Correlative Factors About Subthalamic Nucleus Deep Brain Stimulation Of Parkinson's Disease And SPECT Imaging Study

PART 1 : Correlative factors analysis about Subthalamic nucleus deep brain stimulation of Parkinson's diseaseSECTION 1Relation of the clinic characteristic of Parkinson's disease and STN-DBS result.Objective: To summarize the result of STN-DBS and explore it's relation about the PD patient's clinic characteristic, including responsibility of levodopa, duration of the disease, sexuality, age, different symptom, and bilateral or unilateral operation. Methods: A total of 77 cases of PD were treated by STN-DBS from January 2000 to March 2005, and we followup 68 cases for 3 months to 5 years, including bilateral stimulation 36 cases and unilateral stimulation 32 cases. All patiens assessed by UPDRS under medication on or off and stimulation on or off. Results: 1. Postoperation UPDRS Hand Ⅲ scores are significantly decreased under stimulation on condition. But long term UPDRS motor scores increased when stimulation stops after operation. 2. Improvement rate of UPDRS III: the younger group is higher than the elder group under off-medication after operation (P<0. 05) , longer course group is higher than shorter course group (P<0. 05) , no difference between H&Y stage 2-2.5 group and stage 3 group, but significantly higher than stage 4-5 group (P<0. 01) . 3. The UPDRS Ⅲ improvement rate of levodopa treament pre-operation is positively correlated with post-operation. 4. Off-medication on-stimulation state, UPDRS scores improvement rate is different for different symptom of PD, tremor and rigidity are mainly improved, then the bradykinesia and axial symptom secondly, speech have on change. But long-term result shows the bradykinesia and axial symptom is developped when stimulation is off. 5. UPDRS Ⅲ scores are all improved in unilateraland bilateral operation gurop under off-medication, but the improvement rate of bilateral stimulation group is more higher (P<0. 01) , (bilateral 51.1 + 18.9%, unilateral 31.9 + 9.6%) . Moreover bilateral stimulation also can improve axial symptom and dyskinesia, decrease the levodopa dosage, but unilateral stimulation group has no significant change. Conclusion: STN-DBS can significantly improve the UPDRS III scores of the PD patients, especially improve the off-medication state scores. Aged, long disease course, high H&Y stage patients's improvement rate of UPDRS motor scores is relatively lower. Responsibility of levodopa pre-operation can predict the effect of the operation. Except speech, bilateral stimulation can improve most symptoms of PD, especially tremor and rigidity, and is more effective than unilateral stimulation.SECTION 2Correlative factors analysis of the target localizationObjective: To explore the correlative factors of the target localization for subthalamic deep brain stimulation. Methods: To review 68 PD cases who underwent STN-DBS in our hospital. We fix the CRW head frame according to the Yao baseline, locate the target through MRI image, micro-electrode recording , macro-stimulation, C-model X-ray machine, and instant post-operation MRI to verify the target. Results: With the reference of Yao baseline, the plane of the headframe is almost parallel the AC-PC plane, included angle is 1 + 1.63 degree. The average intercommissural distance is 23. 2 + 1. 3mm, has no difference of Zhang yuqing' s group and corpse brain data of foreign literature, but is different from the literature of domestic dead brain. The subthalamic nucleus is visible on the MRI image of axial plane inferior to the (midcommissural point) and coronalplane posterior to the MCP. There is no significant difference of X, Y average coordinate between pre-operation target localization and post-operation target verification, but the Z coordinate is found 1.06 mm deeper than pre-operation localization. In our group best coordinate is: X=ll —13 mm (12. 015 + 0. 63 mm), Y=-0. 5—3. 5 mm (-2.125+0. 64 mm), Z=-2. l~-5. 5 mm (-4.145 + 0. 82 mm) . Conclusions: Yao baseline is a good reference for headframe fix. MRI can provide accuracy ICD length, we found no race difference of ICD. MRI direct localization for the STN is accurate and reliable, the anatomic localization of MRI play the critical role, electrophysiologic localization can verify the target and must based on the anatomic localizaton. Our best location of the STN suggest: the center and dorsal of the STN stimulation produce optimal effect.SECTION 3Programming of subthalamic nucleus deep brain stimulationObjective: To explore programming of subthalamic nucleus(STN) deep brain stimulation(DBS) intro- and post- operation among patient with Parkinson's disease (PD). Methods: To review 68 PD cases who underwent STN-DBS and analysis the adjustment of stimulate parameters intro- and post- operation. Results: monopolar stimulation is used in 32 cases who underwent unilateral operation;36 cases underwent bilateral operation: 25 cases stimulated by bipolar model, 8 cases stimulated by monopolar model, 3 residual cases accepted monopopar stimulation and bipolar on another side. Electrode contact was found superior shift in 7 cases. UPDRS motor Score improvement of bilateral stimulation is better than that of unilateral stimulation. Conclusions: Voltage adjustment effects the symptom of PD markedly while the adjustment of pulsewidth and frequency is less used relatively. Proper parameter settings (bipolar, voltage1—4V, pulsewidth 90p.s, frequency 180~190Hz;monopolar, voltage 1~ 3. 5v) of STN-DBS is safe and efficacious in PD patients. Bilateral STN-DBS leads to the better symptomatic improvement.SECTION 4Complications of subthalamic nucleus deep brain stimulation for Parkinson's diseaseObjective:To summarize the complication of subthalamic nucleus (STN)deep brain stimulation (DBS) Parkinson's disease (PD). Methods: With the help of MRI and microelectrode recording technique in target localization, 77 PD patients underwent STN-DBS. Patients were followed up 3 months to 5 years and complications were analysised. Results: Operation-related complications were electrode dislocation 2 cases, thoracic subcutaneous fluid accumulation 5 cases, scalp erosion of extension lead connector 1 case, thoracic subcutaneous infection 1 case;stimulation-related complications includes dyskinesia 19 cases, paresthesia 18 cases, memory impairment 2 cases, mood change 7 cases, eye opening apraxia 1 case;hardware failure includes stimulator exceptional shut off 2 cases, battery exhausted 1 case. Conclusions: Complications of STN-DBS is acceptable and can be led to a better result with proper treatment. STN-DBS is a kind of microinvansive operation.SECTION 5Subthalamic nucleus deep brain stimniation in the treatment of Parkinson's disease after ablationObjective: Practicability and surgical outcome were explored among PD patients who underwent subthalamic nucleus(STN) deep brain stimulation (DBS) with a previous ablation. Methods: With the help of MRI and microelectrode recording technique in target localization, 12 PD patients with previous ablation operations underwent STN-DBS, included unilateral STN in 8 cases, bilateral STN in 4 cases. Among these patients, 11 had previous unilateral pallidotomy, 1 had previous simultaneous unilateral pallidotomy and thalamotomy. Results: STN-DBS could improve symptoms of PD patients with a prior ablation operation to different extent, especially those with unilateral ablation and underwent bilateral DBS. UPDRS motor and ADL scores decreased significantly and dosage of L —Dopa intake decreased prominently three months after operation. No surgical complication occurred. Conclusions: STN-DBS is safe and efficacious in patients with a previous ablation surgery. Bilateral STN-DBS lead to the better symptomatic improvement and reduction in L —Dopa intake in patients.PART 2 : SPECT imaging study of subthalamic nucleus deep brain stimulation for Parkinson's diseaseObjective: To study the SPECT image change of PD patients who underwent STN-DBS, and explore the mechanism of STN-DBS for PD treatment. Methods: To select 10 cases advanced PD patients randomly, radioactive uptake in striatum were detected by SPECT examination pre-operation and after 1 week post-operation and accepted 3 days continusly stimulation . 4 cases who accepted unilateral STN-DBS underwent SPECT re-examination after 6 months or 12 months. Results: The radioactive uptake in striatum of DAT and D2R are all decreased obviously in these advanced PD patients, the concentration of radioactivity in the bilateral straitum is dissymmetry, the circumsciption of straitum shrink. There is no "Tcm-TRODAT-1 or 131I-epidepride radioactive uptake difference was found between pre- and post- operation, (P<0. 05). SPECT re-examination of 4 cases after 6-12 months show that DAT radioactive uptake increased in 3 patients's straitum, D2R radioactive uptake unchanged, DAT and D2R radioactive uptake all decreased in 1 case. Conclusions: The function of DAT and D2R in bilateral straitum doesnot change in short-term after STN-DBS treatment, STN-DBS maybe change the pathological neural discharge in the basal ganglia in short time and produce the theraputic effect . However, long-term STN stimulation maybe improve the DAT function.