Moro E, Scerrati M, Romito L M, Roselli R, Tonali P, Albanese A
Istituto di Neurologia Università Cattolica del Sacro Cuore, Rome, Italy.
Neurology. 1999 Jul 13;53(1):85-90. doi: 10.1212/wnl.53.1.85.
To reduce antiparkinsonian medication in parkinsonian patients with bilateral high frequency subthalamic nucleus (STN) stimulation.
Parkinsonian syndromes are characterized by hyperactivity of the STN. Preliminary data indicate that functional inactivation of the STN may reduce the requirement for dopaminergic therapy in PD.
Bilateral quadripolar leads were implanted stereotactically in the STN of seven patients with advanced PD (mean age, 57.4 years; mean disease duration, 15.4 years). High-frequency stimulation was applied for 24 hours a day. Following implantation, antiparkinsonian medication was reduced to the minimum possible and stimulation was gradually increased. The patients were evaluated in the practically defined "off" and "on" conditions using the Unified Parkinson's Disease Rating Scale (UPDRS) and the Schwab & England scale. The average follow-up was 16.3+/-7.6 months. A battery of neuropsychological tests was applied before and 9 months after the implant.
Parkinsonian features improved in all patients--the greatest change seen in rigidity, then tremor, followed by bradykinesia. Compared with the presurgical condition, off-drug UPDRS motor scores improved by 41.9% on the last visit (p = 0.0002), UPDRS activities of daily living (ADL) scores improved by 52.2% (p = 0.0002), and the Schwab & England scale score improved by 213% (p = 0.0002). The levodopa-equivalent daily dose was reduced by 65%. Night sleep improved in all patients due to increased mobility at night, and in five patients insomnia was resolved. All patients gained weight after surgery and their appetite increased. The mean weight gain at the last follow-up was 13% compared with before surgery. During the last visit, the stimulation amplitude was 2.9+/-0.5 V and the total energy delivered per patient averaged 2.7+/-1.4 W x10(-6). The results of patient self-assessment scales indicated a marked improvement in five patients and a moderate improvement in the other two. The neuropsychological data showed no changes. Side effects were mild and tolerable. In all cases, a tradeoff between the optimal voltage and the severity of side effects made it possible to control parkinsonian signs effectively. The most marked side effects directly related to STN stimulation consisted of ballistic or choreic dyskinesias of the neck and the limbs elicited by contralateral STN stimulation above a given threshold voltage, which varied depending on the individual.
Parkinsonian signs can be controlled by bilateral high-frequency STN stimulation. The procedure is well tolerated. On-state dyskinesias were greatly reduced, probably due to the reduction of total antiparkinsonian medication. Bilateral high-frequency STN stimulation compensated for drug reduction and elicited dyskinesias, which differ from those observed following dopaminergic medication. ADL improved significantly, suggesting that some motor tasks performed during everyday chores, and that are not taken into account in the UPDRS motor score, also improved.
减少双侧高频丘脑底核（STN）刺激的帕金森病患者的抗帕金森药物用量。
帕金森综合征的特征是STN功能亢进。初步数据表明，STN的功能失活可能会降低帕金森病患者对多巴胺能治疗的需求。
对7例晚期帕金森病患者（平均年龄57.4岁；平均病程15.4年）进行立体定向双侧四极电极植入STN。每天进行24小时高频刺激。植入后，将抗帕金森药物减至尽可能低的水平，并逐渐增加刺激强度。使用统一帕金森病评定量表（UPDRS）和施瓦布与英格兰量表在实际定义的“关”和“开”状态下对患者进行评估。平均随访时间为16.3±7.6个月。在植入前和植入后9个月进行一系列神经心理学测试。
所有患者的帕金森病症状均有改善——僵硬改善最明显，其次是震颤，然后是运动迟缓。与术前相比，末次随访时停药状态下UPDRS运动评分提高了41.9%（p = 0.0002），UPDRS日常生活活动（ADL）评分提高了52.2%（p = 0.0002），施瓦布与英格兰量表评分提高了213%（p = 0.0002）。左旋多巴等效日剂量减少了65%。所有患者夜间睡眠因夜间活动增加而改善，5例患者失眠得到解决。所有患者术后体重增加，食欲增强。末次随访时平均体重较术前增加了13%。末次随访时，刺激幅度为2.9±0.5V，每位患者的总能量平均为2.7±1.4W×10⁻⁶。患者自我评估量表结果显示，5例患者有显著改善，另外2例有中度改善。神经心理学数据无变化。副作用轻微且可耐受。在所有病例中，通过在最佳电压和副作用严重程度之间进行权衡，可以有效控制帕金森病体征。与STN刺激直接相关的最明显副作用包括在给定阈值电压以上由对侧STN刺激引起的颈部和肢体的弹道样或舞蹈样运动障碍，其因个体而异。
双侧高频STN刺激可控制帕金森病体征。该手术耐受性良好。“开”状态下的运动障碍大大减少，可能是由于抗帕金森药物总量的减少。双侧高频STN刺激弥补了药物减量并引发了运动障碍，这些运动障碍与多巴胺能药物治疗后观察到的不同。ADL有显著改善，表明日常琐事中执行的一些运动任务（这些任务在UPDRS运动评分中未被考虑）也得到了改善。
