Romito L M, Scerrati M, Contarino M F, Iacoangeli M, Bentivoglio A R, Albanese A
Carlo Besta National Neurologic Institute, Milan, Italy.
J Neurosurg Sci. 2003 Sep;47(3):119-28.
High frequency stimulation of the subthalamic nucleus (STN) is gaining recognition as a new symptomatic treatment for Parkinson's disease (PD). The first available long-term observations show the stability of the efficacy of this procedure in time.
Quadripolar leads were implanted bilaterally under stereotactic conditions in the STN of patients with advanced PD. High frequency stimulation was applied for 24 hours a day. Following implant, antiparkinsonian medication was reduced as much as possible and stimulation was gradually increased. The patients were evaluated in the practically defined "off" condition and in the "on" condition using the unified PD rating scale (UPDRS) and the Schwab & England scale. Neuropsychological testing was performed before and after the implant. Thirty-three patients were followed up for at least 3 months and 13 among them until 36 months.
The patients had a mean age of 56.8+/-7.1 years and a mean disease duration of 13.8+/-5.5 years; they were followed-up for an average of 25.7+/-13.5 months. At the time of the last available visit, the stimulation amplitude was 2.47+/-0.40 V (the total energy delivered averaged 1.57+/-0.8 microW). The levodopa-equivalent daily dose was reduced by 56.2% (p<0.001). Parkinsonian features were improved in all patients, the greatest changes were seen for tremor, gait, bradykinesia and postural stability, then rigidity and limb akinesia. Compared with the pre-implant conditions, the UPDRS motor score in the "off" condition was improved by 51.6% at the time of the last visit (p<0.001), the UPDRS activities of daily living score was improved by 68.5% (p<0.001), the Schwab & England scale was improved by 196.8% (p<0.001). The neuropsychological data did not show significant changes. Night sleep improved in all patients, due to increased mobility at night. In almost all patients insomnia was resolved. All patients gained weight after surgery with an increase of 11.1% (p<0.001) compared to their pre-implant weight. The most common permanent side effects consisted in hypophonia and dysarthria, transient side effects were increased sexuality and mania, the most common side effects related to stimulation were ballic or choreic dyskinesias. The most common adverse event related to the surgical procedure was transient psychosis; unexplained switching-off of the stimulator was the most common device-related effect.
This study extends our recently published 3-years FU series. It confirms again that symptomatic efficacy of STN stimulation is retained during the 2(nd) and 3(rd) years following the implant, without any obvious decay of efficacy or need for increase of energy delivered. Improvement of dyskinesias also persists and the procedure is well tolerated. Side effects and adverse events are sometimes severe, but can be managed in most cases. The improvement of daily living activities outweighs by far the motor benefit, indicating that the use of this procedure significantly improves the patients' lifestyle.
丘脑底核（STN）高频刺激作为帕金森病（PD）的一种新的对症治疗方法正逐渐得到认可。首批可得的长期观察结果显示了该治疗方法疗效的时间稳定性。
在立体定向条件下，将四极电极双侧植入晚期PD患者的STN。每天进行24小时高频刺激。植入后，尽可能减少抗帕金森病药物用量，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”状态和“开”状态下对患者进行评估。在植入前后进行神经心理学测试。33例患者至少随访3个月，其中13例随访至36个月。
患者平均年龄为56.8±7.1岁，平均病程为13.8±5.5年；平均随访25.7±13.5个月。在最后一次可获得访视时，刺激幅度为2.47±0.40V（平均传递的总能量为1.57±0.8微瓦）。左旋多巴等效日剂量减少了56.2%（p<0.001）。所有患者的帕金森病特征均有改善，震颤、步态、运动迟缓及姿势稳定性改善最为明显，其次是强直和肢体运动不能。与植入前相比，最后一次访视时“关”状态下的UPDRS运动评分提高了51.6%（p<0.001），UPDRS日常生活活动评分提高了68.5%（p<0.001），施瓦布与英格兰量表提高了196.8%（p<0.001）。神经心理学数据未显示出显著变化。所有患者夜间睡眠均有改善，原因是夜间活动增加。几乎所有患者的失眠症状均得到缓解。所有患者术后体重增加，与植入前体重相比增加了11.1%（p<0.001）。最常见的永久性副作用为声音低沉和构音障碍，短暂性副作用为性欲增强和躁狂，与刺激相关的最常见副作用为投掷样或舞蹈样运动障碍。与手术相关的最常见不良事件为短暂性精神病；刺激器不明原因关闭是最常见的与设备相关的效应。
本研究扩展了我们最近发表的3年随访系列。再次证实，STN刺激的对症疗效在植入后的第2年和第3年得以保留，疗效无明显衰减，也无需增加传递的能量。运动障碍的改善也持续存在，且该治疗方法耐受性良好。副作用和不良事件有时较为严重，但大多数情况下可进行处理。日常生活活动的改善远远超过运动方面的益处，表明该治疗方法的使用显著改善了患者的生活方式。
