Subtalamotomía bilateral diferida guiada por microrregistros. Resultados motores a un año / Bilateral delayed subtalamotomy guided by micro-records. One-year motor results

Introducción: diferentes técnicas quirúrgicas representan una alternativa para el tratamiento de la enfermedad de Parkinson avanzada (EP). El gran desarrollo en las últimas décadas de modernas técnicas de imágenes sumado a los avances del registro neurofisiológico nos permiten localizar y generar lesiones en forma precisa, con bajo número de complicaciones y excelentes resultados funcionales. Objetivo: Describir los resultados motores obtenidos a los 12 meses post-operatorios de pacientes con diagnóstico de EP avanzada sometidos a subtalamotomía bilateral diferida guiada por microrregistro. Material y Métodos: Se seleccionaron 9 pacientes con diagnóstico de EP avanzada de acuerdo a los criterios de la United Kingdom Parkinson´s Disease Brain Bank, evaluando los efectos de la subtalamotomía bilateral en dos tiempos quirúrgicos. Resultados: Una marcada mejoría de los síntomas cardinales como rigidez, bradicinesia y temblor se observó en todos los pacientes, fundamentalmente en la condición de “off”, y en menor medida también en condición “on”. Se destaca un significativo control de las fluctuaciones motoras y discinesias. Conclusión: La subtalamotomía bilateral diferida guiada por microregistro es un método útil y efectivo en el tratamiento de los síntomas motores de la Enfermedad de Parkinson.

Introduction: in the treatment of advanced Parkinson´s disease (PD) there are different surgical techniques that represent a valid alternative. The development of modern images techniques and neurofisiological recording allow us to generate accurate lesions, with low complications and excellent functional results. Objective: Describe motor results 12 months post-surgical of patients with advanced PD submitted to bilateral and deferred subthalamotomy guided by microrecording. Material and Methods: We selected 9 patients with advanced PD diagnosis in concordance with United Kingdom Parkinson`s Disease Brain Bank criteria, evaluating the effects of bilateral subthalamotomy in two different surgical steps. Results: A marked improvement of cardinal symptoms such as rigidity, bradykinesia and tremor was observed in all patients, fundamentally in “off” condition, and lesser extent in “on” condition. We highlighted a significant control of motor fluctuations and dyskinesias. Conclusion: Bilateral and deferred suthalamotomy guided by microrecording is an effective and useful method in treatment of cardinal motor symptoms of PD.

A Case of Hemichorea with Primary Somatosensory Cortical Infarction / 대한뇌졸중학회지

Hemichorea is caused by various diseases but stroke is the most common cause. The usual lesions of the stroke related hemichorea are the contralateral subthalamus or basal ganglia. Few cases with cortical lesion have been reported. But hemichorea with primary somatosensory cortical lesion has not yet been reported. We report a case with hemichorea after acute infarction of the contralateral primary somatosensory cortex.

Microelectrode Recording-Guided Deep Brain Stimulation in Patients with Movement Disorders

OBJECTIVE: The authors analyzed the findings of microelectrode recording data and reported the surgical outcomes of movement disorder patients. METHODS: Since February 2000, the authors have used DBS for the movement disorders. We evaluated 4 patients who were followed more than 12 months after operation. One patient with essential tremor was treated with thalamic stimulation and three patients with idiopathic advanced Parkinson's disease with bilateral subthalamic nucleus stimulation. The electrodes were inserted under microelectrode recording. Clinical assessments were performed preoperatively and postoperatively by neurologist. RESULTS: All features of parkinsonian symptoms improved and the greatest benefit occurred in off-time and ADL. Interestingly our three patients with advanced Parkinson's disease did not have off-time after bilateral stimulation of subthalamic nucleus. There were no adverse side effects related to microelectrode recording or DBS procedure in all 4 patients. In our results of microelectrode recording of subthalamic nucleus, subthalamus showed higher firing rate than that of substantia nigra pars reticularis. Mean burst frequency of subthalamic nucleus was much higher than that of substantia nigra pars reticularis. CONCLUSION: The first trials of DBS in Korea also demonstrated favorable outcomes for movement disorders.

Blockade of the Subthalamo-nigral Pathway Prevents the Motor Component of Pilocarpine Induced Generalized Convulsive Seizure in Rats

BACKGROUND: The substantia nigra pars reticulata is a critical site for the control of epileptic seizures. The potentiation of the inhibitory gamma-amino butyric acid (GABA) ergic input from the striatum to the substantia nigra pars reticulata suppresses primary or secondary generalized seizures in rats. Recent data suggests that the projection from the subthala-mus to the substantia nigra pars reticulata plays a critical role in the control of some forms of epileptic seizures. METHODS: We examined the possible involvement of the excitatory glutamatergic input from the subthalamic nucleus (STN) to the substantia nigra in pilocarpine-induced seizures by the direct injection of GABA receptor agonist (muscimol) and n-methyl- D-aspartate (NMDA) receptor antagonist (MK-801) into the substantia nigra pars reticularis (SNr) and the subthalamic nucleus respectively. Sprague-Dawley rats were classified into four groups depending on the pretreatment; the injection of saline (STN sham) or muscimol (STN) into the subthalamic nucleus, and the injection of saline (SNr sham) or MK-801 (SNr) into the substantia nigra. Seizure was induced by the intraperitoneal injection of pilocarpine (400 mg/kg). RESULTS: Mean seizure stages in the STN group (1.5 +/-0.5) and SNr group (1.3 +/-0.5) were significantly lower than STN sham group (4.8 +/-0.4) and SNr sham group (4.8 +/-0.4) (P <0.05). Electroencephlograms showed typical status epilepticus patterns in the sham operation group but only discrete ictal discharges with slowing and intermittent ictal spikes were shown in both STN and SNr group. Viable cell numbers in the CA1 and CA3 in STN and SNr groups were significantly higher than those of the sham group (P <0.05). CONCLUSIONS: These results provide evidence for the role of subthalamo-nigral projections in the modulation of pilocarpine-induced seizures.

MR Imaging of Kernicterus: A Case Report

Kernicterus is a neurologic syndrome, resulting from the preferential deposition of unconjugated bilirubin in the globus pallidus, subthalamus, hippocampus, and brain stem. The characteristic finding of kernicterus revealed by T2-weighted MR imaging is irreversible, bilaterally symmetrical high signal intensities in the globus pallidus. We report an atypical case of kernicterus, in which follow-up MR imaging of the globus pallidus demonstrated reversible signal intensity.

Nasopharyngeal recordings of N18 far-field potential in Somatosensory Evoked Potential ( SEP )

BACKGROUNDS: The widespread N18 in the median nerve SEP is a broad negativity following positive far-field potentials and is widely distributed over the scalp. It is suggested that the N18 may be originated from subthalamus or upper brainstem nuclei. But there remains substantial controversy regarding its origin. Recently, it is proposed that the N18 is generated in the medulla. For the evaluation of its origin, we used nasopharyngeal electrode for recording SEP stimulated by median nerve stimulation. METHODS: Standard methods of recording SEP were used in 19 normal adults(36 sides, 19-68 years, 9 males). 11 patients with following locations of the lesions were studied: 2 high cervical cord, 1 ponto-medullary junction, 3 pons, and 5 thalamus. We evaluated the N18 potentials at ventral medulla level, using nasopharyngeal electrode and recorded them at scalp by non-cephalic reference recording. We compared the amplitude and duration of the N18 at scalp with those at nasopharyngeal electrode. RESULTS: The mean amplitude and duration of N18 at scalp showed no significant difference from that at nasopharyngeal electrode(1.76+/-0.4 microvolt, 16.48+/-2.47 msec and 1.75+/-0.4 microvolt, 16.56+/-2.19 msec, p>0.5). The N18 was absent in 2 patients with high cervical cord lesions. The amplitude and duration of the N18 were normal in all other patients with brainstem and thalamic lesions, including a patient with lesion at the ponto-medullary junction. CONCLUSIONS: These results suggested that N18 is generated in the medulla and not more rostrally in the brainstem.

A Case of Hemichorea Ipsilateral to the Basal Ganglia Hemorrhage

Hemichorea is usually caused by lesions in the contralateral subthalamus and basal ganglia. Ipsilateral lesions have rarely been reported to be responsible for the abnormal movement. A 27 year-old woman with well-controlled hyper-thyroidism presented with sudden involuntary movements in the right limbs and a mild headache. The movements were random, irregular, repetitive, and most prominent in the right hand and forearm, but also found in the right leg and face. She experienced no weaknesses in the contralateral limbs. A brain magnetic resonance imaging(MRI) taken after 7 days showed early subacute hematoma in the right basal ganglia. There were no lesions in the left hemisphere. In a cerebral angiography, the bilateral major cerebral vessels were narrowed around the circle of Willis. We critically review previous reports of and explanations for the development of ipsilateral hemichorea.

A Case of chronic acquired hepatocerebral degeneration caused by a porto-systemic shunt by multiple anomalous vessels

BACKGROUND AND SIGNIFICANCE: Chronic acquired hepatocerebral degeneration(CAHD) is a heterogenous disorder that can occur with a primary neurologic, hepatic, or combined presentation. Characteristic radiologic finding is high signal in globus pallidus on T1WI MRI, and which is associated with increased level of Manganese. We experienced a patient with CAHD presenting various involuntary movements. Our patient had multiple anomalous vessels with a porto-systemic shunt in abdomen in absence of liver cirrhosis. CASE: A 74-years-old female was admitted because of gradually progressive buccal and lingual choreiform movements with moderate generalized chorea. In our patient, T1 weighted MRI of the brain showed symmetric high signal intensity in both globus pallidus and subthalamus. Increased ammonia level(165umol/L) and Manganese level(7.75ug/dl) in whole blood, pancytopopenia in peripheral blood smear and a multiple vessel anomaly with a porto-systemic shunt on abdominal ultrasonography and CT were found. These involuntary movements had a dramatic response to neuroleptics and nearly disappeared within 5 days. CONCLUSION: We report one patient with chronic acquired hepatocerebral degeneration which had a porto-systemic shunt by anomalous vessels and various involuntary movements.

Dopaminergic Neurons in the Diencephalon of Striped Field MouseApodemus agrarius coreae / 대한해부학회지

The distributions and morphological characteristics of neurons displaying immunoreactivity to the catecholamine synthetic enzymes, tyrosine hydroxylase[TH], dopamine-beta-hydroxylase[DBH], and phenyletha-nolamine-N-methyltransferase[PNMT] were examined in the adjacent sections of the diencephalon of the striped field mouse [Apodemus agrarius coreae].Only TH-, and no DBH- or PNMT-immunoreactive neurons were found in the diencephalon. In the preoptic area, TH-immunoreactive neurons were found in the anterior preoptic nucleus of Loo[APN], periventricular preoptic nucleus, medial preoptic nucleus, lateral preoptic nucleus and suprachiasmatic nucleus. In the hypothalamus, TH-immunoreactive neurons were found in theparaventricular hypothalamic nucleus, periventricular gray, retrochiasmatic area,anterior hypothalamic nucleus of anterior hypothalamic area and retrochiasmatic region of the hypothalamus. In the rostral tuberal region of the hypothalamus, TH-immunoreactive neurons were found in the paraventricular nucleus, periventricular gray and arcuate nucleus. In the midtuberal region of the hypothalamus, TH-immunoreactive neurons were found in the paraventricular nucleus, dorsomedial hypothalamic nucleus, zona incerta and arcuate nucleus. In the caudal tuberal region of the hypothalamus, dorsal hypothalamic nucleus, posterior hypothalamic complex and arcuate nucleus.