1730陶英群沈阳军区总医院神经外科-陶英群2014-5-31下午201功能神经外科会场

陶英群李智勇梁国标许峰等解放军神经医学研究所沈阳军区总院神经外科STN-DBSforParkinson’[e-mail]’sDiseaseThesecondmostcommonneurodegenerativedisorderPrevalence–Worldwide:0.3%(entirepopulation);1-2%(60years)–China:1.7%(65years)Incidence–Worldwide:8-18per100000person-years–China:1.5per100000person-yearsin1986DeepBrainStimulation(DBS)100,000+DBSdeviceshavebeenimplantedworldwideIndications(approvedbyFDA)ConditionMostcommondeepnucleartargets(UnitedStates)ParkinsondiseaseSTN,GPiFDAapprovedEssentialtremorThalamus(Vim)FDAapprovedDystoniaGPi,Thalamus(Vim)FDAapprovedObsessive-compulsivedisorderALICFDAapprovedObsessive-compulsivedisorderNAc,VC/VS,ITPBeingstudiedSpasmodicdysphoniaThalamus(Vim)BeingstudiedOrthostatictremorThalamus(Vim)BeingstudiedMeigesyndromeGPi,Thalamus(Vim)BeingstudiedClusterheadacheHypothalamusBeingstudiedSUNCTHypothalamusBeingstudiedTrigeminalneuropathyHypothalamusBeingstudiedTrigeminalneuralgiaHypothalamusBeingstudiedChronicparoxysmalhemicraniaHypothalamusBeingstudiedChronicpainThalamus(VPL/VPM,Vc),PAG/PVGBeingstudiedTourettesyndromeGPi,thalamus(CM/pf)BeingstudiedAggressivebehaviorHypothalamusBeingstudiedDepressionCingulum,VS,STN,GPi,ITP,NAc,ALIC,LHBeingstudiedEpilepsyThalamus(CM/pf,AN),ICN,STN,hippocampusBeingstudiedCamptocormiaGPi,STNBeingstudiedRestlesslegssyndromeSTNBeingstudiedObesity/addictionsNAcBeingstudiedDisorderofconsciousnessThalamus(CM/pf)BeingstudiedAlzheimerdiseaseFornix/hypothalamusBeingstudiedDBSinChinaFirstDBSsurgeryinChina:19985000+patients,40+medicalcentersDBSinNortheastChinaFirstDBSsurgeryinNortheastChina:2011inTheGeneralHospitalofShenyangMilitaryCommand(GHSMC)Over60PDpatientsunderwentSTN-DBSinGHSMCtillnowDBSinGHSMC•32STN-DBSsurgeriesfrom2011.11-2013.11(27bilateral;5unilateral)–Gender:15male,17female–Age:65.7±5.9(49-80)–Diseasecourse:7.2±3.8(3-19)–H&Y:2～5•Assessments–Pre-operation,3monthsafteroperation–UPDRS;SDS;SCL-90;WAIS.DBSinGHSMC•Results–UPDRSMedOffMedOnPre-operationPost-operationImprove--mentratePre-operationPost-operationImprovementrateUPDRSII(dailylivingactivities)42.2±7.520.4±8.851.7%23.4±7.318.4±6.321.4%UPDRSIII(motorfunction)32.5±7.112.7±2.360.9%15.7±3.212.5±4.322.3%DBSinGHSMC•Results–SCL-90(20patients)•※-statisticaldifferencebetweenPre-operationandChinanorm•□-statisticaldifferencebetweenPre-operationandPost-operationFactorsChinanormPre-operationPost-operationSomatization1.34±0.452.66±0.45※1.69±0.47□obsession1.96±0.612.26±0.341.80±0.31interpersonalsensitivity1.76±0.672.08±0.25※1.63±0.37depression1.57±0.613.04±0.56※1.83±0.52□anxiety1.42±0.432.73±0.53※1.70±0.53□hostility1.50±0.572.15±0.29※1.49±0.29fear1.33±0.472.53±0.33※1.45±0.41□paranoia1.52±0.602.21±0.33※1.51±0.47psychosis1.36±0.472.17±0.311.51±0.42□Discussion-KeyPointsinDBSsurgery•KeyPoint1–PatientSelection•BestCandidateforDBS•levodoparesponsiveness(UPDRSmotorscoreimprovement30%)Discussion-KeyPointsinDBSsurgery•KeyPoint2–Precisetargetlocalizationandleadimplantation•Anatomicallocalization(MRI/CT)•Electrophysiologicallocalization(microelectroderecording,MER)•IntraoperativetestingstimulationDiscussion-KeyPointsinDBSsurgery•KeyPoint3–Reducingsurgicalcomplications•SurgicalpositionofPatient–Headuptilt-reducethelossofcerebrospinalfluidandthethecorrespondingbrainshift–Theendofbedup-preventstressdeformationandslippageofheadframe•Arcincision-reduceincisioncomplications•Sphenotresialocation-morethan3.5cmawayfromthemidlinetopreventelectrodemigrationDBSforPDnon-motorsymptoms•Non-motorsymptomsdominatetheclinicalpictureofadvancedParkinson’sdiseaseandcontributetoseveredisability,impairedqualityoflife,andshortenedlifeexpectancy•Attentionisnowbeingfocusedonthenon-motorsymptomsDiscussion-STNvs.GPiDiscussion-STNvs.GPiDiscussion-STNvs.GPiTargetAdvantageDisadvantageSTN•moreeffectiveinaddressingbradykinesia•moremedicationreduction•less-frequentbatterychanges•morefavorableeconomicprofile•moreseriouscognitivedecline•morecommonwithcognitiveandbehaviouraladverseeventsGPi•moreimprovementindyskinesia•easierprogramming•greaterflexibilityinadjustingMedications•lessmedicationreduction•morebatteryconsumption•Non-motorDiscussion–Non-motorsymptoms(NMS)•Non-motor–Depression&Fatigue/apathy&AnxietyFU=follow-updurationimprovementwithnegativescores,andworseningwithpositivescoresDiscussion–Non-motorsymptoms(NMS)Discussion–Newindications•Depression–20%-30%ofdepressionpatientsfailtorespondtostandardinterventions–SubgenualcingulateregionCg25(Brodmannarea25)ismetabolicallyoveractiveintreatment-resistantdepression(TRD)–Maybergandcolleaguesreportedaclinicstudyin6patientswithTRDusinghighfrequencyCg25DBSDiscussion–Newindications•Depression–StudyofMaybergandcolleaguesDBSElectrodePlacementintheSubgenualCingulateWhiteMatterCg25–Brodmann25Discussion–Newindications•Depression–StudyofMaybergandcolleagues•Clinicalresponse:decreaseHDRSscore50%•Clinicalremission:absoluteHDRSscore8•5ofthe6patientsrespondedafter2monthsofstimulation•4maintainedaresponseafter6months•3achievedremissionornearremissionofillnessDiscussion–Newindications•Depression–StudyofMaybergandcolleaguesThepa