Gallay Marc N, Moser David, Rossi Franziska, Magara Anouk E, Strasser Maja, Bühler Robert, Kowalski Milek, Pourtehrani Payam, Dragalina Christian, Federau Christian, Jeanmonod Daniel
SoniModul, Center for Ultrasound Functional Neurosurgery, Solothurn, Switzerland.
Praxisgemeinschaft für Neurologie, Bern, Switzerland.
Front Surg. 2020 Jan 14;6:76. doi: 10.3389/fsurg.2019.00076. eCollection 2019.
There is a long history, beginning in the 1940s, of ablative neurosurgery on the pallidal efferent fibers to treat patients suffering from Parkinson's disease (PD). Since the early 1990s, we undertook a re-actualization of the approach to the subthalamic region, and proposed, on a histological basis, to target specifically the pallidothalamic tract at the level of Forel's field H1. This intervention, the pallidothalamic tractotomy (PTT), has been performed since 2011 using the MR-guided focused ultrasound (MRgFUS) technique. A reappraisal of the histology of the pallidothalamic tract was combined recently with an optimization of our lesioning strategy using thermal dose control. This study was aimed at demonstrating the efficacy and risk profile of MRgFUS PTT against chronic therapy-resistant PD. This consecutive case series reflects our current treatment routine and was collected between 2017 and 2018. Fifty-two interventions in 47 patients were included. Fifteen patients received bilateral PTT. The median follow-up was 12 months. The Unified Parkinson's Disease Rating Scale (UPDRS) off-medication postoperative score was compared to the baseline on-medication score and revealed percentage reductions of the mean of 84% for tremor, 70% for rigidity, and 73% for distal hypobradykinesia, all values given for the treated side. Axial items (for voice, trunk and gait) were not significantly improved. PTT achieved 100% suppression of on-medication dyskinesias as well as reduction in pain ( < 0.001), dystonia ( < 0.001) and REM sleep disorders ( < 0.01). Reduction of the mean L-Dopa intake was 55%. Patients reported an 88% mean tremor relief and 82% mean global symptom relief on the operated side and 69% mean global symptom improvement for the whole body. There was no significant change of cognitive functions. The small group of bilateral PTTs at 1 year follow-up shows similar results as compared to unilateral PTTs but does not allow to draw firm conclusions at this point. MRgFUS PTT was shown to be a safe and effective intervention for PD patients, addressing all symptoms, with varying effectiveness. We discuss the need to integrate the preoperative state of the thalamocortical network as well as the psycho-emotional dimension.
从20世纪40年代开始，就有通过毁损苍白球传出纤维来治疗帕金森病（PD）患者的悠久历史。自20世纪90年代初以来，我们重新采用了针对丘脑底区域的方法，并在组织学基础上提出，将Forel氏H1区水平的苍白球丘脑束作为特定靶点。自2011年起，我们使用磁共振引导聚焦超声（MRgFUS）技术进行了这种干预，即苍白球丘脑束切断术（PTT）。最近，对苍白球丘脑束的组织学进行了重新评估，并结合热剂量控制对我们的毁损策略进行了优化。本研究旨在证明MRgFUS PTT治疗慢性药物难治性PD的疗效和风险状况。这个连续病例系列反映了我们目前的治疗常规，收集于2017年至2018年期间。纳入了47例患者的52次干预。15例患者接受了双侧PTT。中位随访时间为12个月。将术后未服药时的统一帕金森病评定量表（UPDRS）评分与基线服药时的评分进行比较，结果显示，治疗侧震颤平均减少84%，强直平均减少70%，远端运动迟缓平均减少73%。轴向项目（声音、躯干和步态）没有明显改善。PTT实现了对服药时异动症的100%抑制，同时疼痛（<0.001）、肌张力障碍（<0.001）和快速眼动睡眠障碍（<0.01）也有所减轻。左旋多巴的平均摄入量减少了55%。患者报告手术侧震颤平均缓解88%，整体症状平均缓解82%，全身整体症状平均改善69%。认知功能没有显著变化。在1年随访时，一小部分双侧PTT的结果与单侧PTT相似，但目前还无法得出确凿结论。MRgFUS PTT被证明是一种对PD患者安全有效的干预措施，能解决所有症状，但其有效性各不相同。我们讨论了整合丘脑皮质网络术前状态以及心理情感维度的必要性。
