Neurosurgery for Refractory Schizophrenia: A Systematic Literature Review

Schizophrenia is a chronic and disabling psychiatric disease that can be refractory to conventional treatment. The present study aims to gather information about the circuitry related to schizophrenia to describe possible surgical targets, and to establish whether psychosurgery can be a safe and effective treatment option for refractory schizophrenia. A systematic review of the literature was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. An electronic search was performed in the Pubmed and BVSalud databases using medical subject headings (MeSH) combined with Boolean operators. Out of the 724 studies retrieved, 13 were included in the review. Regarding leucotomy without a stereotactic approach, we found side effects such as irritability, nervous excitement, cases of disinhibition, and compromised normal social control. In other stereotactic procedures, there was some improvement, mainly regarding aggressiveness and positive symptoms; an anterior capsulotomy had an efficacy rate of 74% according to the Clinical Global Impression (CGI) rating scales. The only deep brain stimulation (DBS) case report found in our study described a significant improvement in the positive and negative symptoms. The use of a stereotactic approach enables psychosurgery to be a safe and effective treatment option in cases of refractory schizophrenia, improving the quality of life and the symptoms. Cognitive and negative symptoms remain a challenge in the treatment of schizophrenia, revealing that more targets in the circuitrymust be surgically explored. Furthermore,more clinical trials are needed to compare these many surgical techniques and targets, using a standard evaluation parameter. The results show that DBS has a promising future in the treatment of refractory schizophrenia.

Deep Brain Stimulation as a Treatment Approach for Anorexia Nervosa: a Systematic Literature Review

Anorexia nervosa is a psychiatric disorder characterized by distortions of body size, weight, and shape perception, as well as by food restriction and/or binge and purging behaviors. It mostly affects young women and causes severe negative impacts on their physical, psychological, and social health. Recent studies have analyzed deep brain stimulation (DBS), a neurosurgical procedure that involves electrode implantation in strategical brain areas, to obtain remission of the symptoms of anorexia nervosa. The results showed that the stimulation of areas associated to the neurocircuitry of anorexia nervosa, such as nucleus accumbens, anterior cingulate cortex, ventral striatum, and bed nucleus of the stria terminalis, provokes beneficial responses in terms of bodymass index, quality of life, social functioning, and psychiatric comorbidities. Nevertheless, broader investigations are needed to endorse the clinical usage of DBS in the management of anorexia nervosa.

Deep Brain Stimulation for the Treatment of Resistant Depression: Systematic Review of the Literature

Depression is the leading cause of disability worldwide, and it is related to high suicide rates. Furthermore, a great number of patients do not respond to any of the available treatments. Deep brain stimulation (DBS), a versatile technology with expanding indications, is considered a potential treatment for resistant depression. However, in over 10 years of clinical research, its efficacy has not been completely proven. Although new trials using DBS for treatment-resistant depression keep emerging, two of the three Level I evidence-based studies recently conducted have not provided conclusive data. Methodological limitations andmajor biases have compromised the obtention of clearer results. In this systematic review of the literature, we intend to critically assess the clinical trials performed in this field.

Estimulación cerebral profunda: tratamiento para pacientes con diagnóstico de trastorno obsesivo-compulsivo resistente / Deep brain stimulation: treatment for patients diagnosed with disorder obsessive-compulsive resistant

El trastorno obsesivo-compulsivo (TOC) afecta al 2% de la población general, llegando en ocasiones a causar un deterioro funcional severo y de la calidad de vida de las personas afectadas. Entre el 10 y el 30% de los pacientes con este trastorno no responde a los tratamientos recomendados: farmacológicos y terapia cognitivo-conductual. La Food and Drug Administration de los Estados Unidos (FDA) aprobó en el año 2008 la Estimulación cerebral profunda (ECP) para pacientes con TOC resistente a tratamiento. La ECP, utilizada frecuentemente para el tratamiento de la enfermedad de Parkinson refractaria, es una opción viable para los pacientes con TOC resistente, con efectos adversos poco frecuentes y transitorios. (AU)

Obsessive-compulsive disorder (OCD) affects 2% of the general population, sometimes resulting in severe impairment of functional capacity and quality of life of affected people. Between 10 and 30% of these patients do not respond to recommended treatments: pharmacological and cognitive behavioral therapy. In 2008, the FDA approved Deep Brain Stimulation (DBS) for patients with OCD resistant to treatment. DBS, frequently used for the treatment of refractory Parkinson's disease, is a viable option for the treatment of patients with resistant OCD, with infrequent and transient adverse effects. (AU)

Deep brain stimulation in parkinson disease

The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize producers to assist the reasoning and decision-making of doctors. The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending on the conditions and the clinical status of each patient.

Acoustic voice modifications in individuals with Parkinson disease submitted to deep brain stimulation

Introduction: Subthalamic nucleus deep brain stimulation (STN-DBS) improvesmotor function in individuals with Parkinson disease (PD). The evidence about the effects of STN-DBS on the voice is still inconclusive. Objective: To verify the effect of STN-DBS on the voice of Brazilian individuals with PD. Methods: Sixteen participants were evaluated on the Unified Parkinson Disease Rating Scale-Part III, and by the measurement of the acoustic modifications in on and off conditions of stimulation. Results: The motor symptoms showed significant improvement with STN-DBS on. Regarding the acoustic measures of the voice, only the maximum fundamental frequency (fhi) showed a statistical difference between on- and off-conditions, with reduction in off-condition. Conclusion: Changes in computerized acoustic measures are more valuable when interpreted in conjunction with changes in other measures. The single finding in fhi suggests that DBS-STN increases vocal instability. The interpretation of this result should be done carefully, since it may not be of great value if other measures that also indicate instability are not significantly different (AU)

Estimulación cerebral profunda en enfermedad de Parkinson / Deep brain stimulation in Parkinson's disease

Background: Deep brain stimulation is an essential therapeutic tool in Parkinson's disease. Aim: To assess the results of a series of patients with Parkinson's disease treated with micro-electrode guided subthalamic nucleus stimulation. Material and Methods: Twenty patients with idiopathic Parkinson's disease were studied (10 males). Three months after surgery, we analyzed the change in motor disturbances, medication need to control symptoms and quality of life. Results: We observed a significant improvement in all the assessed variables. Motor involvement determined as OFF hours and expressed as percentage of the day changed from 30 ± 15 to 10 ± 7% in the preoperative and postoperative periods, respectively. ON hours without dyskinesia changed from 17 ± 16 to 78 ± 21%. ON hours with dyskinesia changed from 53 ± 23 to 12 ± 15%. Medication need changed from 1,505 ± 499 to 1,214 ± 528 levodopa equivalents. Parkinson's Disease Questionnaire 39 score changed from 62.9 ± 22.7 to 34.3 ± 18.5. During the 5-year follow-up a continuous improvement of symptoms was observed. Conclusions: Micro-electrode guided subthalamic nucleus functional surgery in patients with Parkinson's disease has good immediate and late results.

The advances of Deep Brain Stimulation (DBS) for treatment of Parkinson's disease (PD)

Advanced Parkinson's disease (PD) is characterized by the presence of motor fluctuations, various degrees of dyskinesia, and disability with functional impact on daily living and independence. Therapeutic management aims to extend levodopa (L-DOPA) benefit while minimizing motor complications and includes, in selected cases, the implementation of drug infusion and surgical techniques. The concept of deep brain stimulation (DBS) for PD was introduced over 20 years ago, but our understanding of the nuances of this procedure continues to improve. This review aims to demonstrate the advances of DBS in the treatment of PD patients. (AU)

Increased sexual arousal in patients with movement disorders / Exacerbação do impulso sexual em pacientes com distúrbios do movimento

ABSTRACT Increased of sexual arousal (ISA) has been described in different neurological diseases. The purpose of this study was present a case series of ISA in patients with movement disorders. Method Fifteen patients with different forms of movement disorders (Parkinson’s disease, Huntington’s disease, Tourette´s syndrome, spinocerebellar ataxia type 3), were evaluated in the Movement Disorders Unit of the Federal University of Paraná. Results Among Parkinson’s disease patients there were seven cases with different forms of ISA due to dopaminergic agonist use, levodopa abuse, and deep brain stimulation (DBS). In the group with hyperkinetic disorders, two patients with Huntington’s disease, two with Tourette’s syndrome, and four with spinocerebellar ataxia type 3 presented with ISA. Conclusions ISA in this group of patients had different etiologies, predominantly related to dopaminergic treatment or DBS in Parkinson’s disease, part of the background clinical picture in Huntington’s disease and Tourette’s syndrome, and probably associated with cultural aspects in patients with spinocerebellar ataxia type 3.

RESUMO A exacerbação do impulso sexual (EIS) tem sido descrita em diversas doenças neurológicas. O objetivo deste estudo foi apresentar uma série de casos de EIS em pacientes com distúrbios do movimento. Métodos Quinze pacientes com diferentes formas de distúrbios do movimento (Doença de Parkinson, doença de Huntington, síndrome de Tourette, ataxia espinocerebellar tipo 3), foram avaliados na Unidade de Distúrbios de Movimento-Universidade Federal do Paraná. Resultados Entre os pacientes com doença de Parkinson houve sete casos com diferentes formas de EIS devido ao uso de agonista dopaminérgico, abuso de levodopa ou estimulação cerebral profunda (DBS). No grupo com distúrbios hipercinéticos, dois pacientes com doença de Huntington, dois com síndrome de Tourette, e quatro com ataxia espinocerebelar tipo 3 apresentaram EIS. Conclusões EIS nesses pacientes decorreu de diferentes etiologias, relacionadas com o tratamento dopaminérgico ou DBS na doença de Parkinson, parte do quadro clinico na doença de Huntington e síndrome de Tourette, e provavelmente relacionado com aspectos culturais em pacientes com ataxia espinocerebelar tipo 3.

Electrode Position and the Clinical Outcome after Bilateral Subthalamic Nucleus Stimulation

We compared the surgical outcome with electrode positions after bilateral subthalamic nucleus (STN) stimulation surgery for Parkinson's disease. Fifty-seven patients treated with bilateral STN stimulations were included in this study. Electrode positions were determined in the fused images of preoperative MRI and postoperative CT taken at six months after surgery. The patients were divided into three groups: group I, both electrodes in the STN; group II, only one electrode in the STN; group III, neither electrode in the STN. Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn and Yahr stage, and activities of daily living scores significantly improved at 6 and 12 months after STN stimulation in both group I and II. The off-time UPDRS III speech subscore significantly improved (1.6 +/- 0.7 at baseline vs 1.3 +/- 0.8 at 6 and 12 months, P < 0.01) with least L-dopa equivalent daily dose (LEDD) (844.6 +/- 364.1 mg/day at baseline; 279.4 +/- 274.6 mg/day at 6 months; and 276.0 +/- 301.6 mg/day at 12 months, P < 0.001) at 6 and 12 months after STN deep brain stimulation (DBS) in the group I. Our findings suggest that the better symptom relief including speech with a reduced LEDD is expected in the patients whose electrodes are accurately positioned in both STN.

Hypersexuality following subthalamic nucleus stimulation for Parkinson's disease.

Subthalamic nucleus (STN) stimulation is an established surgical treatment for Parkinson's disease (PD). Though the motor benefits of STN stimulation are well understood, its cognitive and behavioral effects are still not fully understood. Manic psychosis, hypersexuality, pathological gambling and mood swings are associated with advanced PD. There have been reports to suggest improvement or worsening in these symptoms following STN deep brain stimulation (DBS). We report two cases as the sole behavioral side-effects of STN stimulation despite good clinical improvement on long-term follow-up. These patients and literature review suggests the complex role of STN stimulation in motor and behavioral control.

Complicaciones quirúrgicas y mecánicas de la estimulación cerebral profunda en el tratamiento de la enfermedad de Parkinson / Surgical and mechanical complications of deep cerebral stimulation in Parkinson's diseases treatment

Introducción: La estimulación cerebral del núcleo subtalámico es un método eficaz y en expansión para el tratamiento de la enfermedad de Parkinson. Aunque se trata de un procedimiento poco invasivo puede presentar complicaciones quirúrgicas y efectos secundarios indeseables. Método: entre marzo de 2001 y diciembre de 2006, hemos implantado 208 electródos subtalámicos en 100 pacientes afectados de enfermedad de Parkinson, en el Hospital Clínico de Santiago de Compostela. Se revisan las complicaciones quirúrgicas y mecánicas o de hardware presentadas tanto durante la cirugía como en el seguimiento que osciló entre 6 y 63 meses (media 27 meses). No hubo fallecimientos ni se perdió el control de ningún paciente. Resultados: se presentaron 20 complicaciones quirúrgicas en los 100 pacientes (20 por ciento) y 9 complicaciones mecánicas (9 por ciento). Las complicaciones quirúrgicas más habituales fueron 8 casos de malposición o migración de los electródos, 5 casos de infección, 3 hemorragias subcorticales y 3 episodios convulsivos. Entre las complicaciones mecánicas se presentaron 7 episodios de disfunción de la batería y 2 casos de ruptura del electródo. Conclusiones: la estimulación cerebral profunda es un tratamiento a largo plazo que requiere de controles continuados. Las complicaciones quirúrgicas y de hardware no suponen un riesgo vital importante sin embargo tienen un coste económico importante.

Introducction: Subthalamic nucleus stimulation for patients with medically refractory Parkinson disease is expanding. Although nonablative and minimally invasive, this procedure may give rise to many surgical complications and side effects. Methods: from March 2001 to December 2006, 208 subthalamic stimulator devices were implanted in 100 patients with Parkinson disease at Clinic Hospital of Santiago de Compostela (Spain). The author prospectively documented surgical and hardware complications occurring at the time of surgery and at subsequent neurologic and surgical evaluations for an average of 27 months, ranging from 6 to 63 months. No patients were lost to follow-up or died. Results: There were 20 adverse events related to surgery in 100 patients (20 percent)and 9 hardware-related complications (9 percent). The most important surgical complications were 8 electrodes migration or malposition, 5 infections, 3 subcortical haemorrhages and 3 seizures whereas the hardware complications were 7 stimulator malfunction and 2 electrode breakages. Conclusions: Deep brain stimulation is a life-long therapy that requires a life-long follow-up. Complications due to surgery or hardware are not life-threatening but are expensive in economic terms and in terms of patients suffering.