Parkinson Disease: Zabek M

Zabek M, Sławek J, Harat M, Koszewski W, Opala G, Friedman A. · Oddział Neurochirurgii Czynnościowej i Chorób Układu Pozapiramidowego, Klinika Neurochirurgii, Akademia Medyczna, ul Debinki 7, 80-211 Gdańsk. · Neurol Neurochir Pol. · Pubmed #16463215 links to  free full text

Abstract: The authors present the current views on the use of electrical stimulation in selected movement disorders (Parkinson's disease, dystonia) and pain syndromes (central and neuropathic pain) refractory to pharmacological therapy. Stimulation should be applied in cases with an established diagnosis (especially Parkinson's disease and dystonia) and with a lack of efficacy despite the best available medical therapy. Therefore it should be the last treatment option, except of generalized dystonia, where it seems to be nowadays the treatment of choice. Suggested selection criteria are based on experience of different centers and on current medical literature. They are published to make the procedure more rational and more available in Poland.

Sobstyl M, Zabek M. · Klinika Neurochirurgii i Urazów Ooerodkowego Układu Nerwowego CMKP, ul. Kondratowicza 8, 03-242 Warszawa. · Neurol Neurochir Pol. · Pubmed #17103355 links to  free full text

Abstract: Dystonia refers to movement disorders characterized by sustained muscle contractions that produce abnormal postures and twisting movements. First-line therapy for dystonia includes several classes of pharmacologic agents. Botulinum toxin injections are the treatment of choice for several forms of focal dystonia. Many patients with dystonia do not benefit from these treatments, and for those patients whose symptoms are sufficiently troublesome, surgical treatment can be used to reduce symptoms and to improve function. Formerly the ablative procedures of thalamotomy and pallidotomy were used. More recently, deep brain stimulation (DBS) has emerged not only as the preferred surgical treatment for advanced idiopathic form of Parkinson's disease and severe forms of essential tremor but also for dystonia. For dystonia, stimulation directed at the globus pallidus internus has been the most thoroughly studied to date. Advantages of DBS include its relatively non-destructive nature, its adjustability and reversibility, and its capacity to be used bilaterally in a single surgical session. Use of DBS to treat dystonia is a rapidly evolving area, and preliminary evidence suggests that primary dystonia linked to genetic mutation, especially DYT-1 positive generalized dystonia, and other primary dystonias respond most dramatically to treatment with DBS, whereas secondary dystonia tends to be less responsive.

Zabek M, Sobstyl M. · Klinika Neurochirurgii, CMKP, Wojewódzki Szpital Bródnowski w Warszawie, Warszawa. · Neurol Neurochir Pol. · Pubmed #16794960 links to  free full text

Abstract: Deep brain stimulation (DBS) is a neurosurgical treatment of Parkinson's disease and other movement disorders. This surgical technique is applied to three brain targets: the ventral intermediate nucleus of the thalamus (Vim), the globus pallidus internus (Gpi) and the subthalamic nucleus (STN). Vim DBS improves contralateral parkinsonian tremor. STN and GPi DBS improve contralateral bradykinesia, rigidity, parkinsonian tremor and also levodopa-induced dyskinesia. There is little comparative data between bilateral STN and bilateral GPi procedures but the improvement with bilateral STN DBS seems more pronounced than with bilateral GPi DBS. Moreover, only STN BDS allows a significant decrease of antiparkinsonian medication. The other advantage of STN over GPi DBS is the lower consumption of current. The DBS procedure contrary to ablative surgery has the unique advantage of reversibility and adjustability over time. Patients with no behavioral, mood and cognitive impairments benefit the most from bilateral STN DBS. The stimulation-induced adverse effects related to DBS are reversible and adjustable. More specific adverse effects related do hardware are: disconnection, lead breaking, erosion or infection. The disadvantage of DBS is a relatively high cost. The setting of stimulation parameters to achieve the best clinical result may be very time-consuming. Most authors agree that DBS is a safer and more favorable procedure than ablative surgery.

Sobstyl M, Zabek M, Koziara H. · Kliniki Neurochirurgii CMKP, Wojewódzkiego Szpitala Bródnowskiego w Warszawie. · Neurol Neurochir Pol. · Pubmed #12910841 No free full text.

Abstract: Among all the extrapiramidal movement disorders Parkinson's disease (PD) is the one most often submitted to neurosurgical treatment. Technical advances in neurosurgery, neuroimaging and neurophysiology, as well as shortcomings of chronic Levodopa medication (i.e. on/off fluctuations, violent dyskinesia and painful dystonia) have greatly contributed to the renewed interest in the surgical treatment of PD. The attainment of a better understanding of the basal ganglia function and of PD pathophysiology has also encouraged centers to treat Parkinson's disease in recent years. This article presents the current model of PD and the rationale for using GPi, thalamus and STN as target sites in stereotactic surgery.

Jagielski J, Kubiczek-Jagielska M, Sobstyl M, Koziara H, Błaszczyk J, Zabek M, Zaleski M. · Klinika Neurochirurgii, CMKP, ul. Kondratowicza 8, 03-232 Warszawa. · Neurol Neurochir Pol. · Pubmed #16628509 links to  free full text

Abstract: BACKGROUND AND PURPOSE: In advanced stages of Parkinson's disease (PD) beside resting tremor, rigidity, and bradykinesia, most patients reveal severe balance instability. The goal of this study is to determine objectively postural control changes using static posturography after neurosurgical treatment (unilateral posteroventrolateral pallidotomy). MATERIAL AND METHODS: 15 patients with advanced idiopathic PD underwent unilateral posteroventrolateral pallidotomy. The study group was composed of 8 men and 7 women. The mean disease duration until operation was 12.5+/-3.5 years, and the mean age of the patients at the time of surgery was 65.8+/-4.1 years. Postural control changes were assessed objectively by static computerized posturography and subjectively according to items of posture, gait and postural stability derived from Part III (motor examination) UPDRS. All evaluations of the balance system were performed preoperatively in the off and on condition, and also two weeks postoperatively in the same conditions. RESULTS: It was found that the majority of posturographic parameters in the off condition were improved after neurosurgical treatment. The improvement in the on condition was less pronounced. For example, the mean path length in the off condition during eyes opened was 318+/-159 mm before pallidotomy, and after surgery it was 240.9+/-119.2 mm in off. The difference was statistically significant (p < 0.005, t=3.11). CONCLUSIONS: Pallidotomy improves postural control changes in the early postoperative period, which can be proved by static computerized posturography.

Sobstyl M, Zabek M, Koziara H, Kadziołka B, Mossakowski Z. · Klinika Neurochirurgii i Urazów Ooerodkowego Układu Nerwowego, CMKP, ul. Kondratowicza 8, 03-242 Warszawa. · Neurol Neurochir Pol. · Pubmed #16628508 links to  free full text

Abstract: BACKGROUND AND PURPOSE: To assess the effectiveness of unilateral thalamotomy for the treatment of parkinsonian tremor and other motor signs of Parkinson's disease (PD). MATERIAL AND METHODS: Between 1999 and 2004, 41 patients with idiopathic tremor dominant PD were treated surgically in the Neurosurgical Department of Postgraduate Medical Center in Warsaw. Stereotactic thalamotomy was performed with Leksell stereotactic frame (model G) using intraoperative macrostimulation. The patients were assessed according to the Unified Parkinson's Disease Rating Scale version 3. (UPDRS) before and after thalamotomy in the off state. The progression of PD was also evaluated according to the Hoehn and Yahr scale in the off state and also Schwab and England was used to assess the disability of the patients. The patients were evaluated before thalamotomy in the off state, and 3, 12, 24 and 36 months after surgery, according to the above mentioned clinical rating scales. RESULTS: The authors report their results among 41 patients who underwent stereotactic thalamotomy 3 years postoperatively. At 3 years follow-up (in the group of 19 patients) the contralateral tremor from the presurgical value of 11.2 (items 20 - 21 UPDRS) decreased to 2.6. The rigidity in contralateral limbs at 3 years follow-up was 1.7 (item 22 UPDRS) when compared to 2.8 (item 22 UPDRS) preoperative value. Thalamotomy had no effect on bradykinesia or other manifestations of PD such as balance or gait disturbance. There were 13 transient and 6 permanent complications. CONCLUSIONS: Thalamotomy using intraoperative macrostimulation in carefully selected patients is a beneficial operation for the control of medically refractory parkinsonian resting and postural tremor. The effect of unilateral thalamotomy on tremor is long lasting.

Sobstyl M, Dzierzecki S, Zabek M, Koziara H, Kadziołka B, Mossakowski Z. · Klinika Neurochirurgii, Centrum Medycznego Kształcenia Podyplomowego w Warszawie, Warszawa. · Neurol Neurochir Pol. · Pubmed #17330184 links to  free full text

Abstract: The aims of the study were to present the surgical technique of bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) and to analyze our experience with the MedtronicStealthStation Treon neuronavigation system and Framelink 4.1 software in targeting STN using single-unit extracellular action potentials (microrecording). The prospective study included 2 patients with bilateral STN DBS. The STN boundaries were mapped using microrecording, without microstimulation and recording of kinesthetic cells. For macrostimulation the longest trajectory with neuronal activity characteristic of STN was chosen. The patients were assessed using Unified Parkinson's Disease Rating Scale UPDRS version 3 and Schwab and England Scale. Postoperatively we did not notice intracerebral haemorrhage. Also there were no transient or permanent side effects. The mean number of microelectrode tracts was 4 per STN. Framelink 4.1 software is reliable to plan individual microelectrode trajectories and help avoid the intraparenchymal vessels.

Sobstyl M, Zabek M, Koziara H, Kadziołka B. · Klinika Neurochirurgii CMKP w Warszawie. · Neurol Neurochir Pol. · Pubmed #15098353 No free full text.

Abstract: Many patients with Parkinson's disease (PD) suffer from severe bilateral appendicular off (bradykinesia, rigidity, tremor) and on (dyskinesia, dystonia) symptoms. After unilateral pallidotomy several of these patients still suffer from severe bradykinesia, rigidity, or dyskinesia of the ipsilateral side. In addition such symptoms as walking difficulty, freezing, trunk, neck, or facial dyskinesia are not significantly alleviated after unilateral pallidotomy. These patients seem to be good candidates for bilateral staged pallidotomy. The aim of this study is to evaluate the motor symptoms after staged bilateral pallidotomy in advanced PD patients. 34 patients were studied. The patients were assessed using UPDRS version 3, Hoehn and Yahr scale, Schwab and England scale before and up to 24 months after surgery in off and on state. In off drug state, the total motor score of the UPDRS compared to preoperative off drug state was improved by 61% at 24 months of follow-up. All cardinal features of PD improved significantly in postoperative drug off state compared to drug off state before bilateral pallidotomy--parkinsonian tremor (items 20-21) by 62%, rigidity (item 22 UPDRS) by 81% and bradykinesia (items 23-26) by 67%. Also gait including falling, freezing, walking (items 13-14-15 UPDRS) and gait and postural stability (items 29-30 UPDRS) showed good improvement by 69% with bilateral pallidotomy in off drug phases. There was minimal improvement in motor score of UPDRS in on state. Duration of dyskinesia and severity of dyskinesia (items 32-33 UPDRS) showed dramatic improvement after bilateral pallidotomy. Bilateral pallidotomy affords impressive elimination of all appendicular and truncal dyskinesias, dystonias, and generally improved all symptoms in off state.

Sobstyl M, Zabek M, Koziara H, Kadziołka B. · Klinika Neurochirurgii CMKP w Warszawie. · Neurol Neurochir Pol. · Pubmed #15098350 No free full text.

Abstract: There is little information on the efficacy of various surgical interventions in terms of health-related quality of life in Parkinson's disease (PD) patients. Most studies evaluated only motor symptoms of PD after surgical treatment avoiding subjective patient's assessment. The goal of this study is the assessment of surgical treatment of PD on quality of life using Parkinson's Disease Questionnaire (PDQ-39). To 134 patients PDQ-39 questionnaires were send, 91 of them responded. Among 91 patients 32 underwent unilateral thalamotomy, 38 unilateral pallidotomy and 21 bilateral staged pallidotomy. The patients were assessed at baseline and 3 to 6 months after surgery. The PDQ-39 recorded significant improvement in mobility, activity of daily living and stigma in thalamotomy and pallidotomy group. The most striking improvement was noticed in bilateral pallidotomy group. After bilateral pallidotomy improvement was noticed in mobility, ADL, emotional well being, stigma and bodily discomfort. Our results indicate that quality of life in PD patients after surgical treatment is measurable according to PDQ-39 and the most benefit is noted in patients who underwent bilateral staged pallidotomy.

Friedman A, Harat M, Opala G, Sławek J, Zabek M. · Klinika Neurochirurgii-Oddział Neurochirurgii Czynnościowej i Chorób Układu Pozapiramidowego Akademia Medyczna w Gdańsku ul. Debinki 7, 80-211 Gdańsk. · Neurol Neurochir Pol. · Pubmed #15098326 No free full text.

Abstract: Renewed interest (also in Poland) in the neurosurgical treatment of Parkinson's Disease is the main cause of referring patients to stereotactic surgery. It is the result of our improved understanding of functional anatomy of basal ganglia and development of neurophysiological, neuroimaging and neurosurgical techniques. Various surgical options and possible targets offer different functional benefits, but due to almost 10 years experience we are aware of limited results and possible complications as well. There is a need of minimal standard of patient's evaluation before selection to surgery. The selection criteria include: good diagnosis of Parkinson's Disease, at least 5 years from the onset of symptoms, good responsiveness to L-dopa or apomorphine, exclusion of severe depression and dementia, neuroimaging (MRI) before surgery and optimal (but ineffective) pharmacological therapy before surgery.

Zabek M, Sobstyl M, Koziara H. · Kliniki Neurochirurgii, CMKP Wojewódzkiego Szpitala Bródnowskiego w Warszawie. · Neurol Neurochir Pol. · Pubmed #14558491 No free full text.

Abstract: Dopamine deficiency in the nigrostriatal system leads to a series of changes in the basal ganglia, resulting in an increased neuronal activity of the subthalamic nucleus (STN). Reduction of the STN glutaminergic excitatory effect on the main output structures of the basal ganglia (globus pallidum pars interna GPi and substantia nigra pars reticulata SNr) is accompanied by a marked alleviation of parkinsonian motor sings in the MPTP monkey model of parkinsonism. Also a high-frequency stimulation of STN in the MPTP monkey model of parkinsonism produced the same clinical effect as did lesioning. Due to these observations bilateral deep subthalamic stimulation was introduced in the treatment of PD patients with severe akinetic-rigid form of this disease. Four patients with akinetic-rigid PD form of PD were included in the study. The electrodes for deep brain stimulation were implanted in two separate surgical interventions in every case. The second implantation was performed not earlier than at least 3 months after the first procedure. Evaluations using the UPDRS were conducted before surgery in "on" and "off" conditions and at 3, 6 and 12 months after the bilateral implantation. Bilateral DBS STN seems to be the best stereotactic target in controlling motor symptoms in the "off" condition in the treatment of PD patients with severe symptoms. The technique enables a dramatic reduction in the daily dose of L-dopa.

Zabek M, Sobstyl M, Koziara H. · Kliniki Neurochirurgii CMKP, Wojewódzkiego Szpitala Bródnowskiego w Warszawie. · Neurol Neurochir Pol. · Pubmed #14558490 No free full text.

Abstract: Deep brain stimulation (DBS) of the ventral intermediate thalamic nucleus (Vim) has been recently introduced by Benabid and his colleagues as a new surgical procedure in the treatment of tremor-dominant Parkinson's disease (PD). The advantage of DBS Vim over lesioning (thalamotomy) is its reversibility and adjustability with the same clinical effect, but without the need to make a destructive thalamic lesion. In this procedure high-frequency stimulation is employed to simulate a thalamic lesion using an implanted electrode connected to a subcutaneously placed neuropacemaker. Four patients with tremor-dominant PD were included in the study. There were 3 men and one women. Three stimulators were implanted in the left and one in the right cerebral hemisphere. The patients were evaluated using clinical scales, before and up to 24 months after surgery. Adverse effects associated with chronic Vim stimulation were mild and reversible. Chronic thalamic stimulation is effective for drug-resistance parkinsonian tremor suppression, with few adverse side-effects. The method results in a significant improvement of function.