Search

Neuromodulation therapy -vagus nerve stimulation (VNS) and deep brain stimulation (DBS)- is one of the therapeutic options for drug-resistant epilepsy. With the increasing number of DBS implantations in women with epilepsy, it has become a burning issue whether DBS is safe in pregnancy. We report here two women with epilepsy who gave birth to healthy children with DBS therapy. We describe two cases, a 30-year-old woman and a 37-year-old woman. Both were implanted with DBS due to drug-resistant epilepsy. Both of our patients showed a significant improvement after DBS implantation and thereafter gave birth to a healthy child with DBS treatment. The severity and frequency of epileptic seizures did not change during pregnancy and after childbirth. Although a Caesarean section was performed in one case, pregnancies and births were essentially problem-free. At present, the two- and four-year-old children are healthy. Considering these cases, previously described VNS cases, and DBS cases with non-epileptic indications; we suggest that pregnancy and childbirth are safe in epilepsy patients with DBS, moreover, DBS treatment has probably no effect on foetal abnormalities or breastfeeding.

Several pilot trials and the Clinical Evaluation of the Infinity Deep Brain Stimulation System (PROGRESS) study have found that directional stimulation can provide a wider therapeutic window and lower therapeutic current strength than omnidirectional stimulation.We conducted a single-center, open-label, registry-based, comparative trial to test the hypothesis that directional stimulation can be associated with a greater reduction in the total daily dose of antiparkinsonian medications (ApMeds) than omnidirectional stimulation.A total of 52 patients with directional and 57 subjects with omnidirectional bilateral subthalamic deep brain stimulation (STN-DBS) were enrolled. Preoperatively and 12 months postoperatively, the dose of different ApMeds, the number of tablets used daily, the severity of motor and nonmotor symptoms using the Movement Disorder Society-sponsored Unified Parkinson Disease Rating Scale, and the health-related quality of life (HRQoL) using the 39-item Parkinson's Disease Questionnaire (PDQ-39) were assessed.According to the changes in the levodopa equivalent daily dose, directional STN-DBS led to a 13% greater reduction in the total daily dose of ApMed. The 10.3% greater reduction in the dose of levodopa was the main contributor to this difference. The number of different ApMed types also could be decreased in a greater manner with directional stimulation. The improvement in the severity of motor and nonmotor symptoms was comparable; however, we detected a 15.8% greater improvement in the global HRQoL among patients with directional stimulation according to the changes in the summary index of the PDQ-39. The total electrical energy delivered per second was comparable between the groups at 12-month postoperative visit, whereas the amplitude of stimulation was significantly lower and the impedance was significantly higher with directional leads.Directional programming can further increase the reduction in the total daily dose of ApMed after STN-DBS. In addition, directional stimulation can have additional beneficial effects on the global HRQoL. The greater reduction of ApMed doses did not require more energy-consuming stimulation with directional stimulation.

The evaluation of hand dexterity is an important marker for the success of DBS (deep brain stimulation) operation in patients with Parkinson's disease. In this study we applied a simple, semiquantitative optical dental plaque staining technique for the evaluation of the hand dexterity. Ten patient with Parkinson's disease were involved in the study. After dental students aided tooth brushing, bacterial dental deposits (plaque) were stained then photographed, and quantified under standard conditions before and after DBS surgery. Our results showed a significant decrease in dental plaque deposits after DBS operation. This simple technique seems to be a routinely applicable marker for the evaluation of the hand dexterity. Our future plans is repeating the previous experiement on a higher number of cases.A DBS- (deep brain stimulation, mély agyi stimuláció) mûtéttel kezelt Parkinson-kóros betegek kézügyességének mérésével adatokat nyerhetünk a mûtét sikerességérôl, amely a beteg várhatóan javuló életminôségét is elôre­vetíti. Tanulmányunkban arra kerestük a választ, hogy az általunk fogászati vizsgálat során alkalmazott optikai és plakkfestési technika alkalmas-e a rutinszerû, egyszerû használatra, a mûtét sikerességének megítélésére. Tíz Parkinson-kóros beteget vontunk be a vizsgálatba. Fogorvostan-hallgatók által felügyelt fogmosás után több alkalommal standard körülmények között a fogakon kép­zô­dô bakteriális depozitum (dentális plakk) megfestését követôen lefényképeztük a frontfogakat. A digitális fény­kép­felvételeken mértük a fogak plakkal való fedettségét. Eredményeink szerint a fogmosási hatékonyság a DBS-mûtétet követôen szignifikánsan javult, aminek hátterében a betegek kézügyességének javulása állhat. Távolabbi célunk az, hogy a fenti módszert nagyobb esetszámon is alkalmazzuk a betegek tüneti javulásának megítélésére.

Background and purpose Deep brain stimulation (DBS) involves placing electrodes within specific deep brain nuclei. For movement disorders the most common indications are tremors, Parkinsons disease and dystonias. Surgeons mostly employ MR imaging for preoperative target selection. MR field geometrical distortion may contribute to target-selection error in the MR scan which can contribute to error in electrode placement. Methods In this paper we compared the STN target planning coordinates in six parkinsonian DBS patients. Each patient underwent target planning in 1T and 3T MRI. We statistically compared and analysed the target-, and the fiducial coordinates in two different magnetic fileds. Results The target coordinates showed no significant differences (Mann-Whitney test, p > 0.05), however we found significant difference in fiducial coordinates (p < 0.01), in 3T MRI it was more pronounced (mean ± SD: 0.8 ± 0.3 mm) comparing to 1T (mean ± SD: 0.4 ± 0.2 mm). Conclusion Preliminary results showed no significant differences in planning of target coordinates comparing 1T to 3T magnetic fields.

Deep brain stimulation (DBS) involves placing electrodes within specific deep brain nuclei. For movement disorders the most common indications are tremors, Parkinsons disease and dystonias. Surgeons mostly employ MR imaging for preoperative target selection. MR field geometrical distortion may contribute to target-selection error in the MR scan which can contribute to error in electrode placement.In this paper we compared the STN target planning coordinates in six parkinsonian DBS patients. Each patient underwent target planning in 1T and 3T MRI. We statistically compared and analysed the target-, and the fiducial coordinates in two different magnetic fileds.The target coordinates showed no significant differences (Mann-Whitney test, p0.05), however we found significant difference in fiducial coordinates (p0.01), in 3T MRI it was more pronounced (mean ± SD: 0.8 ± 0.3 mm) comparing to 1T (mean ± SD: 0.4 ± 0.2 mm).Preliminary results showed no significant differences in planning of target coordinates comparing 1T to 3T magnetic fields.A mély agyi stimuláció a gyógyszeres kezeléssel nem befolyásolható mozgászavarok műtéti kezelésének rutinszerűen alkalmazott módszere. A műtétet a klinikai gyakorlatban elsősorban Parkinson-kór, essentialis tremorok, és dystoniák kezelésére alkalmazzuk. A célterületek többsége MR morfológiai vizsgálatokkal jól láthatóvá tehető. A mágneses erőterek növelésével azonban a képi információ torzulása következik be, ami oda vezethet, hogy az MR-képen látott anatómiai struktúrák a valóságban nem ugyanott helyezkednek el. Arra keres­tük a választ, hogy az 1 T, és 3 T mágneses erőterekben kijelölt célkoordinátákban, valamint az MR lokalizációs keret referenciapontjainak koordinátáiban (rodmarking accuracy) kimutatható-e eltérés.Hat, Parkinson-kórban szenvedő beteg mély agyi stimulációs műtéti tervezése kapcsán a subthalamicus magokat jelöltük ki célpontként. A két különböző mágneses térben nyert koordinátaadatokat statisztikai módszerekkel hasonlítottuk össze.Az 1 T és a 3 T erőterekben végzett cél­koordináta összehasonlító eredményeink matematikailag ugyan mutattak eltérést, azonban ez nem volt szignifikáns (Mann-Whitney-próba, p0,05). Ugyanakkor az MR-lokalizáló keret referenciapont koordinátáinak (accuracy) összehasonlítása során szignifikáns (p0,01) különbséget találtunk. Ez az érték az erősebb mágneses térben nagyobb számadatot mutatott (3T accuracy átlag ± SD: 0,8 ± 0,3 mm), mint a gyengébb mágneses térben (1T accuracy átlag ± SD: 0,4 ± 0,2 mm).Előzetes eredményeink nem igazoltak matematikailag szignifikáns eltérést a célkoordinátákban az 1 T és 3 T erősségű mágneses terek összehasonlítása során.

Background: Sleep problems are among the most common non-motor symptoms of Parkinson’s disease (PD). The PD Sleep Scale 2nd version (PDSS-2) improved the original PDSS by adding more items on different aspects of sleep problems, making it a more robust tool to evaluate the severity of sleep disturbances. However, previous studies on deep brain stimulation (DBS) have not used the PDSS-2. Objective: To determine if the PDSS-2 could detect improvement reliably in sleep problems after bilateral subthalamic nucleus DBS for PD. Methods: In this prospective study, 25 consecutive patients undergoing DBS implantation were enrolled. Patients were examined twice: 1 week prior to the DBS implantation (baseline) and 12 months postoperatively. Severity of PD symptoms were assessed by the Movement Disorders Society Unified PD Rating Scale (MDS-UPDRS) and the Non-Motor Symptoms Scale (NMSS). Presence and severity of sleep disturbances were specifically measured by PDSS-2. Results: Total score of MDS-UPDRS improved from 81 (median, interquartile-range: 63–103) to 55 points (median, IQR: 46–75, p < 0.001). Health-related quality of life, measured by PDQ-39, also improved from 29 (IQR: 18–40) to 15 (IQR: 9–28) points (p = 0.002). Most domains of NMSS also improved. At baseline 13 patients reported sleep problems, but 1 year after DBS implantation only 3 did (p = 0.012). Although only 6 out of 15 items showed a significant decrease after DBS implantation, the total score of PDSS-2 decreased from 24 (IQR: 17–32) to 10 (IQR: 7–18) points (P < 0.001). Conclusions: Based on our results, PDSS-2 can detect improvements in sleep quality reliably after DBS implantation.

BACKGROUND The recently published "EarlyStim" study demonstrated that deep brain stimulation (DBS) for the treatment of Parkinson's disease (PD) with early fluctuations is superior to the optimal pharmacological treatment in improving the quality of life and motor symptoms, and preserving sociocultural position. Our retrospective investigation aimed to evaluate if DBS therapy was able to preserve the working capabilities of our patients. METHODS We reviewed the data of 39 young (< 60 years-old) PD patients who underwent subthalamic DBS implantation at University of Pecs and had at least two years follow-up. Patients were categorized into two groups based on their working capabilities: Patients with active job ("Job+" group, n = 15) and retired patients (without active job, "Job-" group, n = 24). Severity of motor symptoms (UPDRS part 3), quality of life (EQ-5D) and presence of active job were evaluated one and two years after the operation. RESULTS As far as the severity of motor symptoms were concerned, similar (approximately 50%) improvement was achieved in both groups. However, the postoperative quality of life was significantly better in the Job+ group. Majority (12/15, 80%) of Job+ group members were able to preserve their job two years after the operation. However, only a minimal portion (1/24, 4.2%) of the Job- group members was able to return to the world of active employees (p < 0.01, McNemar test). CONCLUSION Although our retrospective study has several limitations, our results fit well with the conclusions of "EarlyStim" study. Both of them suggest that with optimal timing of DBS implantation we may preserve the working capabilities of our patients.

Background: Dyskinesia is among the most troublesome symptoms of advanced Parkinson's disease (PD). The recently developed Unified Dyskinesia Rating Scale (UDysRS) can simultaneously measure several subjective and objective aspects of dyskinesia, irrespective of the other motor symptoms of PD. Despite the advantages of deep brain stimulation (DBS), previous studies on DBS have not used the UDysRS yet. Methods: In this prospective study, 71 consecutive patients undergoing DBS implantation were enrolled. Patients were examined twice: 1 week prior to the DBS implantation (baseline) and 12 months postoperatively. The severity of PD-related symptoms was assessed by the Movement Disorders Society Unified PD Rating Scale (MDS-UPDRS). The presence and severity of dyskinesia were specifically measured by the UDysRS and patient diaries. Results: At baseline, all 71 patients had dyskinesia, but 1 year after DBS implantation, 25 patients were dyskinesia-free, and an additional 19 had only mild dyskinesia. The total score on the UDysRS decreased from 38.0 ± 17.8 to 10.8 ± 13.0 (p < 0.001). Besides this, all parts of the UDysRS showed significant improvement after STN DBS treatment, and the magnitude of these changes had a large effect size. The total score of MDS-UPDRS improved from 76.5 ± 24.3 to 60.4 ± 21.4 points (p < 0.001). Conclusions: Based on our results, UDysRS can reliably detect improvements in dyskinesia after DBS implantation.

Introduction: Among the non-motor features of Parkinson’s disease (PD), cognitive impairment is one of the most troublesome problems. Highly sensitive and specific screening instruments for detecting dementia in PD (PDD) are required in the clinical practice. Methods: In our study we evaluated the sensitivity and specificity of different neuropsychological tests (Addenbrooke’s Cognitive Examination, ACE; Frontal Assessment Battery, FAB and Mattis Dementia Rating Scale, MDRS) in 73 Parkinson’s disease patients without depression. By receiver operating characteristic curve analysis, these screening instruments were tested against the recently established clinical diagnostic criteria of PDD. Results: Best cut-off score for ACE to identify PDD was 80 points (sensitivity ¼ 74.0%, specificity ¼ 78.1%). For FAB the most optimal cut-off value was 12 points (sensitivity ¼ 66.3%, specificity ¼ 72.2%); whereas for MDRS it was 125 points (sensitivity ¼ 89.8%, specificity ¼ 98.3%). Among the examined test batteries, MDRS had the best clinicometric profile for detecting PDD. Conclusion: Although the types of applied screening instruments might differ from movement disorder clinic to clinic within a country, determination of the most specific and sensitive test for the given population remains to be an important task. Our results demonstrated that the specificity and sensitivity of MDRS was better than those of ACE, FAB and MMSE in Hungary. However, further studies with larger sample size and more uniform criteria for participation are required to determine the most suitable screening instrument for cognitive impairment.

Deep brain stimulation of the subthalamic nuclei (STN) is a well established treatment in advanced Parkinson's disease (PD). Based on the clinical efficacy and elicited side-effects, both unipolar and bipolar stimulation modes may be applied. Bipolar stimulation usually produces a more focused and therefore thinner area of tissue activated during stimulation than unipolar stimulation does. The primary aim of our clinical study was to quantify the different clinical efficacy between these two stimulation modes. Twenty-one patients with PD previously underwent bilateral STN DBS implantation were involved in the study. Approximately three years after the implantation, we evaluated rigidity, tremor and bradykinesia according to the Unified Parkinson's disease Rating Scale in a practically off condition. Keeping the cathode of the chronic stimulation setting constant, the amplitude of stimulation was changed between 0 and 3.6 V by 0.2 V steps. Subsequently, the improvements in rigidity, tremor and bradykinesia were compared between unipolar and bipolar modes using 60 μs pulse-width and 130 Hz frequency. Within the examined amplitude range, unipolar stimulation usually had a significantly higher efficacy than bipolar stimulation; however, also with a higher rate of side-effects (19% vs. 0%). Depending on the evaluated parkinsonian symptoms, the efficacy of uni- and bipolar stimulation was different. To achieve the same level of improvement during bipolar stimulation, approximately 0.4-0.5 V higher amplitude was required than in unipolar mode. However in some cases, the efficacy of bipolar stimulation was unable the reach that of unipolar stimulation within the examined amplitude range.

Background/Aims: We investigated adaptive reorganization in Parkinson’s disease (PD) by fMRI using a passive movement task and compared the brain activation patterns of 10 patients with left- versus right-sided dominant symptoms. Five healthy controls were also investigated with the same settings. Methods: We grouped patients according to the predominant side of symptoms; thus, a right-sided dominant and a left-sided dominant group was formed. The paradigm consisted of a 4-finger passive movement task, which altered with resting states. For each subject, this examination was performed twice: on the left and on the right hand separately. Results: In healthy controls, motor-related areas contralateral to the moving fingers showed activation on fMRI. Concerning PD patients, motor-related areas of the ipsilateral hemisphere – including the primary motor cortex, supplementary motor area, and basal ganglia – seemed to be involved in the motor reorganization in PD. However, we could only demonstrate this reorganization in patients with right-sided dominant symptoms. Conclusions: We suggest that the human brain in PD tries to compensate for the failure of the basal ganglia motor loop by employing alternative (ipsilateral) motor pathways, indicating that a complex reorganization can also take place in disorders like PD which affect the whole motor-related network.

The origin of the high rate of depression in idiopathic Parkinson's disease (PD) is unknown. We applied voxel-based morphometry (VBM), as a sensitive tool in detection of gray matter MR density alterations, to find differences in depressed and nondepressed PD patients. Patients with idiopathic PD were classified into depressed (DPD) and nondepressed (NDPD) groups based on the Montgomery-Asberg Depression Rating Scale (MADRS). Subsequently, a group comparisons were performed between depressed PD (n = 23), nondepressed PD (n = 27) and normal healthy controls (NC, n = 16). There was no difference in gray matter density comparing healthy controls to any PD groups. However, when NDPD and DPD cohorts were compared, density alteration of the bilateral orbitofrontal, bilateral rectal gyrus, and also the right superior temporal pole was detected in the depressed subgroup. Exploratory analyses revealed an inverse correlation of MADRS scores and severity of VBM alteration in these regions beside the right medial temporal gyrus, anterior and medial cingular gyrus, and parahippocampal gyrus. These results suggest that depression in PD is related to gray matter decrease in the bilateral orbitofrontal and right temporal regions as well as the limbic system.

The recently published "EarlyStim" study demonstrated that deep brain stimulation (DBS) for the treatment of Parkinson's disease (PD) with early fluctuations is superior to the optimal pharmacological treatment in improving the quality of life and motor symptoms, and preserving sociocultural position. Our retrospective investigation aimed to evaluate if DBS therapy was able to preserve the working capabilities of our patients.We reviewed the data of 39 young (60 years-old) PD patients who underwent subthalamic DBS implantation at University of Pécs and had at least two years follow-up. Patients were categorized into two groups based on their working capabilities: Patients with active job ("Job+" group, n = 15) and retired patients (without active job, "Job-" group, n = 24). Severity of motor symptoms (UPDRS part 3), quality of life (EQ-5D) and presence of active job were evaluated one and two years after the operation.As far as the severity of motor symptoms were concerned, similar (approximately 50%) improvement was achieved in both groups. However, the postoperative quality of life was significantly better in the Job+ group. Majority (12/15, 80%) of Job+ group members were able to preserve their job two years after the operation. However, only a minimal portion (1/24, 4.2%) of the Job- group members was able to return to the world of active employees (p0.01, McNemar test).Although our retrospective study has several limitations, our results fit well with the conclusions of "EarlyStim" study. Both of them suggest that with optimal timing of DBS implantation we may preserve the working capabilities of our patients.

A recent study has proved that unilateral deep brain stimulation (DBS) of the subthalamic nucleus has bilateral effects. However, it is still unclear whether unilateral ventral intermediate thalamic nucleus (Vim) DBS exerts exclusively contralateral or bilateral effects on tremor. Previous studies demonstrated a clinically irrelevant improvement on the nontarget side after thalamic stimulator implantation, which was considered to be solely the result of mechanical effects. We report here the case of a 55-year-old woman in whom unilateral thalamic DBS can stop the disabling postural-kinetic tremor in both hands. Simultaneous surface electromyography (sEMG), accelerometry, and video recordings were obtained to evaluate the underlying mechanism. After the right Vim DBS was turned off, moderate rest tremor appeared in both hands accompanied by bilateral bursts on sEMG. Because right hand tremor cannot simply reflect the mechanical overflow of the left side, the bilateral improvement caused by right Vim DBS is probably due to an active tremor reduction in this particular case.

We present the case of a 66-year-old man who has been treated for essential tremor since the age of 58. He developed mild cerebellar gait ataxia seven years after tremor onset. Moderate, global brain atrophy was identified on MRI scans. At the age of 68, only temporary tremor relief could be achieved by bilateral deep brain stimulation of the ventral intermedius nucleus of the thalamus. Bilateral stimulation of the subthalamic nucleus also resulted only in transient improvement. In the meantime, progressive gait ataxia and tetraataxia developed accompanied by other cerebellar symptoms, such as nystagmus and scanning speech. These correlated with progressive development of bilateral symmetric hyperintensity of the middle cerebellar peduncles on T2 weighted MRI scans. Genetic testing revealed premutation of the FMR1 gene, establishing the diagnosis of fragile X-associated tremor/ataxia syndrome. Although this is a rare disorder, it should be taken into consideration during preoperative evaluation of essential tremor. Postural tremor ceased two years later after thalamotomy on the left side, while kinetic tremor of the right hand also improved.

There is a great need for MRI examinations of patients who have previously undergone deep brain stimulator (DBS) implantation. The current guidelines pertain only to a 1.5-Tesla horizontal-bore scanner complying with strict safety regulations. Moreover, almost all published in vitro and in vivo studies concerning patient safety are carried out on 1.5 Tesla MR scanners. The aim of our work is to share our clinical experience of 1.0-Tesla brain MR imaging. During the past four years, 34 patients with different types of implanted DBS systems underwent 1.0-Tesla MR examinations to answer diagnostic or clinical questions. Apart from the scanner type applied, all other safety instructions were strictly followed. The MRI itself made no significant difference to the measured impedances or the stimulation parameters required to achieve the optimal therapeutic results. From theoretical considerations, it may be assumed that 1.0-Tesla MRI can be performed safely on DBS-implanted patients, provided that all other recommendations are adhered to.

Ablation and deep brain stimulation (DBS) can treat pharmacologically uncontrollable tremor. Here, we compared the postoperative electrophysiological changes in resting hand tremor after 32 ablations and 12 DBS implantations in patients with severe tremor-dominant idiopathic Parkinson's disease (PD) and essential tremor (ET). Short- and long-term accelerometric data were acquired after surgery and were compared to the preoperative tremor. After effective surgical treatments, significant rest tremor reduction and increase in both frequency and approximate entropy (ApEn) were detected in all PD cases, irrespective of the type and target of intervention. However, the long-term effect of DBS implantation on tremor reduction was significantly better compared to that after ablative treatments. In cases of thalamotomy, the postoperative increase in frequency and ApEn was significantly larger in essential tremor compared to PD, suggesting that the etiology of tremor may influence the size of the similar changes. However, cases where clinical tremor re-emerged 6 to 12 months after the surgery, no change in frequency and ApEn was detected on the second postoperative day, despite an initial tremor reduction and clinical improvement similar to the effective operations. Our results suggest that uniform postoperative changes in rest tremor and the increase in frequency and ApEn could be due to attenuation of pathological oscillators and might be immediate indicators of the effectiveness of neurosurgical treatments relieving tremor.

Objectives. Our investigation aimed at evaluating if bilateral subthalamic deep brain stimulation (DBS) could preserve working capability in Parkinson’s disease (PD).Materials. We reviewed the data of 40 young (n=20) and “no job” group (n=20). Baseline characteristics were comparable. Quality of life (EQ-5D) and presence of active job were evaluated preoperatively and 2 years postoperatively.Results. Although similar (approximately 50%) improvement was achieved in the severity of motor and major nonmotor symptoms in both groups, the postoperative quality of life was significantly better in the “active job” group (0.687 versus 0.587, medians,p<0.05). Majority (80%) of “active job” group members were able to preserve their job 2 years after the operation. However, only a minimal portion (5%) of the “no job” group members was able to return to the world of active employees (p<0.01).Conclusions. Although our study has several limitations, our results suggest that in patients with active job the appropriately “early” usage of DBS might help preserve working capability and gain higher improvement in quality of life.

In the present lecture we provide an overview on the electrophysiological procedures (microelectrode recording and intraoperative stimulation) during deep brain stimulation surgery. The technical requirements and the improvements during microelectrode recording will be also discussed. Currently there are conflicting data on the role of microelectrode recording during deep brain stimulation electrode implantation. Whereas, some centers never perform microelectrode recording during DBS surgery, others claim that it may improve the accuracy of electrode implantation and is associated with better outcome and meaningful clinical benefit. On the other hand, some data suggest that microelectrode recording can increase the risk of intraoperative hemorrhage while other data do not support this theory. In the lecture, all of these controversial issues will be covered.

¶ Four patients harbouring a colloid cyst of the 3rd ventricle were operated on endoscopically. With the “classical” monoportal technique, through a precoronal burr hole only partial removal could be achieved in the first case. As the crucial point of the procedure is the safe dissection of the cyst from the thela chorioidea and from the internal cerebral veins, adequate control of the posterior rim of the foramen of Monro and the roof of the 3rd ventricle is mandatory. Accordingly in other three cases a CT-guided biportal endoscopic technique was applied, which permitted radical removal of the entire cyst with maximum safety. CT-guidance is essential for optimal planning after careful study of the individual anatomy. In this way the rigid scopes are moved exclusively along their own axes throughout the procedure, the resulting brain damage thereby being minimal. With regard to all circumstances of the procedure, the use of flexible endoscopes appears to be inappropriate and biportal endoscopy offers itself as the method of choice.

Spinal cord stimulation has become an established clinical option for treatment of refractory chronic pain and angina pectoris, but its precise mechanism of action is unclear. We investigated the effect of spinal cord stimulation (SCS) on heart rate variability (HRV) and evaluating its influence on the sympathetic/parasympathetic balance in chronic pain. MATERIALS AND PURPOSE: Seven patients (three men, four women) with SCS due to chronic pain were included. The SCS was programmed in three different ways: (i) to stimulate at an amplitude known to generate paresthesias (ON-state), (ii) at a subliminal level (SUB state), or (iii) switched off (OFF-state). HRV analysis was based on 5-min segments of the consecutive normal RR intervals and was performed with custom software (Kubios HRV Analysis).The mean heart rate was higher in ON state compared to SUB state (p = 0.018) and the high-frequency component of the HRV was lower in ON compared to OFF period (p = 0.043). Other HRV parameters values did not significantly differ during the three tested periods.Spinal cord stimulation in chronic pain seems to be accompanied by reduced parasympathetic tone, unlike SCS in angina pectoris where previous studies found a reduced cardiac sympathetic tone. Our study might lead to understand the mechanism of action of SCS We investigated a relatively small number of patients, which is the main limitation of our study. Thus, further studies with larger number of patients are required for validation of our results.

Objectives There is a debate on the potential advantageous effects of bilateral subthalamic deep brain stimulation (DBS) in the treatment of Parkinson’s disease (PD) with early fluctuations. Our investigation aimed to evaluate if DBS therapy could preserve working capability. Materials & methods We reviewed the data of 40 young ( Results Although similar (approximately 50%) improvement was achieved in the severity of motor and major non-motor symptoms in both groups, the postoperative quality of life was significantly better in the ‘Active job’ group (0.687 vs. 0.587, medians, p Conclusions Although our study has several limitations, our results suggest that in patients with active job the appropriately ‘early’ usage of DBS might help preserve working capability in a two-year time-frame and gain higher improvement in quality of life.

Background: Status dystonicus (SD) is a rare, life-threatening disorder characterized by acute worsening of generalized dystonia. Methods: This study was conducted to characterize the pathogenesis, clinical course, and prognosis of SD. We reviewed the records of six centers and analyzed them together with all the cases previously reported in the literature. Results: Eighty-nine episodes occurring in 68 patients were studied. The majority of patients were males (64.7%), were

Bilateral deep brain stimulation of the subthalamic nuclei (STN) is a well-established and cost-effective treatment in advanced PD.To quantitatively analyze the change in use of antiparkinsonian drugs one year after subthalamic deep brain stimulator (DBS) implantation in patients with idiopathic Parkinson's disease (PD).Eighteen consecutive patients with advanced PD underwent bilateral STN DBS implantation were involved in the study. The stimulation achieved a stable and clear clinical benefit in all of the cases. One year after the implantation, drug usage of patients was analyzed and correlated with the postoperative symptomatic improvement measured by the modified Hoehn-Yahr, Schwab and England, and Unified Parkinson's Disease Rating Scales. Because none of the investigated variables followed the normal distribution, non-parametric Wilcoxon signed-rank, McNemar and Kendell's T tests were applied.Preoperatively, the patients used 12.05 +/- 4.57 tablets a day out of 3.19 +/- 0.97 different antiparkinsonian drugs, which was significantly reduced by deep brain stimulation to the application of 7.00 +/- 2.96 tablets out of 1-3 (1.84 +/- 0.76) drugs (p0.001). Meanwhile, the usage of amantadine, MAO-B and COMT inhibitors was also significantly decreased (p0.05). The dosage of dopaminerg medication was significantly lowered from 1136 mg to 706 mg expressed in levodopa equivalent dosage (p0.001) whereas the UPDRS-III also improved by 48.6%.Our study is in accordance with previously published international findings that antiparkinsonian medication can be significantly lowered after bilateral STN DBS. Because not only the dosage, but also the applied number of tablets were decreased, it may have resulted in a better compliance and quality of life.

Objective The cause or the physiological role of deja vu (DV) in healthy people is unknown. The pathophysiology of DV-type epileptic aura is also unresolved. Here we describe a 22-year-old woman treated with deep brain stimulation (DBS) of the left internal globus pallidus for hemidystonia. At certain stimulation settings, DBS elicited reproducible episodes of DV. Methods Neuropsychological tests and single-photon-emission computed tomography (SPECT) were performed during DBS-evoked DV and during normal DBS stimulation without DV. Results SPECT during DBS-evoked DV revealed hyperperfusion of the right (contralateral to the electrode) hippocampus and other limbic structures. Neuropsychological examinations performed during several evoked DV episodes revealed disturbances in nonverbal memory. Conclusion Our results confirm the role of mesiotemporal structures in the pathogenesis of DV. We hypothesize that individual neuroanatomy and disturbances in gamma oscillations or in the dopaminergic system played a role in DBS-elicited DV in our patient.

Deep brain stimulation is a widely used technique for the treatment of movement disorders. This method is a breakthrough in treatment of drug-resistant idiopathic Parkinson's disease, essential tremor and dystonia. The aim of the present paper is to give an inside overview of the postoperative management like fine tuning of the stimulation and balancing the antiparkinsonian medication. We also discuss the advantage of the use of the (Access Therapy) patient controller. After reviewing the stimulation-related side-effects and their management, the contraindicated medical procedures are discussed.

Although there is a relatively high prevalence of both idiopathic Parkinson's disease (PD) and epilepsy in the elderly population, and PD occurs more frequently in people with epilepsy, there are no studies investigating the efficacy and tolerability of antiepileptic drugs (AEDs) in people with PD. We describe the case of a 71-year-old man with PD who experienced several seizures. The initiation of antiepileptic treatment with oxcarbazepine (OXC) provoked a severe, long-lasting psychotic state. The patient had previously experienced similar psychotic episodes during dopamine agonist therapy. Because recent animal studies have proven that OXC and its active metabolite exert important dopamine- and serotonin-promoting effects in the limbic area, we assumed that in our case the OXC-induced psychosis was mediated by the dopaminergic system. We concluded that OXC should be used with care in cases of a constellation of PD and epilepsy because of its possible psychiatric side effects. The dopaminergic effect of OXC and its active metabolite might also play an ambivalent, but important role in the treatment of alcohol addiction and bipolar disorder; therefore, further studies are required to investigate its psychopharmacological aspects.

Ablative neurosurgical interventions are widely used for the treatment of advanced Parkinson's disease. However, in some cases, the achieved result is temporary and repeat operation is necessary to obtain a permanent effect. By analyzing 30 ablative surgeries using comparative accelerometry, we looked for a biological marker predicting the efficiency. In 27 cases where clinical symptoms were permanently improved, a significant increase in rest tremor frequency was observed in addition to reduction in tremor intensity. In contrast, in those three cases where the clinical effect of the surgery was only temporary, the frequency of tremor remained unchanged despite of the transitory decrease in intensity. We thus hypothesize that postoperative change in frequency of tremor but not the intensity may predict the outcome of ablative treatments.

The objective of this study was to evaluate the changes in the concentrations of certain brain metabolites in 13 patients with Parkinson's disease before and after bilateral subthalamic nucleus (STN DBS). The N -acetylaspartate (NAA)/choline (Chol), NAA/creatine (Cr), Chol/Cr ratios were determined by single voxel Proton magnetic resonance spectroscopy ( 1 H-MRS) studies on 1.0 T unit using short TE stimulated echo acquisition mode (STEAM) sequence. Spectra were obtained from the right and left globus pallidus, and left fronto-basal cortex. The patients were also assessed according to the UPDRS part III, in the “medication-on and off” conditions. Conclusions: after STN DBS cortical NAA/Cho, NAA/Cr ratios increased significantly, which were highly correlated with the significant improvements of the UPDRS scores.

A 53-year-old woman underwent several ischemic stroke-like episodes and later developed incomplete, bilateral ophthalmoplegia, left vision deterioration, and bilateral tremor. The clinical course, laboratory data, and muscle histology led to a diagnosis of mitochondrial encephalomyopathy. No other etiology could be identified in the background of her disabling bilateral postural-kinetic tremor. As this tremor did not respond to pharmacological therapy, left thalamotomy and subsequently right thalamic deep brain stimulator (DBS) implantation were performed, which resulted in an excellent clinical outcome. The Fahn-Tolosa-Marin Tremor Rating Scale improved from 110 to 11 points. This case suggests that the rare tremor caused by mitochondrial encephalopathy may be treated long-term with either thalamotomy or thalamic DBS implantation.

The objective of this study was to determine the influence of stereotactic ablative surgical interventions on the time required for the performance of manual tasks (i.e. performance time) in patients with Parkinson's disease (PD). We studied 28 patients after pallidotomy and pallido-thalamotomy who were evaluated at four time: before the operation, and 2 days, 3 and 6 months postoperatively. The speed of performance of handwriting and drawing were assessed by means of a chronometer using certain parts of an international standard scale (modified by Fahn). The patients were also assessed according to the Unified Parkinson's Disease Rating Scale (UPDRS) part III. The patients were divided into two groups. Those in group A had relief of all main Parkinsonian symptoms after pallidotomy including tremor. The patients in group B had no relief of tremor straight after pallidotomy. For them the pallidotomy was completed with thalamotomy in the same sitting, which had resulted in cessation of tremor. The time of performance of the manual tasks diminished significantly in all cases in both groups (Student's t-test: p

Although significant improvement of motor function following bilateral pallidotomy for the treatment of Parkinson's disease has been proved, the cognitive sequelae have not been clearly defined. There are recurrent loops interconnecting specific areas of the frontal cortex and the basal ganglia, suggesting the continuity or complementary functioning between these areas.Pre- and postoperative cognitive function was evaluated in 19 Parkinsonian patients who underwent bilateral pallidotomy in order to clarify its effects on cognitive function. All patients were evaluated one day before the procedure and 12+ months after surgery using neuropsychological tests (Raven Progressive Matrices and Bergen Facial Recognition Test). Proper performance in these tests requires reasoning, abstraction and spatial memory, involving strongly the frontal functions. These functions could be described in terms of the "working memory" concept. Hand Mental Rotation Test was used as comparing task not involving frontal functions. Scores were analyzed by Student's t-test.Modest improvement was observed in these cognitive functions as assessed by Raven Progressive Matrices (p0.0688) and a significant change in the complex parts of Bergen Facial Recognition Test (p0.0547; p0.0468) was also noticed, but no change was registered in mental rotation tasks.Present data revealed that bilateral pallidotomy is associated with modest and long-lasting improvement in tasks involving the "working memory".

INTRODUCTION Better understanding of the basic mechanism of disorders of movement, together with improvements in surgery and electrophysiological techniques have led to a resurge of interest in the surgical treatment of patients with tremor. Ventrolateral thalamotomy has been considered to be an alternative neurosurgical treatment for disabled persons including those with drug-resistant Parkinson s disease and other types of tremor. PATIENTS AND METHODS Thirty four of 47 patients had Parkinson s disease (n= 23), essential tremor (n= 4), multiple sclerosis (n= 5), olivopontocerebellar lesion (n= 1) and posttraumatic tremor (n= 1) and did not show satisfactory improvement after drug treatment. The lesions were made in the thalamic nucleus. In 26 patients simultaneous recordings were made of nerve activity in the thalamus and of burst activity. RESULTS In 23% of the cases the appropriate site for the final lesion could not be determined in accordance with electrostimulation of the empirical objective. In these patients the objective was determined after observation of the electrophysiological activity localized to the burst activity seen during the operation. The patients were followed-up for 6-24 months (average 12 months); 88% of them had no tremor or moderate contralateral tremor. The patients were assessed on a modified Fahn scale. Average scoring fell from a preoperative evaluation of 73.8 points to 34.0 after three months; 30.7 after six months, 32.0 after 9 months, 37.1 after 12 months and 35.2 points after 18 months. CONCLUSION Of 47 thalamotomies done, 13 (29%) were successful and 5 (10%) maintained their original state, but no cases became worse or had serious complications.

INTRODUCTION Medial thalamotomy is one of the first stereotactic operations to have been used for neurogenic pain, has a low complication rate and no risk of the development of iatrogenic neurogenic pain. It represents selective local relief for all types of pain, without causing somatosensorial deficit. PATIENTS AND METHODS We did 39 posteromedial thalamotomies in patients with persistent intractable pain due to various disorders. The pain was assessed pre- and postoperatively on the VAS (Visual Analogic Scale). RESULTS Half of the patients operated on had relief of pain after thalamotomy. In 84% (n = 39) of our cases this relief occurred on the second day, in 70% (n = 35) after three months, in 63% (n = 27) after six months, in 64% (n = 25) after nine months, in 62% (n = 23) of the patients after 12 months, and in 62% (n = 22) after 24 months. Three patients had temporary complications and one a permanent complication, but this did not make him an invalid. CONCLUSION Posteromedial stereotactic thalamotomy under MR guidance can provide safe, effective treatment for persistent, intractable pain.