Unilateral ablative lesions of the subthalamic nucleus in moderate-to-advanced Parkinson's disease/Orta-ileri evre Parkinson hastaliginda subtalamik nukleusun unilateral ablatif lezyonlari

• Published in: Noro-Psikiyatri Arsivi p. 114
• Main Authors: Hanagasi, Hasmet A, Barlas, Orhan
• Format: Journal Article
• Language: English
• Published: AVES 01-06-2011
• Subjects: Ablation (Surgery); Brain stimulation; Diagnostic imaging; Health aspects; Parkinson's disease; Risk factors; Turkey
• ISSN: 1300-0667
• DOI: 10.4274/npa.y6010

Objective: Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been reported to be effective in alleviating all parkinsonian motor symptoms and motor complications in moderate-to-advanced Parkinson's disease (PD). We have studied the effects of unilateral STN lesions on moderate-to-advanced PD. Methods: Eleven patients (eight male, three female) with moderate-to-advanced PD were studied. Before surgery, all patients suffered from one or more motor complications (wearing-off and on-off phenomena, dyskinesias). All patients had Hoehn and Yahr stage 3 or 4 in off-drug condition and were evaluated with the Unified Parkinson's Disease Rating Scale (UPDRS). The follow-up time ranged between 12 and 20 months (mean: 14 ± 2.94 months). STN was identified through CT and MRI scans. STN lesions were performed unilaterally using thermocoagulation. Results: Subthalamotomy induced a marked motor improvement contralaterally, ipsilaterally and axially. Mean "on" time total UPDRS and motor scores decreased from 61.7 ± 19.2 to 31.6 ± 15.7 (p=0.001) and from 26.1 ± 11.1 to 15 ± 11.1 (p=0.02), respectively. Total 'on' time period increased by 50% in eight patients but did not change in the remaining three. Nine patients had disabling dyskinesia and six of these patients improved significantly (mean 40%, UPDRS part IV). Compared to pre-surgical doses, the levodopa-equivalent dose was reduced in eight patients, increased in one and left unchanged in the remaining two patients during the postoperative phase. Notably, only one out of eleven patients developed hemiballismus. Hemiballistic movements emerged immediately after the ablation and were ameliorated under treatment within two weeks after surgery. Conclusion: We conclude that subthalamotomy is a safe and effective treatment for moderate-to-advanced PD. In cases in which DBS is not feasible, subthalamotomy may be considered as an alternative procedure. (Archives of Neuropsychiatry 2011; 48:114-8) Key words: Parkinson disease, motor complications, subthalamotomy, deep brain stimulation Amac: Orta-ileri evre Parkinson hastaligi (PH) tedavisinde, subtalamik nukleusa (STN) yonelik derin beyin stimulasyonu (DBS) ameliyatlarinin tum parkinsonyan motor semptomlara ve motor komplikasyonlara karsi yarar sagladigi bilinmektedir. Bu calismada unilateral STN lezyonlarinin orta-ileri PH'daki etkileri arastirilmistir. Yontemler: Orta-ileri evre PH olan 11 hasta (8 erkek, 3 kadin) calismaya alindi. Cerrahi oncesinde hastalarin tamaminda motor komplikasyonlardan biri veya birkaci (doz sonu kotulesmesi, "acik-kapali" donemler, diskinezi) vardi. Hastalarin tamami "kapali" donemlerinde Hoehn-Yahr olcegine gore 3 veya 4 evre-sindeydiler ve Birlesik Parkinson Hastaligi Degerlendirme Olcegi (BPHDO)'ne gore degerlendirildiler. Hastalarin izlenme sureleri 12 ile 20 ay (ortalama: 14 [+ or - ] 2.94) arasinda degisiyordu. Subtalamik nukleusun saptanmasinda bilgisayarli tomografi ve manyetik rezonans incelemeleri kullanildi. Subtalamik nukle-us lezyonlari tek tarafli olarak termokoagulasyon kullanilarak yapildi. Bulgular: Subtalamotomi kontralateral, ipsilateral ve aksiyel motor bulgularda belirgin duzelme sagladi. Ortalama "acik" donemdeki toplam BPHDO skoru 61.7 ± 19.2'den 31.6 ± 15.7'ye (p=0.001) ve BPHDO motor bolum skoru 26.1 ± 11.1'den 15 ± 11.1'e (p=0.02) dustu. Toplam "acik" zamani 8 hastada %50 oraninda artti, ancak diger 3 hastada belirgin degisiklik olmadi. Maluliyet verici diskinezileri olan 9 hastanin 6'sinda belirgin iyilesme hali goruldu (BPHDO-bolum IV ortalama %40). Cerrahi oncesi ve sonrasi levodopa-esdeger dozlari karsilastirildiginda 8 hastaninki azaldi, 1 hastanin artti ve geri kalan 2'sinde degismedi. Onbir hastanin sadece 1'inde hemiballismus gelisti. Hemiballistik hareketler ablas-yondan hemen sonra ortaya cikti ve tedavi ile iki hafta icinde tamamen duzeldi. Sonuc: Sonuc olarak subtalamotomi orta-ileri PH'da guvenilir ve etkili bir yontemdir. Derin beyin stimulasyonunun mumkun olmadigi vakalarda subtalamato-mi alternatif bir yontem olarak dusunulebilir. (Noropsikiyatri Arsivi 2011; 48:114-8) Anahtar kelimeler: Parkinson hastaligi, motor komplikasyonlar, subtalamatomi, derin beyin stimulasyonu