✓ Using a new perforator, the authors have developed a new dual-floor burr-hole method for use in deep brain stimulation therapy. The modification is called “dual-floor” because the usual 15-mm-diameter burr hole, which is located centrally and reaches the dura mater, is surrounded by a 4-mm-wide rim that is also planed downward by the new perforator to a depth of 4 mm. This dual-floor burr hole is adjusted to fit the burr-hole ring and cap that are are supplied by the electrode manufacturer. Such a method eliminates bulging of the scalp just over the burr-hole ring and cap. In addition, it is helpful for securing a tight fixation between the burr-hole ring and the skull.
Takamitsu Yamamoto, Yoichi Katayama, Kazutaka Kobayashi, Hideki Oshima, and Chikashi Fukaya
Yoichi Katayama, Masahiko Kasai, Hideki Oshima, Chikashi Fukaya, Takamitsu Yamamoto, Katsuhiko Ogawa, and Tomohiko Mizutani
Object. A blinded evaluation of the effects of subthalamic nucleus (STN) stimulation was performed in levodopaintolerant patients with Parkinson disease (PD). These patients (Group I, seven patients) were moderately or severely disabled (Hoehn and Yahr Stages III–V during the off period), but were receiving only a small dose of medication (levodopa-equivalent dose [LED] 0–400 mg/day) because they suffered unbearable side effects. The results were analyzed in comparison with those obtained in patients with advanced PD (Group II, seven patients) who were severely disabled (Hoehn and Yahr Stages IV and V during the off period), but were treated with a large dose of medication (500–990 mg/day).
Methods. The patients were evaluated twice at 6 to 8 months after surgery. To determine the actual benefits afforded by STN stimulation to their overall daily activities, the patients were maintained on their medication regimen with optimal doses and schedules. Stimulation was turned off overnight for at least 12 hours. It was turned on in the morning (or remained turned off), and each patient's best and worst scores on the Unified Parkinson's Disease Rating Scale during waking daytime activity were recorded as on- and off-period scores, respectively. The order of assessment with respect to whether stimulation was occurring was determined randomly.
The STN stimulation markedly improved daily activity and total motor scores in Group I patients. The percentage time of immobility (Hoehn and Yahr Stages IV and V) became 0% in patients who were intermittently immobile while not receiving stimulation. Improvements were demonstrated in tremor, rigidity, akinesia, and gait subscores. The STN stimulation produced less marked but still noticeable improvements in the daily activity and total motor scores in Group II patients. The percentage time of immobility as well as the LED was reduced in patients who displayed intermittent immobility with pronounced motor fluctuations while not receiving stimulation. Improvements were demonstrated in tremor, rigidity, and dyskinesia subscores in these patients. In contrast, STN stimulation did not improve the overall daily activities at all in patients who had become unresponsive to a tolerable dose of levodopa and were continuously immobile, even though these patients' tremor and rigidity subscores were still improved by stimulation.
Conclusions. Consistent with earlier findings, the great benefit of STN stimulation in levodopa-intolerant patients is that STN stimulation can reduce the level of required levodopa medication. This suggests that STN stimulation could be a therapeutic option for patients with less-advanced PD by allowing levodopa medication to be maintained at as low a dose as possible, and to prevent adverse reactions to the continued use of large-dose levodopa.
Takamitsu Yamamoto, Yoichi Katayama, Toshikazu Kano, Kazutaka Kobayashi, Hideki Oshima, and Chikashi Fukaya
Object. The tremor-suppression effect resulting from long-term stimulation of the thalamic nucleus ventralis intermedius (Vim) and the nucleus ventralis oralis posterior (Vop) was examined in the treatment of parkinsonian, essential, and poststroke tremor.
Methods. After identifying the accurate anterior border of the nucleus ventrocaudalis (Vc), deep brain stimulation (DBS) electrodes with four contacts were inserted into the Vim—Vop region at an angle of between 40 and 50° from the horizontal plane of the anterior commissure—posterior commissure line. Two distal contacts were placed on the Vim side and two proximal contacts on the Vop side. The best sites of stimulation and parameters of bipolar stimulation were selected in each case and follow-up examinations were conducted for at least 2 years.
In all 15 cases of parkinsonian tremor (18 sides) and in 14 of 15 cases of essential tremor (24 of 25 sides), cathodal stimulation of the Vim side with anodal stimulation of the Vop side was determined to be the best choice to suppress the tremor. In poststroke tremor, however, six of 12 cases (six of 12 sides) were selected for cathodal stimulation of the Vop side with anodal stimulation of the Vim side. The average stimulation intensity 1 month after initiation of DBS was 1.61 V in cases of parkinsonian tremor, 1.99 V in cases of essential tremor, and 2.39 V in cases of poststroke tremor. A comparison of stimulation intensities required at 1 and 24 months after initiation of DBS revealed that the lowest effective stimulation intensity increased 24.2% in cases of parkinsonian tremor, 21% in cases of poststroke tremor, and 46.9% in cases of essential tremor. Suppression of tremor was achieved in all cases (42 cases, 55 sides) during a period of 2 years. Nevertheless, two cases of poststroke tremor required dual-lead stimulation at the unilateral Vim—Vop region from the start of DBS, and two cases of essential tremor and one case of poststroke tremor required a stimulation intensity that was high enough to evoke unpleasant paresthesia and slight motor contraction during the follow-up period.
Conclusions. Effective stimulation sites and stimulation intensities differ in different kinds of tremor; Vim and Vop stimulation is necessary in many cases. Interactions of the Vim and Vop under the control of interconnected areas of the motor circuitry may play an important role in both the development and DBS-induced suppression of tremor.
Takamitsu Yamamoto, Yoichi Katayama, Chikashi Fukaya, Hideki Oshima, Masahiko Kasai, and Kazutaka Kobayashi
✓ Reversibility and adaptability are preferred features of long-term therapeutic deep brain stimulation (DBS). In such therapy, a permanent stimulating electrode with four contact points is placed at the stimulation site and, generally speaking, bipolar stimulation is induced by various pairs of adjacent contact points on one electrode. The stimulation sites are thus all located along the trajectory of the implanted electrode. In a patient with unilateral severe essential tremor, the authors implanted two electrodes side by side and parallel to each other in the unilateral thalamic ventralis intermedius nucleus. Using these electrodes, the authors were able to deliver current flow not only along the electrode trajectory, but also between the two electrodes in a direction parallel to the anterior commissure—posterior commissure line. Although individual stimulations, delivered by each of the two electrodes using all parameters and all stimulation points, were unable to stop the patient's tremor completely without adverse effects, the new stimulation method, in which electrical currents passed between the two electrodes, effected complete abolition of the tremor without adverse effects. With the aid of this method, one can use two electrodes, implanted in parallel and side by side, to achieve maximum efficacy and to reduce adverse effects in some instances of DBS therapy.
Hideki Oshima, Yoichi Katayama, Chikashi Fukaya, Toshikazu Kano, Kazutaka Kobayashi, Takamitsu Yamamoto, and Yutaka Suzuki
✓Beginning-of-dose motor deterioration (BDMD) is a complication of levodopa medications in Parkinson disease (PD) that is presumably caused by inhibitory effects of levodopa. Only limited experience of BDMD has been described in the literature. The authors report the case of a patient with PD who demonstrated a marked BDMD while being treated with standard levodopa medications. This 55-year-old woman had a 12-year history of PD and a 10-year history of levodopa treatment. Marked exacerbation of symptoms occurred 15 to 20 minutes after every dose of levodopa at 100 mg and lasted approximately 15 minutes. The PD symptoms, particularly tremor and rigidity, were exacerbated more markedly during this period than during the wearing-off deterioration. The BDMD could be controlled very well by subthalamic nucleus (STN) stimulation without any change in the regimen of levodopa medications. These observations suggest that the BDMD was inhibited by STN stimulation through a direct effect.
Chikashi Fukaya, Yoichi Katayama, Toshikazu Kano, Takafumi Nagaoka, Kazutaka Kobayashi, Hideki Oshima, and Takamitsu Yamamoto
Writer's cramp is a type of idiopathic focal hand dystonia characterized by muscle cramps that accompany execution of the writing task specifically. In this report, the authors describe the clinical outcome after thalamic deep brain stimulation (DBS) therapy in patients with writer's cramp and present an illustrative case with which they compare the effects of pallidal and thalamic stimulation. In addition to these results for the clinical effectiveness, they also examine the best point and pattern for therapeutic stimulation of the motor thalamus, including the nucleus ventrooralis (VO) and the ventralis intermedius nucleus (VIM), for writer's cramp.
The authors applied thalamic DBS in five patients with writer's cramp. The inclusion criteria for the DBS trial in this disorder were a diagnosis of idiopathic writer's cramp and the absence of a positive response to medication. The exclusion criteria included significant cognitive dysfunction, active psychiatric symptoms, and evidence of other central nervous system diseases or other medical disorders. In one of the cases, DBS leads were implanted into both the globus pallidus internus and the VO/VIM, and test stimulation was performed for 1 week. The authors thus had an opportunity to compare the effects of pallidal and thalamic stimulation in this patient.
Immediately after the initiation of thalamic stimulation, the neurological deficits associated with writer's cramp were improved in all five cases. Postoperatively all preoperative scale scores indicating the seriousness of the writer's cramp were significantly lower (p < 0.001). In the patient in whom two DBS leads were implanted, the clinical effect of thalamic stimulation was better than that of pallidal stimulation. During the thalamic stimulation, the maximum effect was obtained when stimulation was applied to both the VO and the VIM widely, compared with being applied only within the VO.
The authors successfully treated patients with writer's cramp by thalamic DBS. Insofar as they are aware, this is the first series in which writer's cramp has been treated with DBS. Thalamic stimulation appears to be a safe and valuable therapeutic option for writer's cramp.
Hideki Oshima, Yoichi Katayama, Takashi Morishita, Koichiro Sumi, Toshiharu Otaka, Kazutaka Kobayashi, Yutaka Suzuki, Chikashi Fukaya, and Takamitsu Yamamoto
The objective of this study was to evaluate the efficacy of chronic subthalamic nucleus (STN) stimulation for alleviating pain related to Parkinson disease (PD).
Among 163 consecutive patients undergoing STN stimulation, 69 were identified as experiencing pain preoperatively that was related to their PD. All 69 patients suffering from pain were followed up prospectively for 12 months after surgery. All patients described the severity of their pain according to a visual analog scale (VAS) preoperatively and at 2 weeks, 6 months, and 12 months postoperatively. Pain unrelated to PD was not studied.
Several types of pain related to PD, the categories of which were based on a modification of 2 previous classifications (Ford and Honey), can occur in such patients: 1) musculoskeletal pain, 2) dystonic pain, 3) somatic pain exacerbated by PD, 4) radicular/peripheral neuropathic pain, and 5) central pain. The overall mean VAS score was significantly decreased postoperatively by 75% and 69% at 2 weeks and 6 months, respectively (p < 0.001). The mean VAS score at 12 months was also decreased by 80%, but 6 instances of pain (3 reports of somatic back pain and 3 reports of radicular/peripheral neuropathic pain) required additional spinal surgery to alleviate the pain severity. The results were analyzed using the Wilcoxon signed-rank test and demonstrated a significant reduction in VAS scores at all follow-up assessments (p < 0.001). Musculoskeletal pain and dystonic pain were well alleviated by STN stimulation. In contrast, somatic pain exacerbated by PD and peripheral neuropathic pain originating from lumbar spinal diseases, such as spondylosis deformans and/or canal stenosis, often deteriorated postoperatively despite attenuation of the patients' motor disability. Patients with central pain were poor responders.
This study found that STN stimulation produced significant improvement of overall pain related to PD in patients with advanced PD, and the efficacy continued for at least 1 year. The present results indicate that musculoskeletal pain and dystonic pain responded well to STN stimulation, but patients with back pain (somatic pain) and radicular/peripheral neuropathic pain originating from spinal disease have a potential risk for postoperative deterioration of their pain.
Kazutaka Kobayashi, Yoichi Katayama, Hideki Oshima, Mitsuru Watanabe, Koichiro Sumi, Toshiki Obuchi, Chikashi Fukaya, and Takamitsu Yamamoto
Holmes' tremor (HT) is generally considered to be a symptomatic tremor associated with lesions of the cerebellum, midbrain, or thalamus. Deep brain stimulation (DBS) therapy for essential tremor and parkinsonian tremor has proved quite successful. In contrast, surgical treatment outcomes for HT have often been disappointing. The use of 2 ipsilateral DBS electrodes implanted in parallel within the thalamus for severe essential tremor has been reported. Since dual-lead stimulation within a single target can cover a wider area than single-lead stimulation, it produces greater effects. On the other hand, DBS of the subthalamic area (SA) was recently reported to be effective for refractory tremor.
The authors implanted 2 DBS electrodes (one at the nucleus ventralis oralis/nucleus ventralis intermedius and the other at the SA) in 4 patients with HT. For more than 2 years after implantation, each patient's tremor was evaluated using a tremor rating scale under the following 4 conditions of stimulation: “on” for both thalamus and SA DBS; “off” for both thalamus and SA DBS; “on” for thalamus and “off” for SA DBS; and “on” for SA and “off” for thalamus DBS.
The tremor in all patients was improved for more than 2 years (mean 25.8 ± 3.5 months). Stimulation with 2 electrodes exerted greater effect on the tremor than did 1-electrode stimulation. Interestingly, in all patients progressive effects were observed, and in one patient treated with DBS for 1 year, tremor did not appear even while stimulation was temporarily switched off, suggesting irreversible improvement effects.
The presence of both resting and intentional/action tremor implies combined destruction of the pallidothalamic and cerebellothalamic pathways in HT. A larger stimulation area may thus be required for HT patients. Multitarget, dual-lead stimulation permits coverage of the wide area needed to suppress the tremor without adverse effects of stimulation. Some reorganization of the neural network may be involved in the development of HT because the tremor appears several months after the primary insult. The mechanism underlying the absence of tremor while stimulation was temporarily off remains unclear, but the DBS may have normalized the abnormal neural network.
The authors successfully treated patients with severe HT by using dual-electrode DBS over a long period. Such DBS may offer an effective and safe treatment modality for intractable HT.