Thalamotomy, DBS-Vim, and DBS-GPi for generalized dystonia: a case report.
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Abstract:
Generalized dystonia is a disabling disorder that can severely affect quality of life. Pharmacological treatment is unsatisfactory, and surgical therapy has been the focus for symptom improvement. We present the first case report of a patient with disabling generalized dystonia treated with a thalamotomy and deep brain stimulation of the thalamus and globus pallidus (DBS-Vim, DBS-GPi). His tremor and dystonic symptoms have dramatically improved through combining these surgical interventions.Keywords:
Thalamotomy
Movement Disorders
Pallidotomy
Thalamic stimulator
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During the last decade, it has become clear that deep brain stimulation (DBS) therapy provides a dramatic improvement in the symptoms of movement disorders. We have experienced DBS in 110 patients with various types of involuntary movements, and confirmed the benefits of stimulation of the thalamic nucleus ventralis intermedius (Vim), internal globus pallidus (GPi) and subthalamic nucleus (STN) in these patients. DBS therapy affords the best effect on tremor when the Vim is selected as the stimulation site. DBS therapy is also useful for controlling rigidity when the GPi or STN is stimulated. Improvements of bradykinesia and gait disturbance are often induced by DBS therapy involving the GPi or STN. Dopa-induced dyskinesia can be attenuated effectively by the direct and/or indirect effects of DBS therapy. DBS of the Vim also provides excellent control of post-stroke involuntary movements, including hemiballism and hemichoreoathetosis. Dystonia in young patients is controlled effectively by DBS of GPi. Ablative procedures for control of involuntary movement disorders, such as thalamotomy and pallidotomy, always carry a risk associated with creating additional lesions in an already damaged brain. In contrast, there is not such a risk in DBS therapy. This modality of therapy is an important option in treating involuntary movements.
Subthalamic Nucleus
Pallidotomy
Movement Disorders
Thalamotomy
Thalamic stimulator
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Cervical dystonia
Subthalamic Nucleus
Zona incerta
Thalamotomy
Movement Disorders
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Deep brain stimulation (DBS) is used as a surgical treatment of movement disorders such as Parkinson's disease, dystonia and essential tremor. Fundamental understanding of DBS effects on the pathological neural circuitry remains insufficient. In 2002 DBS of the subthalamic nucleus (STN) and the globus pallidus internus (GPi) was approved for use in patients with PD. Next year, DBS of Gpi and STN for dystonia received a Humanitarian Device exemption from the FDA. The commonly targets for DBS are subthalamic nucleus (STN) or globus pallidus internus (GPi) for Parkinson's disease, Gpi for dystonia and ventro-intermediate (VIM) nucleus of the thalamus for essential tremor. However, VIM DBS cannot sufficiently improve akinesia and rigidity. Pedunculopontine nucleus (PPN) is currently investigated as potential target to improve gait and posture. It is determined that DBS sometimes influences not only motor functions but also the cognitive and affective functions of patients. In this article we review the present state of DBS for movement disorders, appropriate indications, practical effects and stimulation-induced adverse events established in previous studies. We discuss target selection and the effect of DBS on motor and non-motor symptoms of Parkinson's disease, dystonia and essential tremor.
Subthalamic Nucleus
Movement Disorders
Pedunculopontine nucleus
Thalamotomy
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Movement Disorders
Cervical dystonia
Neuroradiology
Etiology
Subthalamic Nucleus
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Even before the deep brain stimulation (DBS) era, stereotactic functional neurosurgery such as thalamotomy and pallidotomy had been used for control of medically intractable dystonia (Cooper, 1976; Lozano et al., 1997). However, unreliability and variability in the results and furthermore, needs for bilateral surgery in most patients with generalized dystonia and the occurrence of unacceptable adverse effects including dysarthria and cognitive impairment have greatly limited their use. In this regard, DBS, which provides a more stable response with fewer side effects, has revolutionized the treatment of dystonia. The first report of DBS for dystonia was by Mundinger in 1977 (Mundinger, 1997). Since then, over the past few decades, bilateral globus pallidus internus (GPi) DBS has emerged as the best therapeutic option for medication-refractory dystonia (Lang, 2011).
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近年種々の運動障害疾患に対して脳深部刺激療法（DBS）が行われている．パーキンソン病（PD）には視床下核（STN）または淡蒼球内節（GPi）のDBSが行われ，その有効性や長期成績が示されている．DBSはPDの全般的な運動症状を改善し，STN刺激ではドパミン作動性薬剤が大幅に減量できる．DBSと薬物治療との併用でより長期的な症状の進行に対処可能となる．難治性振戦には視床Vim核のDBSが行われるが，最近posterior subthalamic area（PSA）も注目されている．また全身性ジストニアにはGPi DBSが有効である．薬物で症状改善が困難な運動障害疾患に対してDBSを検討すべきである．
Subthalamic Nucleus
Movement Disorders
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This is a proposal of the Movement Disorder Society for a clinical classification of tremors. The classification is based on the distinction between rest, postural, simple kinetic, and intention tremor (tremor during target-directed movements). Additional data from a medical history and the results of a neurologic examination can be combined into one of the following clinical syndromes defined in this statement: enhanced physiologic tremor, classical essential tremor (ET), primary orthostatic tremor, task- and position-specific tremors, dystonic tremor, tremor in Parkinson's disease (PD), cerebellar tremor, Holmes' tremor, palatal tremor, drug-induced and toxic tremor, tremor in peripheral neuropathies, or psychogenic tremor. Conditions such as asterixis, epilepsia partialis continua, clonus, and rhythmic myoclonus can be misinterpreted as tremor. The features distinguishing these conditions from tremor are described. Controversial issues are outlined in a comment section for each item and thus reflect the open questions that at present cannot be answered on a scientific basis. We hope that this statement provides a basis for better communication among clinicians working in the field and stimulates tremor research.
Clonus
Psychogenic disease
Intention tremor
Movement Disorders
Postural tremor
Resting tremor
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Choreoathetosis
Thalamic stimulator
Movement Disorders
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