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We report a patient with advanced Parkinson's disease, including severe and frequent off periods with freezing of gait, moderate dysphonia, and some cognitive impairment, who underwent bilateral subthalamic nucleus (STN) stimulation. The patient was followed for 1 year after surgery, showing persistent good mobility without off periods and without freezing, which reverted completely when stopping the stimulation. There was deterioration of cognition as well as increased aphonia and drooling, all of which remained when the stimulation was turned off. The striking improvement in motor symptoms following STN stimulation was not paralleled by improvement in disability, probably as a result of a cognitive decline, suggesting a diagnosis of Parkinson's disease with dementia. We conclude that chronic STN stimulation is efficient in alleviating akinetic motor symptoms including gait freezing; this surgery should be offered before patients start to exhibit speech or cognitive disturbances.

Fifty-eight patients, 36 with essential tremor (ET) and 22 with Parkinson's disease (PD), received deep brain stimulation (DBS) in the thalamic ventral intermediate (Vim) nucleus. The mean follow-up was 17 months for ET and 21 months for PD patients. Stimulation parameters were adjusted as needed, at various intervals after surgery. Results were assessed using routine clinical evaluation and established outcome scales. All patients needed incremental increase in stimulation parameters at various intervals during the first 6-12 months after surgery. The mean voltage 1 week postoperatively was 1. 45 V in PD patients, and 1.37 V in ET patients. Twelve months later, the figures were 2.14 V in PD and 2.25 V in ET patients. At 1 year, the Essential Tremor Rating Scale (ETRS) improved from 54 to 28 (p < 0.0001). The motor part of the Unified Parkinson's Disease Rating Scale (UPDRS) improved from 37 to 26 (p < 0.01). Tremor items of the UPDRS improved more markedly (p < 0.0001). One week postoperatively 90% of PD, and 89% of ET patients were tremor free. One year later, 70% of PD and 60% of ET patients remained mostly tremor free. Upon switching off stimulation, there was a clear tendency for tremor rebound (p = 0.07) in the PD group, requiring continuous 24-hour stimulation in some patients. Permanent non-adjustable ataxia was induced by stimulation in 2 PD patients., (Copyright 2000 S. Karger AG, Basel)

Trigeminal nerve microvascular decompression (MVD) relieves the pain in a great majority of patients. However, there has been a debate regarding whether the pain-relieving effect is due to the decompression itself or a surgical trauma to the nerve. In 37 consecutive patients, the facial sensibility was quantitatively assessed and the function of other cranial nerves was investigated before and after MVD. The patients were followed for 1-5 years (mean 3.4 years) to assess the surgical outcome. Twelve patients (32%) experienced a mild postoperative sensory deficit assessed by clinical examination. When measured quantitatively with electrical stimulation, sensory thresholds for perception and pain were elevated more than 25% in 16 of the patients (43%). All together 19 patients (51%) did not have any sensory deficit as assessed by either of the two methods used. No severe postoperative cranial nerve dysfunctions were noted in this series. Three patients (8%) had a recurrence of pain at 7-9 months postoperatively. Two of those patients had a moderate elevation of measured sensory thresholds. All 19 patients with no cranial nerve deficits after MVD experienced an excellent pain relief. It seems that trauma to the trigeminal nerve is not a prerequisite for obtaining pain relief after MVD for trigeminal neuralgia.