Stereotactic and Functional Neurosurgery最新文献

Introduction: Deep brain stimulation (DBS) is an established therapy that can significantly improve patients' quality of life in several disorders. Besides its benefits, hardware-related problems including erosion and wound infections are well known problems. In the present series, we describe a novel phenomenon manifesting as denial for hardware-related skin erosion in patients with movement disorders benefiting from DBS in various targets.

Methods: Patients were collected from two large DBS cohorts over a period of 28 years. The skin erosion was identified upon the occasion of a routine follow-up with the patients apparently being unaware/not noticing its occurrence. Demographic, clinical and operative data were analyzed. Additionally, the hardware-related skin erosion and its time of diagnosis, as well as the consecutive treatment were registered.

Results: Overall, five patients were identified with denial for hardware-related skin erosion. Three were men, two were women. The mean age at surgery was 66 years (range, 54 to 78). Three patients had dystonia, two patients had Parkinson's disease. DBS targets were the globus pallidus internus, and various thalamic nuclei. All patients benefited markedly from chronic DBS (mean improvement of 76.7% according to the specific rating scales). The hardware-related skin erosion was diagnosed at a median follow-up of 18 months after DBS implantation (range, 5 to 264 months). Despite multiple surgical attempts at preservation, the neurostimulation system was ultimately explanted in three patients.

Conclusion: Denial towards hardware-related skin erosion in DBS, most probably denial, is a rare but potentially serious complication during chronic DBS.

Background Brain atrophy is common in Parkinson's disease (PD) and contributes to motor and cognitive decline. However, the predictive value of neuroimaging-based volumetric measures for motor outcomes following deep brain stimulation (DBS) remains unclear. This study examines whether preoperative volumetric assessment can predict motor outcomes after subthalamic nucleus (STN) DBS in PD. Methods Preoperative T1-weighted 3D MP-RAGE MRI scans were analyzed to measure subcortical, ventricular, and cortical volumes using Brainlab software. Motor outcomes were assessed by changes in the Movement Disorder Society - Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III) scores pre- and postoperatively in 39 participants. Stepwise logistic regression was performed to determine associations between brain volumes and DBS response. Results Smaller substantia nigra compacta volume (0.81 [IQR 0.74-0.85] vs 0.72 [IQR 0.69-0.73]), larger ventricular system (26.1 [IQR 21.4-30.05] vs 34.1 [IQR 28.6-40.87]), and lower atrophy ratio (41.76 [IQR 37.59-50.71] vs 29.63 [IQR 25.9-36.55]) were significantly associated with reduced motor improvement following STN-DBS. The predictive model based on these values demonstrated excellent performance (AUC 0.95, 95% CI: 0.87-1; p < 0.01) in forecasting poorer DBS treatment outcomes as measured by the MDS-UPDRS-III scale. Conclusions Our findings highlight the impact of enlargement of ventricular system and brain atrophy, particularly of the substantia nigra, on motor outcomes after STN-DBS. The association between atrophy measures and executive dysfunction suggests that subclinical dementia may underlie poor DBS response. Future studies should further explore the role of neurodegeneration in DBS response to optimize patient selection and electrode targeting.

Background: Local field potentials (LFPs) represent the summed electrical activity of neuronal populations and provide a critical window into synaptic and oscillatory dynamics across brain networks. In recent decades, advances in deep brain stimulation (DBS) and chronic sensing technology have established LFPs as essential biomarkers for understanding movement disorders and optimizing neuromodulation therapies.

Summary: This review synthesizes evidence on LFPs in movement disorders, focusing on methodological aspects, functional characterization, disease-specific findings, and clinical applications. In Parkinson's disease (PD), exaggerated beta-band activity in the subthalamic nucleus (STN) and globus pallidus internus (GPi) correlates with bradykinesia and rigidity, while dyskinesias are linked to broadband gamma activity and disrupted cross-frequency coupling. Essential tremor (ET) shows tremor-frequency synchronization in the thalamus and related networks. In dystonia, theta and alpha oscillations in the GPi correlate with symptom severity and guide DBS targeting. Tics in Tourette syndrome involve thalamic low-frequency oscillations, while chorea in Huntington's disease is associated with elevated beta-gamma power. Clinically, LFPs are increasingly used for intraoperative targeting, postoperative programming, outpatient monitoring, and as biomarkers for adaptive DBS (aDBS).

Key messages: LFPs provide fundamental insights into disease-specific neural oscillations across PD, ET, dystonia, tics, and chorea. Pathological patterns serve as reliable biomarkers of symptom states. By leveraging these signals, DBS can be more accurately targeted, programming can be streamlined, and long-term outpatient monitoring can be enhanced. aDBS based on LFP biomarkers is already in clinical use for PD, offering superior motor control and fewer side effects than conventional stimulation.

Background: Subthalamic nucleus deep brain stimulation (STN-DBS) effectively improves motor symptoms in Parkinson's disease (PD), but long-term survival outcomes and mortality predictors remain unclear. This study aimed to evaluate survival and 10-year clinical outcomes after STN-DBS.

Methods: We retrospectively analyzed 608 patients with PD who underwent bilateral STN-DBS between 2006 and 2023. Kaplan-Meier and Cox regression analyses assessed survival and preoperative predictors. Motor (MDS-UPDRS Part III), cognitive (MoCA, MMSE), and medication (LEDD) data were compared between baseline and 10 years postoperatively.

Results: During a mean follow-up of 4.8 ± 3.5 years, 42 deaths (6.9%) occurred, yielding an age-adjusted mortality rate of 3.3 per 100,000 population. The estimated 5- and 10-year survival rates were 95% and 77%, respectively. The most frequent cause of death was aspiration pneumonia (11.9%). In multivariate Cox analysis, lower preoperative MoCA scores (HR = 0.83, 95% CI 0.73-0.95, p < 0.01) and higher OFF-state MDS-UPDRS Part III scores (HR = 1.03, 95% CI 1.00-1.07, p < 0.05) independently predicted mortality, whereas age at surgery was not significantly associated with survival. Among 118 patients with 10-year follow-up, OFF-state motor and cognitive scores worsened significantly (p < 0.01), while ON-state motor scores (p = 0.21) and total LEDD (p = 0.06) remained stable, suggesting sustained motor control and medication-sparing effects.

Conclusions: Long-term survival after STN-DBS in PD was favorable. Preoperative cognitive and motor status, rather than age, determined long-term prognosis, emphasizing the enduring therapeutic value of STN-DBS.

Introduction: Freezing of gait (FOG) in advanced Parkinson's disease (PD) remains a therapeutic challenge, with conventional subthalamic nucleus deep brain stimulation (STN-DBS) demonstrating limited efficacy.

Methods: This multicenter, prospective, single-blind study investigated the effects of combined high-frequency (HF) STN stimulation and ultra-low-frequency (ULF) substantia nigra pars reticulata (SNr) stimulation in six PD patients with refractory FOG. Assessments included Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale (MDS-UPDRS) Part III, New Freezing of Gait Questionnaire (NFOGQ), Gait and Falls Questionnaire (GFQ) and Schwab & England Activities of Daily Living (ADL) scale.

Results: Dual-target stimulation significantly outperformed STN-only stimulation in improving appendicular motor symptoms (MDS-UPDRS Part III: p = 0.04 medication-ON, p = 0.009 medication-OFF) and reducing FOG severity (NFOGQ: p = 0.02, GFQ: p=0.01 vs. STN-DBS). Postural stability remained unchanged, while ADL scores improved clinically (p = 0.04). Volume of tissue activated (VTA) analysis revealed more STN VTA connectivity in cerebrum, in contrast with more SNr VTA connectivity in cerebellum.

Conclusion: These findings highlight the potential of dual-target free-frequency DBS for multimodal symptom control in PD and hopefully bring new sights in understanding mechanisms of DBS treatments in FOG.

Introduction: Subthalamic deep brain stimulation (STN-DBS) is an established treatment for Parkinson's disease (PD); however, long-term motor outcomes vary, affecting patients' quality of life. Identifying the factors that influence these heterogeneous motor outcomes is essential. This study investigated the factors influencing heterogeneous motor outcomes in patients with PD after STN-DBS and developed predictive models using preoperative demographic and clinical factors.

Methods: We studied 92 patients with PD who underwent bilateral STN-DBS at the Beijing Tiantan Hospital between 2020 and 2022. Motor outcomes were assessed preoperatively and 1 and 12 months postoperatively. Patients were grouped based on different motor outcomes (change in Unified Parkinson's Disease Rating Scale Part III scores) between the 12- and 1-month assessments: those achieving minimal clinically significant motor improvement (MCID+) and those who did not (MCID-). Machine-learning models were used to predict outcomes based on preoperative factors.

Results: The MCID+ group (n = 46) showed significantly better motor outcomes at the 1-year follow-up than the MCID- group (n = 46, mean difference 10.47, p < 0.001). A lower levodopa equivalent daily dose (p < 0.01), reduced anxiety (p < 0.05), reduced depression (p < 0.001), and milder freezing of gait (p < 0.05) were associated with better motor outcomes. Predictive models using logistic regression and XGBoost achieved a high accuracy (82%) in forecasting motor outcomes.

Conclusions: Preoperative non-motor factors, particularly emotional status, significantly affected motor outcomes following STN-DBS. Machine-learning models enhance prognostic accuracy and offer the potential for personalized treatment strategies.

Introduction: Bilateral temporal lobe epilepsy represents a subset of patients with medically intractable epilepsy that is particularly difficult to treat. This systematic review and meta-analysis aimed to evaluate the safety and efficacy of three neuromodulation techniques - vagus nerve stimulation (VNS), responsive neurostimulation (RNS), and deep brain stimulation (DBS) - in refractory bilateral temporal lobe epilepsy (BTLE).

Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a thorough electronic literature search using Ovid MEDLINE, Ovid Embase, and PubMed databases. Data from the selected studies were extracted, analyzed, and a quality assessment was performed. Meta-analysis was performed comparing mean seizure reduction rates in VNS, RNS, and DBS.

Results: Twenty studies (4 VNS, 7 RNS, 9 DBS) involving 142 BTLE patients were included in the systematic review. Meta-analysis of 12 studies (2 VNS, 5 RNS, 5 DBS) revealed comparable efficacy between VNS (61.69%), RNS (67.51%), and DBS (66.68%), with no statistically significant difference (p = 0.932) between the modalities. All three techniques demonstrated efficacy in seizure reduction. Additionally, complication rates did not significantly differ between VNS, RNS, and DBS.

Conclusion: This study provides a comprehensive assessment of existing data regarding the use of neuromodulation in refractory BTLE. VNS, RNS, and DBS demonstrated comparable efficacy, supporting their consideration in treatment planning. Clinical decision-making should weigh factors such as surgical candidacy, patient preferences, comorbidities, and side effect profiles. Further research, including standardized reporting and head-to-head trials, is vital for optimizing treatment protocols and expanding our understanding of neuromodulation's impact on seizure reduction, quality of life, and cognitive outcomes in patients with BTLE.

Introduction: Tremor-predominant Parkinson's disease (TPPD) generally responds favorably to deep brain stimulation (DBS) targeting the subthalamic nucleus (STN). However, traditional stereotactic targeting of the STN does not universally yield the anticipated intraoperative improvement, prompting exploration of additional targets to achieve optimal results prior to permanent implantation of electrodes. The posterior subthalamic area (PSA), including the caudal zona incerta (cZI), have been associated with tremor suppression and can be easily compared to the neighboring STN intraoperatively.

Methods: We retrospectively compared intraoperative and clinical outcomes in tremor-dominant PD patients who prospectively underwent dual trajectory microelectrode monitor targeting the STN and PSA/cZI. We compared the neurophysiology and tremor response of both the central (STN) and posterior (PSA) trajectories in 22 patients and analyzed outcomes in those who ultimately received traditional STN (16) or PSA/cZI lead implantation (12).

Results: While both groups achieved substantial overall motor improvement under chronic stimulation, intraoperative test stimulation through the posterior path produced more consistent tremor arrest compared with STN. These findings suggest that positioning the DBS lead further posteriorly to engage the PSA can augment tremor suppression in select cases of TPPD without compromising other parkinsonian symptom relief.

Conclusion: Our results emphasize the value of intraoperative physiological feedback in trajectory selection in tremor-predominant patients and are consistent with emerging literature that PSA/cZI DBS is an effective and potentially superior target for management of tremor in PD.