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Primary generalized dystonia is a medically refractory progressive disease of the brain causing near total functional handicap of affected patients. The authors present the effectiveness of bilateral globus pallidus internus (GPi) stimulation in one patient with primary DYT-1 positive dystonia. Pharmacotherapy completely failed to control generalized dystonic movements. The patient was referred for surgical treatment and underwent bilateral implantation of DBS leads in the GPi. The formal objective assessment included the Burke-Fahn-Marsden dystonia rating scale (BFMDRS). Clinical and functional BFMDRS assessments were performed before and after surgery till 5 years postoperatively. All stimulation-induced side effects were reversible. Chronic bilateral pallidal stimulation is an effective and safe treatment in patients with primary generalized DYT-1 positive dystonia. The effectiveness of pallidal stimulation was proved by the objective validated BFMDRS assessment at 5 years follow-up examination.

Essential tremor (ET) is the most common movement disorder. In most patients the course of ET is mild and pharmacological therapy controls postural and kinetic components of tremor. The first-line treatment of ET is pharmacotherapy with propranolol, primidone and gabapentin. In patients with marked head and voice tremor, local botulinum toxin injections have been found to be very effective. Despite optimal drug therapies it is estimated that approximately 50% of patients with ET have medication-resistant tremor. ET can cause more functional impairment than parkinsonian resting tremor because most prominent components of ET are postural and kinetic ones. For patients with drug-resistant debilitating tremor, surgical therapy (thalamotomy) and more recently deep brain stimulation (DBS) of the ventral intermediate thalamic nucleus (VIM) is a viable treatment modality. Several long-term studies have confirmed the high effectiveness rate of ablative surgery and thalamic DBS in the treatment of ET. The most striking advantage of thalamic DBS is the possibility of performing bilateral surgery in one operative session with a significantly lower rate of side effects. Nowadays the bilateral staged thalamotomy is performed rarely because of unacceptable side effects. Moreover, many authors have observed that in bilaterally stimulated patients the head and voice tremor have diminished in postoperative course. Thalamic DBS is a very efficacious and safe procedure in the treatment of ET.

The aims of the study were to present the surgical technique of bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) and to analyze our experience with the MedtronicStealthStation Treon neuronavigation system and Framelink 4.1 software in targeting STN using single-unit extracellular action potentials (microrecording). The prospective study included 2 patients with bilateral STN DBS. The STN boundaries were mapped using microrecording, without microstimulation and recording of kinesthetic cells. For macrostimulation the longest trajectory with neuronal activity characteristic of STN was chosen. The patients were assessed using Unified Parkinson's Disease Rating Scale UPDRS version 3 and Schwab and England Scale. Postoperatively we did not notice intracerebral haemorrhage. Also there were no transient or permanent side effects. The mean number of microelectrode tracts was 4 per STN. Framelink 4.1 software is reliable to plan individual microelectrode trajectories and help avoid the intraparenchymal vessels.

Dystonia refers to movement disorders characterized by sustained muscle contractions that produce abnormal postures and twisting movements. First-line therapy for dystonia includes several classes of pharmacologic agents. Botulinum toxin injections are the treatment of choice for several forms of focal dystonia. Many patients with dystonia do not benefit from these treatments, and for those patients whose symptoms are sufficiently troublesome, surgical treatment can be used to reduce symptoms and to improve function. Formerly the ablative procedures of thalamotomy and pallidotomy were used. More recently, deep brain stimulation (DBS) has emerged not only as the preferred surgical treatment for advanced idiopathic form of Parkinson's disease and severe forms of essential tremor but also for dystonia. For dystonia, stimulation directed at the globus pallidus internus has been the most thoroughly studied to date. Advantages of DBS include its relatively non-destructive nature, its adjustability and reversibility, and its capacity to be used bilaterally in a single surgical session. Use of DBS to treat dystonia is a rapidly evolving area, and preliminary evidence suggests that primary dystonia linked to genetic mutation, especially DYT-1 positive generalized dystonia, and other primary dystonias respond most dramatically to treatment with DBS, whereas secondary dystonia tends to be less responsive.

Deep brain stimulation (DBS) is a neurosurgical treatment of Parkinson's disease and other movement disorders. This surgical technique is applied to three brain targets: the ventral intermediate nucleus of the thalamus (Vim), the globus pallidus internus (Gpi) and the subthalamic nucleus (STN). Vim DBS improves contralateral parkinsonian tremor. STN and GPi DBS improve contralateral bradykinesia, rigidity, parkinsonian tremor and also levodopa-induced dyskinesia. There is little comparative data between bilateral STN and bilateral GPi procedures but the improvement with bilateral STN DBS seems more pronounced than with bilateral GPi DBS. Moreover, only STN BDS allows a significant decrease of antiparkinsonian medication. The other advantage of STN over GPi DBS is the lower consumption of current. The DBS procedure contrary to ablative surgery has the unique advantage of reversibility and adjustability over time. Patients with no behavioral, mood and cognitive impairments benefit the most from bilateral STN DBS. The stimulation-induced adverse effects related to DBS are reversible and adjustable. More specific adverse effects related do hardware are: disconnection, lead breaking, erosion or infection. The disadvantage of DBS is a relatively high cost. The setting of stimulation parameters to achieve the best clinical result may be very time-consuming. Most authors agree that DBS is a safer and more favorable procedure than ablative surgery.

Background and Purpose: Essential tremor is the most common tremorogenic movement disorder. In the majority of patients the progression of the disease is slow and the pharmacological treatment effectively alleviates tremor. In rare cases of increased essential tremor the surgical treatment (ventrolateral thalamotomy) is indicated. The goal of this study was to assess the effectiveness of unilateral thalamotomy in the treatment of essential tremor., Material and Methods: 10 stereotactic ventrolateral thalamotomies were performed in 9 patients for pharmacologically intractable essential tremor. Right thalamotomy was done in 5 patients and left thalamotomy in 4 patients. The study included five men and four women. Patients were assessed according to the Clinical Rating Scale for Tremor (CRST) before surgery and at 3, 12 and 24 months after thalamotomy., Results: In the postoperative period there was a marked reduction of essential tremor in the contralateral arm and, to a lower extent, in the contralateral leg. The mean presurgery value for contralateral upper extremity postural tremor (scores 5/6 CRST) decreased from 3.5 to mean postsurgery value of 0.6. The tremor reduction contributed to 59% improvement in specific motor tasks of upper extremities (Part B of CRST) at 2 years follow-up. There was also improvement of functional disabilities (Part C of CRST) by 62% when compared to preoperative value 2 years postoperatively., Conclusions: Ventrolateral thalamotomy is a highly effective method in the treatment of essential tremor. The side effects related to surgery are rare and most of them are transient.

Background and Purpose: In advanced stages of Parkinson's disease (PD) beside resting tremor, rigidity, and bradykinesia, most patients reveal severe balance instability. The goal of this study is to determine objectively postural control changes using static posturography after neurosurgical treatment (unilateral posteroventrolateral pallidotomy)., Material and Methods: 15 patients with advanced idiopathic PD underwent unilateral posteroventrolateral pallidotomy. The study group was composed of 8 men and 7 women. The mean disease duration until operation was 12.5+/-3.5 years, and the mean age of the patients at the time of surgery was 65.8+/-4.1 years. Postural control changes were assessed objectively by static computerized posturography and subjectively according to items of posture, gait and postural stability derived from Part III (motor examination) UPDRS. All evaluations of the balance system were performed preoperatively in the off and on condition, and also two weeks postoperatively in the same conditions., Results: It was found that the majority of posturographic parameters in the off condition were improved after neurosurgical treatment. The improvement in the on condition was less pronounced. For example, the mean path length in the off condition during eyes opened was 318+/-159 mm before pallidotomy, and after surgery it was 240.9+/-119.2 mm in off. The difference was statistically significant (p < 0.005, t=3.11)., Conclusions: Pallidotomy improves postural control changes in the early postoperative period, which can be proved by static computerized posturography.

Background and Purpose: To assess the effectiveness of unilateral thalamotomy for the treatment of parkinsonian tremor and other motor signs of Parkinson's disease (PD)., Material and Methods: Between 1999 and 2004, 41 patients with idiopathic tremor dominant PD were treated surgically in the Neurosurgical Department of Postgraduate Medical Center in Warsaw. Stereotactic thalamotomy was performed with Leksell stereotactic frame (model G) using intraoperative macrostimulation. The patients were assessed according to the Unified Parkinson's Disease Rating Scale version 3. (UPDRS) before and after thalamotomy in the off state. The progression of PD was also evaluated according to the Hoehn and Yahr scale in the off state and also Schwab and England was used to assess the disability of the patients. The patients were evaluated before thalamotomy in the off state, and 3, 12, 24 and 36 months after surgery, according to the above mentioned clinical rating scales., Results: The authors report their results among 41 patients who underwent stereotactic thalamotomy 3 years postoperatively. At 3 years follow-up (in the group of 19 patients) the contralateral tremor from the presurgical value of 11.2 (items 20 - 21 UPDRS) decreased to 2.6. The rigidity in contralateral limbs at 3 years follow-up was 1.7 (item 22 UPDRS) when compared to 2.8 (item 22 UPDRS) preoperative value. Thalamotomy had no effect on bradykinesia or other manifestations of PD such as balance or gait disturbance. There were 13 transient and 6 permanent complications., Conclusions: Thalamotomy using intraoperative macrostimulation in carefully selected patients is a beneficial operation for the control of medically refractory parkinsonian resting and postural tremor. The effect of unilateral thalamotomy on tremor is long lasting.

Background and Purpose: The authors report the results of stereotactic surgery for severe posttraumatic tremor in 7 patients., Material and Methods: All patients were severely incapacitated in their daily living activities by mainly kinetic and postural components of Holmes tremor. The 7 patients underwent 8 stereotactic operations. The stereotactic target in all patients was the ventrolateral thalamus. Patients were evaluated using the Clinical Rating Scale For Tremor (CRST) before and up to 24 months after stereotactic thalamotomy., Results: In the postoperative period there was marked amelioration in kinetic and postural components of Holmes tremor in contralateral upper and lower extremity. The mean presurgery value for contralateral upper extremity kinetic tremor (scores 5-6 CRST) dropped from 3.25 to mean postsurgery value of 0.5. There was also a marked functional improvement. It was reduced from a mean value of 71% of maximum disability according to CRST (scores 15-21, part C CRST, 0% independent, 100% total dependent) to 28.5% over 2-year follow-up., Conclusions: Ventrolateral thalamotomy alleviates effectively Holmes tremor and improves greatly performance of activities of daily living.

Deep brain stimulation (DBS) of the ventral intermediate thalamic nucleus (Vim) has been recently introduced by Benabid and his colleagues as a new surgical procedure in the treatment of tremor-dominant Parkinson's disease (PD). The advantage of DBS Vim over lesioning (thalamotomy) is its reversibility and adjustability with the same clinical effect, but without the need to make a destructive thalamic lesion. In this procedure high-frequency stimulation is employed to simulate a thalamic lesion using an implanted electrode connected to a subcutaneously placed neuropacemaker. Four patients with tremor-dominant PD were included in the study. There were 3 men and one women. Three stimulators were implanted in the left and one in the right cerebral hemisphere. The patients were evaluated using clinical scales, before and up to 24 months after surgery. Adverse effects associated with chronic Vim stimulation were mild and reversible. Chronic thalamic stimulation is effective for drug-resistance parkinsonian tremor suppression, with few adverse side-effects. The method results in a significant improvement of function.

Dopamine deficiency in the nigrostriatal system leads to a series of changes in the basal ganglia, resulting in an increased neuronal activity of the subthalamic nucleus (STN). Reduction of the STN glutaminergic excitatory effect on the main output structures of the basal ganglia (globus pallidum pars interna GPi and substantia nigra pars reticulata SNr) is accompanied by a marked alleviation of parkinsonian motor sings in the MPTP monkey model of parkinsonism. Also a high-frequency stimulation of STN in the MPTP monkey model of parkinsonism produced the same clinical effect as did lesioning. Due to these observations bilateral deep subthalamic stimulation was introduced in the treatment of PD patients with severe akinetic-rigid form of this disease. Four patients with akinetic-rigid PD form of PD were included in the study. The electrodes for deep brain stimulation were implanted in two separate surgical interventions in every case. The second implantation was performed not earlier than at least 3 months after the first procedure. Evaluations using the UPDRS were conducted before surgery in "on" and "off" conditions and at 3, 6 and 12 months after the bilateral implantation. Bilateral DBS STN seems to be the best stereotactic target in controlling motor symptoms in the "off" condition in the treatment of PD patients with severe symptoms. The technique enables a dramatic reduction in the daily dose of L-dopa.

Among all the extrapiramidal movement disorders Parkinson's disease (PD) is the one most often submitted to neurosurgical treatment. Technical advances in neurosurgery, neuroimaging and neurophysiology, as well as shortcomings of chronic Levodopa medication (i.e. on/off fluctuations, violent dyskinesia and painful dystonia) have greatly contributed to the renewed interest in the surgical treatment of PD. The attainment of a better understanding of the basal ganglia function and of PD pathophysiology has also encouraged centers to treat Parkinson's disease in recent years. This article presents the current model of PD and the rationale for using GPi, thalamus and STN as target sites in stereotactic surgery.

There is little information on the efficacy of various surgical interventions in terms of health-related quality of life in Parkinson's disease (PD) patients. Most studies evaluated only motor symptoms of PD after surgical treatment avoiding subjective patient's assessment. The goal of this study is the assessment of surgical treatment of PD on quality of life using Parkinson's Disease Questionnaire (PDQ-39). To 134 patients PDQ-39 questionnaires were send, 91 of them responded. Among 91 patients 32 underwent unilateral thalamotomy, 38 unilateral pallidotomy and 21 bilateral staged pallidotomy. The patients were assessed at baseline and 3 to 6 months after surgery. The PDQ-39 recorded significant improvement in mobility, activity of daily living and stigma in thalamotomy and pallidotomy group. The most striking improvement was noticed in bilateral pallidotomy group. After bilateral pallidotomy improvement was noticed in mobility, ADL, emotional well being, stigma and bodily discomfort. Our results indicate that quality of life in PD patients after surgical treatment is measurable according to PDQ-39 and the most benefit is noted in patients who underwent bilateral staged pallidotomy.

Many patients with Parkinson's disease (PD) suffer from severe bilateral appendicular off (bradykinesia, rigidity, tremor) and on (dyskinesia, dystonia) symptoms. After unilateral pallidotomy several of these patients still suffer from severe bradykinesia, rigidity, or dyskinesia of the ipsilateral side. In addition such symptoms as walking difficulty, freezing, trunk, neck, or facial dyskinesia are not significantly alleviated after unilateral pallidotomy. These patients seem to be good candidates for bilateral staged pallidotomy. The aim of this study is to evaluate the motor symptoms after staged bilateral pallidotomy in advanced PD patients. 34 patients were studied. The patients were assessed using UPDRS version 3, Hoehn and Yahr scale, Schwab and England scale before and up to 24 months after surgery in off and on state. In off drug state, the total motor score of the UPDRS compared to preoperative off drug state was improved by 61% at 24 months of follow-up. All cardinal features of PD improved significantly in postoperative drug off state compared to drug off state before bilateral pallidotomy--parkinsonian tremor (items 20-21) by 62%, rigidity (item 22 UPDRS) by 81% and bradykinesia (items 23-26) by 67%. Also gait including falling, freezing, walking (items 13-14-15 UPDRS) and gait and postural stability (items 29-30 UPDRS) showed good improvement by 69% with bilateral pallidotomy in off drug phases. There was minimal improvement in motor score of UPDRS in on state. Duration of dyskinesia and severity of dyskinesia (items 32-33 UPDRS) showed dramatic improvement after bilateral pallidotomy. Bilateral pallidotomy affords impressive elimination of all appendicular and truncal dyskinesias, dystonias, and generally improved all symptoms in off state.

The presence of myomas in the uterus is a relevant factor in infertility cases. Myomas may reduce contractility of the uterus, hinder migration of sperm and vascular changes within myomas themselves interfere with embryo implantation. The paper presents the case of a patient with over 10-year-history of infertility treatment diagnosed with numerous myomas of the uterus. The medical records revealed that the patient had undergone laparoscopy and laparotomy due to the left ovarian cyst and had been subjected to hysteroscopic removal of the uterine partition twice. The patient took part in the IVF programme twice--without success. At our Department the patient underwent laparoscopic myomectomy during which 5 myomas were removed: 4 subserous ones, 1.5-2 cm in diameter and an intramural one, 6 cm in diameter. The sites of the biggest myoma were laparoscopically sewn putting in 3 single sutures. In her next cycle the patient spontaneously conceited. The pregnancy was without serious complications and at 38 weeks was terminated by Caesarian section. The infant was delivered in good general condition (10 Apgar points) and weighted 3,360 g. On Caesarian section no uterine dehiscence following laparoscopic myomectomy was observed.

Unlabelled: 24 patients with clomiphene citrate-resistant PCOS were enrolled in the study. We used low-dose step up protocol of recombinant FSH administration. Ovulation induction by rFSH injection was commenced on 3 day of cycle, at a dose of 50 IU for 7 days initially. The dose was continued at 50 IU, and ultrasonographic scans were performed daily until a dominant follicle had developed to a size of at least 18-20 mm, at which point 5,000 IU of hCG was administrated. If no response was noted after 7 days, the dose was increased by 50 IU for a further 7 days. Insulin and glucose serum levels were determined 7 times: in days 3, 5, 8 of a cycle and later when diameter of ovarian follicle was 10, 12, 16 mm and in the day of hCG injection. Estradiol serum level was determined in 8 day of cycle and when diameter of ovarian follicle was 10, 12, 16 mm and in the day of hCG injection. BMI and WHR was determined in the day of admission to hospital., Results: The correlation between mean insulin level in the examined cycle and BMI and as well as the correlation between mean insulin level and WHR were determined. Mean level of serum glucose increased as the level of estradiol raised. No influence of growth level on insulin level was detected.

The series of 14 hysteroscopic surgery procedures in case of septum uteri were analyzed. All women enrolled into the study were infertile. The malformations were diagnosed by hysterosalpingography and intravaginal ultrasound. The laparoscopic examination of intrauterine serosal surface and operative hysteroscopy were performed in the same time. The 8 mm diameter hysteroscopy with flexible needle was used. The uterine cavity solution was distended by sorbitol and mannitol. The patients left the hospital on the second postoperative day. There was one complication in this study: intravasation of distended fluid. After one month from surgery the pelvis was controlled by HSG. In 12 cases the uterine cavity was restored to a normal shape, in 2 cases the residual uterine septum of less than one centimeter was determined. We concluded that correcting the septum uteri by the small diameter hysteroscope (8 mm) with flexible needle is an effective and safety method for the uterine septum treatment.