [en]

We present a 62 years old man with Parkinson's disease (PD) who underwent bilateral stimulation in the subthalamic nucleus (STN). During the intraoperative evaluation, stimulation through the lowest contact in the right STN area, induced an acute depressive state, during which the patient was crying and expressing that he did not want to live. The patient returned to his normal state of mood within seconds after the cessation of stimulation. Repeated blinded stimulations resulted in the same response. Immediate postoperative magnetic resonance imaging (MRI) revealed that the lowest contact of the right electrode was located in the substantia nigra.

Place, publisher, year, edition, pages
Elsevier, 2008
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-2216 (URN)10.1016/j.parkreldis.2007.04.005 (DOI)
Available from: 2007-04-02 Created: 2007-04-02 Last updated: 2017-12-14Bibliographically approved
5. Pallidotomy versus pallidal stimulation
Open this publication in new window or tab >>Pallidotomy versus pallidal stimulation
2006 (English)In: Parkinsonism & Related Disorders, ISSN 1353-8020, E-ISSN 1873-5126, Vol. 12, no 5, 296-301 p.Article in journal (Refereed) Published
Abstract [en]

Both posteroventral pallidotomy and pallidal deep brain stimulation (DBS) have a documented effect on Parkinsonian symptoms. DBS is more costly and more laborious than pallidotomy. The aim of this study was to analyse the respective long-term effect of each surgical procedure on contralateral symptoms in the same patients. Five consecutive patients, two women and three men, who at first surgery had a mean age of 64 years and a mean duration of disease of 18 years, received a pallidotomy contralateral to the more symptomatic side of the body. At a mean of 14 months later, the same patients received a pallidal DBS on the side contralateral to the pallidotomy. All patients had on–off phenomena and dyskinesias. There were three left-sided and two right-sided pallidotomies, and, subsequently, two left-sided and three right-sided pallidal DBS. The latest evaluation was performed 37 months (range 22–60) after the pallidotomy and 22 months (range 12–33) after the pallidal DBS. Mean UPDRS motor score pre-operatively was 49 and at last follow-up 33 (32.7% improvement, p<0.05). Appendicular items 20–26 contralateral to pallidotomy remained improved more significantly than contralateral to DBS. Dyskinesia scores were also improved more markedly contralateral to the pallidotomy. Two patients exhibited moderate dysarthria and one patient severe dysphonia following DBS. Symptoms contralateral to the chronologically older pallidotomy, especially dyskinesias, rigidity and tremor, were still more improved than symptoms contralateral to the more recent pallidal DBS, despite numerous post-operative patient visits to optimise stimulation parameters.

Keyword
Aged, Aged; 80 and over, Antiparkinson Agents/therapeutic use, Deep Brain Stimulation, Disability Evaluation, Female, Follow-Up Studies, Functional Laterality/physiology, Globus Pallidus/*physiology/*surgery, Humans, Magnetic Resonance Imaging, Male, Middle Aged, Neurosurgical Procedures, Parkinson Disease/drug therapy/*surgery/*therapy, Tomography; X-Ray Computed
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-6171 (URN)10.1016/j.parkreldis.2005.12.007 (DOI)16554182 (PubMedID)
Available from: 2008-01-10 Created: 2008-01-10 Last updated: 2017-12-14Bibliographically approved
6. Thalamic deep brain stimulation in the treatment of essential tremor: a long-term follow-up
Open this publication in new window or tab >>Thalamic deep brain stimulation in the treatment of essential tremor: a long-term follow-up
2007 (English)In: British Journal of Neurosurgery, ISSN 0268-8697, E-ISSN 1360-046X, Vol. 21, no 5, 504-509 p.Article in journal (Refereed) Published
Abstract [en]

Deep brain stimulation (DBS) of the nucleus ventralis intermedius thalami (Vim) in the treatment of essential tremor (ET) is well documented concerning the acute effects. Reports of the long-term effects are, however, few and the aim of the present study was to analyse the long-term efficacy of this treatment. Nineteen patients operated with unilateral Vim-DBS were evaluated with the Essential Tremor Rating Scale (ETRS) before surgery, and after a mean time of 1 and 7 years after surgery. The ETRS score for tremor of the contralateral hand was reduced from 6.8 at baseline to 1.2 and 2.7, respectively, on stimulation at follow-up. For hand function (item 11 – 14) the score was reduced from 12.7 to 4.1 and 8.2, respectively. Vim-DBS is an efficient treatment for ET, also after many years of treatment. There is, however, a decreasing effect over time, most noticeable concerning tremor of action.

Read More: http://informahealthcare.com/doi/abs/10.1080/02688690701552278

Keyword
Activities of Daily Living, Adolescent, Adult, Aged, Aged; 80 and over, Deep Brain Stimulation/*methods, Essential Tremor/diagnosis/surgery/*therapy, Female, Follow-Up Studies, Humans, Male, Middle Aged, Prospective Studies, Thalamus, Treatment Outcome
National Category
Neurology
Identifiers
urn:nbn:se:umu:diva-10668 (URN)10.1080/02688690701552278 (DOI)17922323 (PubMedID)
Available from: 2008-10-17 Created: 2008-10-17 Last updated: 2017-12-14Bibliographically approved

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Citation style
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