苍白球与丘脑底核脑深部电刺激治疗帕金森病。

Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease.

机构信息

Iowa City Veterans Affairs Medical Center, Iowa City, USA.

出版信息

N Engl J Med. 2010 Jun 3;362(22):2077-91. doi: 10.1056/NEJMoa0907083.

DOI:10.1056/NEJMoa0907083

PMID:20519680

Abstract

BACKGROUND

Deep-brain stimulation is the surgical procedure of choice for patients with advanced Parkinson's disease. The globus pallidus interna and the subthalamic nucleus are accepted targets for this procedure. We compared 24-month outcomes for patients who had undergone bilateral stimulation of the globus pallidus interna (pallidal stimulation) or subthalamic nucleus (subthalamic stimulation).

METHODS

At seven Veterans Affairs and six university hospitals, we randomly assigned 299 patients with idiopathic Parkinson's disease to undergo either pallidal stimulation (152 patients) or subthalamic stimulation (147 patients). The primary outcome was the change in motor function, as blindly assessed on the Unified Parkinson's Disease Rating Scale, part III (UPDRS-III), while patients were receiving stimulation but not receiving antiparkinsonian medication. Secondary outcomes included self-reported function, quality of life, neurocognitive function, and adverse events.

RESULTS

Mean changes in the primary outcome did not differ significantly between the two study groups (P=0.50). There was also no significant difference in self-reported function. Patients undergoing subthalamic stimulation required a lower dose of dopaminergic agents than did those undergoing pallidal stimulation (P=0.02). One component of processing speed (visuomotor) declined more after subthalamic stimulation than after pallidal stimulation (P=0.03). The level of depression worsened after subthalamic stimulation and improved after pallidal stimulation (P=0.02). Serious adverse events occurred in 51% of patients undergoing pallidal stimulation and in 56% of those undergoing subthalamic stimulation, with no significant between-group differences at 24 months.

CONCLUSIONS

Patients with Parkinson's disease had similar improvement in motor function after either pallidal or subthalamic stimulation. Nonmotor factors may reasonably be included in the selection of surgical target for deep-brain stimulation. (ClinicalTrials.gov numbers, NCT00056563 and NCT01076452.)

摘要

背景

对于晚期帕金森病患者，脑深部刺激是首选的手术程序。苍白球内侧和丘脑底核是该手术的公认靶点。我们比较了接受苍白球内侧（苍白球刺激）或丘脑底核（丘脑底核刺激）双侧刺激的患者的 24 个月结果。

方法

在七个退伍军人事务部和六个大学医院，我们随机分配了 299 名特发性帕金森病患者，分别接受苍白球刺激（152 例）或丘脑底核刺激（147 例）。主要结局是在接受刺激但未接受抗帕金森药物治疗时，运动功能的变化，由统一帕金森病评定量表第三部分（UPDRS-III）进行盲法评估。次要结局包括自我报告的功能、生活质量、神经认知功能和不良事件。

结果

两组患者的主要结局变化无显著差异（P=0.50）。自我报告的功能也没有显著差异。接受丘脑底核刺激的患者所需的多巴胺能药物剂量低于接受苍白球刺激的患者（P=0.02）。接受丘脑底核刺激后处理速度（视觉运动）的一个组成部分下降比接受苍白球刺激后更明显（P=0.03）。接受丘脑底核刺激后抑郁程度恶化，接受苍白球刺激后改善（P=0.02）。接受苍白球刺激的患者中有 51%发生严重不良事件，接受丘脑底核刺激的患者中有 56%发生严重不良事件，24 个月时两组间无显著差异。