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Vol. 87, No. 1, 2009
Issue release date: February 2009
Section title: Clinical Study
Free Access
Stereotact Funct Neurosurg 2009;87:37–44
(DOI:10.1159/000195718)

Induction of Bradykinesia with Pallidal Deep Brain Stimulation in Patients with Cranial-Cervical Dystonia

Berman B.D.a · Starr P.A.b, c · Marks, Jr. W.J.a, c · Ostrem J.L.a, c
Departments of aNeurology and bNeurological Surgery, University of California, and cDepartment of Veterans Affairs Parkinson’s Disease Research, Education, and Clinical Center (PADRECC), San Francisco, Calif., USA
email Corresponding Author

Abstract

Background: Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is an effective and well-tolerated treatment for idiopathic generalized dystonia. More recently, it has been applied as a treatment for focal and segmental dystonias. This patient population offers an opportunity to study the effects of alteration of pallidal outflow on previously normal limb function. Methods: We sought to retrospectively characterize the extent of novel GPi DBS-induced adverse motor effects in patients with adult-onset cervical and cranial-cervical dystonia using a questionnaire, and compared the findings to dystonia improvement as measured by standard scales. Results: Despite significant improvement in dystonia (65% in mean Burke-Fahn-MarsdenDystonia Rating Scale motor score, p < 0.005, and 59% in mean Toronto Western Spasmodic Torticollis Rating Scale score, p < 0.008), slowing and difficulty with normal motor function was reported in previously nondystonic extremities in 10 of 11 patients. Symptoms were common in both upper and lower extremities and included new difficulties with handwriting (82%), getting up from a chair or in/out of a car (73%), and walking (45%), and were not associated with aberrant lead placement near the internal capsule. Conclusion: Although GPi DBS was shown to be effective in these patients, the influence of GPi DBS on nondystonic body regions deserves further investigation.

© 2009 S. Karger AG, Basel


  

Key Words

  • Dystonia
  • Deep brain stimulation
  • Globus pallidus
  • Cranial-cervical dystonia
  • Bradykinesia

References

  1. Vidailhet M, Vercueil L, Houeto JL, Krystkowiak P, Benabid AL, Cornu P, Lagrange C, Tezenas du Montcel S, Dormont D, Grand S, Blond S, Detante O, Pillon B, Ardouin C, Agid Y, Destee A, Pollak P: Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia. N Engl J Med 2005;352:459–467.
  2. Kupsch A, Benecke R, Muller J, Trottenberg T, Schneider GH, Poewe W, Eisner W, Wolters A, Muller JU, Deuschl G, Pinsker MO, Skogseid IM, Roeste GK, Vollmer-Haase J, Brentrup A, Krause M, Tronnier V, Schnitzler A, Voges J, Nikkhah G, Vesper J, Naumann M, Volkmann J: Pallidal deep-brain stimulation in primary generalized or segmental dystonia. N Engl J Med 2006;355:1978–1990.
  3. Coubes P, Cif L, El Fertit H, Hemm S, Vayssiere N, Serrat S, Picot MC, Tuffery S, Claustres M, Echenne B, Frerebeau P: Electrical stimulation of the globus pallidus internus in patients with primary generalized dystonia: long-term results. J Neurosurg 2004;101:189–194.
  4. Yianni J, Bain P, Giladi N, Auca M, Gregory R, Joint C, Nandi D, Stein J, Scott R, Aziz T: Globus pallidus internus deep brain stimulation for dystonic conditions: a prospective audit. Mov Disord 2003;18:436–442.
  5. Krauss JK, Loher TJ, Pohle T, Weber S, Taub E, Barlocher CB, Burgunder JM: Pallidal deep brain stimulation in patients with cervical dystonia and severe cervical dyskinesias with cervical myelopathy. J Neurol Neurosurg Psychiatry 2002;72:249–256.
  6. Hung SW, Hamani C, Lozano AM, Poon YY, Piboolnurak P, Miyasaki JM, Lang AE, Dostrovsky JO, Hutchison WD, Moro E: Long-term outcome of bilateral pallidal deep brain stimulation for primary cervical dystonia. Neurology 2007;68:457–459.
  7. Ostrem JL, Marks WJ Jr, Volz MM, Heath SL, Starr PA: Pallidal deep brain stimulation in patients with cranial-cervical dystonia (meige syndrome). Mov Disord 2007;22:1885–1891.
  8. Tisch S, Zrinzo L, Limousin P, Bhatia KP, Quinn N, Ashkan K, Hariz M: Effect of electrode contact location on clinical efficacy of pallidal deep brain stimulation in primary generalised dystonia. J Neurol Neurosurg Psychiatry 2007;78:1314–1319.
  9. Burke RE, Fahn S, Marsden CD, Bressman SB, Moskowitz C, Friedman J: Validity and reliability of a rating scale for the primary torsion dystonias. Neurology 1985;35:73–77.
  10. Comella CL, Stebbins GT, Goetz CG, Chmura TA, Bressman SB, Lang AE: Teaching tape for the motor section of the Toronto Western Spasmodic Torticollis Scale. Mov Disord 1997;12:570–575.
  11. Starr PA, Turner RS, Rau G, Lindsey N, Heath S, Volz M, Ostrem JL, Marks WJ Jr: Microelectrode-guided implantation of deep brain stimulators into the globus pallidus internus for dystonia: techniques, electrode locations, and outcomes. J Neurosurg 2006;104:488–501.
  12. Starr PA, Christine CW, Theodosopoulos PV, Lindsey N, Byrd D, Mosley A, Marks WJ Jr: Implantation of deep brain stimulators into the subthalamic nucleus: technical approach and magnetic resonance imaging-verified lead locations. J Neurosurg 2002;97:370–387.
  13. Starr PA: Placement of deep brain stimulators into the subthalamic nucleus or globus pallidus internus: technical approach. Stereotact Funct Neurosurg 2002;79:118–145.
  14. McIntyre CC, Grill WM, Sherman DL, Thakor NV: Cellular effects of deep brain stimulation: model-based analysis of activation and inhibition. J Neurophysiol 2004;91:1457–1469.
  15. Moro E, Lang AE, Strafella AP, Poon YY, Arango PM, Dagher A, Hutchison WD, Lozano AM: Bilateral globus pallidus stimulation for Huntington’s disease. Ann Neurol 2004;56:290–294.
  16. Diederich NJ, Kalteis K, Stamenkovic M, Pieri V, Alesch F: Efficient internal pallidal stimulation in Gilles de la Tourette syndrome: a case report. Mov Disord 2005;20:1496–1499.
  17. Mink JW, Thach WT: Basal ganglia motor control. 1. Nonexclusive relation of pallidal discharge to five movement modes. J Neurophysiol 1991;65:273–300.
  18. Wenger KK, Musch KL, Mink JW: Impaired reaching and grasping after focal inactivation of globus pallidus pars interna in the monkey. J Neurophysiol 1999;82:2049–2060.
  19. Inase M, Buford JA, Anderson ME: Changes in the control of arm position, movement, and thalamic discharge during local inactivation in the globus pallidus of the monkey. J Neurophysiol 1996;75:1087–1104.
  20. Chou KL, Hurtig HI, Jaggi JL, Baltuch GH: Bilateral subthalamic nucleus deep brain stimulation in a patient with cervical dystonia and essential tremor. Mov Disord 2005;20:377–380.
  21. Sun B, Li D, Sun C: Target selection for primary dystonia deep brain stimulation: GPI or STN. Proc Am Soc Stereotact Funct Neurosurg Quadrennial Meet, New York, 2003, p 91.
  22. Zhang JG, Zhang K, Wang ZC, Ge M, Ma Y: Deep brain stimulation in the treatment of secondary dystonia. Chin Med J (Engl) 2006;119:2069–2074.
  23. Kleiner-Fisman G, Liang GS, Moberg PJ, Ruocco AC, Hurtig HI, Baltuch GH, Jaggi JL, Stern MB: Subthalamic nucleus deep brain stimulation for severe idiopathic dystonia: impact on severity, neuropsychological status, and quality of life. J Neurosurg 2007;107:29–36.
  24. Soares J, Kliem MA, Betarbet R, Greenamyre JT, Yamamoto B, Wichmann T: Role of external pallidal segment in primate parkinsonism: comparison of the effects of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced parkinsonism and lesions of the external pallidal segment. J Neurosci 2004;24:6417–6426.
  25. Zhang J, Russo GS, Mewes K, Rye DB, Vitek JL: Lesions in monkey globus pallidus externus exacerbate parkinsonian symptoms. Exp Neurol 2006;199:446–453.
  26. Alterman RL, Miravite J, Weisz D, Shils JL, Bressman SB, Tagliati M: Sixty hertz pallidal deep brain stimulation for primary torsion dystonia. Neurology 2007;69:681–688.
  27. Birdno MJ, Grill WM: Mechanisms of deep brain stimulation in movement disorders as revealed by changes in stimulus frequency. Neurotherapeutics 2008;5:14–25.

  

Author Contacts

Jill L. Ostrem
University of California San Francisco
400 Parnassus Ave, Box 0138
San Francisco, CA 94143 (USA)
Tel. +1 415 502 3576, Fax +1 415 502 4276, E-Mail jill.ostrem@ucsf.edu

  

Article Information

Published online: January 28, 2009
Number of Print Pages : 8
Number of Figures : 3, Number of Tables : 3, Number of References : 27

  

Publication Details

Stereotactic and Functional Neurosurgery

Vol. 87, No. 1, Year 2009 (Cover Date: February 2009)

Journal Editor: Roberts D.W. (Lebanon, N.H.)
ISSN: 1011-6125 (Print), eISSN: 1423-0372 (Online)

For additional information: http://www.karger.com/SFN


Copyright / Drug Dosage / Disclaimer

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

Abstract

Background: Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is an effective and well-tolerated treatment for idiopathic generalized dystonia. More recently, it has been applied as a treatment for focal and segmental dystonias. This patient population offers an opportunity to study the effects of alteration of pallidal outflow on previously normal limb function. Methods: We sought to retrospectively characterize the extent of novel GPi DBS-induced adverse motor effects in patients with adult-onset cervical and cranial-cervical dystonia using a questionnaire, and compared the findings to dystonia improvement as measured by standard scales. Results: Despite significant improvement in dystonia (65% in mean Burke-Fahn-MarsdenDystonia Rating Scale motor score, p < 0.005, and 59% in mean Toronto Western Spasmodic Torticollis Rating Scale score, p < 0.008), slowing and difficulty with normal motor function was reported in previously nondystonic extremities in 10 of 11 patients. Symptoms were common in both upper and lower extremities and included new difficulties with handwriting (82%), getting up from a chair or in/out of a car (73%), and walking (45%), and were not associated with aberrant lead placement near the internal capsule. Conclusion: Although GPi DBS was shown to be effective in these patients, the influence of GPi DBS on nondystonic body regions deserves further investigation.

© 2009 S. Karger AG, Basel


  

Author Contacts

Jill L. Ostrem
University of California San Francisco
400 Parnassus Ave, Box 0138
San Francisco, CA 94143 (USA)
Tel. +1 415 502 3576, Fax +1 415 502 4276, E-Mail jill.ostrem@ucsf.edu

  

Article Information

Published online: January 28, 2009
Number of Print Pages : 8
Number of Figures : 3, Number of Tables : 3, Number of References : 27

  

Publication Details

Stereotactic and Functional Neurosurgery

Vol. 87, No. 1, Year 2009 (Cover Date: February 2009)

Journal Editor: Roberts D.W. (Lebanon, N.H.)
ISSN: 1011-6125 (Print), eISSN: 1423-0372 (Online)

For additional information: http://www.karger.com/SFN


Article / Publication Details

First-Page Preview
Abstract of Clinical Study

Published online: 1/28/2009
Issue release date: February 2009

Number of Print Pages: 8
Number of Figures: 3
Number of Tables: 3

ISSN: 1011-6125 (Print)
eISSN: 1423-0372 (Online)

For additional information: http://www.karger.com/SFN


Copyright / Drug Dosage

Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher or, in the case of photocopying, direct payment of a specified fee to the Copyright Clearance Center.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in goverment regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

References

  1. Vidailhet M, Vercueil L, Houeto JL, Krystkowiak P, Benabid AL, Cornu P, Lagrange C, Tezenas du Montcel S, Dormont D, Grand S, Blond S, Detante O, Pillon B, Ardouin C, Agid Y, Destee A, Pollak P: Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia. N Engl J Med 2005;352:459–467.
  2. Kupsch A, Benecke R, Muller J, Trottenberg T, Schneider GH, Poewe W, Eisner W, Wolters A, Muller JU, Deuschl G, Pinsker MO, Skogseid IM, Roeste GK, Vollmer-Haase J, Brentrup A, Krause M, Tronnier V, Schnitzler A, Voges J, Nikkhah G, Vesper J, Naumann M, Volkmann J: Pallidal deep-brain stimulation in primary generalized or segmental dystonia. N Engl J Med 2006;355:1978–1990.
  3. Coubes P, Cif L, El Fertit H, Hemm S, Vayssiere N, Serrat S, Picot MC, Tuffery S, Claustres M, Echenne B, Frerebeau P: Electrical stimulation of the globus pallidus internus in patients with primary generalized dystonia: long-term results. J Neurosurg 2004;101:189–194.
  4. Yianni J, Bain P, Giladi N, Auca M, Gregory R, Joint C, Nandi D, Stein J, Scott R, Aziz T: Globus pallidus internus deep brain stimulation for dystonic conditions: a prospective audit. Mov Disord 2003;18:436–442.
  5. Krauss JK, Loher TJ, Pohle T, Weber S, Taub E, Barlocher CB, Burgunder JM: Pallidal deep brain stimulation in patients with cervical dystonia and severe cervical dyskinesias with cervical myelopathy. J Neurol Neurosurg Psychiatry 2002;72:249–256.
  6. Hung SW, Hamani C, Lozano AM, Poon YY, Piboolnurak P, Miyasaki JM, Lang AE, Dostrovsky JO, Hutchison WD, Moro E: Long-term outcome of bilateral pallidal deep brain stimulation for primary cervical dystonia. Neurology 2007;68:457–459.
  7. Ostrem JL, Marks WJ Jr, Volz MM, Heath SL, Starr PA: Pallidal deep brain stimulation in patients with cranial-cervical dystonia (meige syndrome). Mov Disord 2007;22:1885–1891.
  8. Tisch S, Zrinzo L, Limousin P, Bhatia KP, Quinn N, Ashkan K, Hariz M: Effect of electrode contact location on clinical efficacy of pallidal deep brain stimulation in primary generalised dystonia. J Neurol Neurosurg Psychiatry 2007;78:1314–1319.
  9. Burke RE, Fahn S, Marsden CD, Bressman SB, Moskowitz C, Friedman J: Validity and reliability of a rating scale for the primary torsion dystonias. Neurology 1985;35:73–77.
  10. Comella CL, Stebbins GT, Goetz CG, Chmura TA, Bressman SB, Lang AE: Teaching tape for the motor section of the Toronto Western Spasmodic Torticollis Scale. Mov Disord 1997;12:570–575.
  11. Starr PA, Turner RS, Rau G, Lindsey N, Heath S, Volz M, Ostrem JL, Marks WJ Jr: Microelectrode-guided implantation of deep brain stimulators into the globus pallidus internus for dystonia: techniques, electrode locations, and outcomes. J Neurosurg 2006;104:488–501.
  12. Starr PA, Christine CW, Theodosopoulos PV, Lindsey N, Byrd D, Mosley A, Marks WJ Jr: Implantation of deep brain stimulators into the subthalamic nucleus: technical approach and magnetic resonance imaging-verified lead locations. J Neurosurg 2002;97:370–387.
  13. Starr PA: Placement of deep brain stimulators into the subthalamic nucleus or globus pallidus internus: technical approach. Stereotact Funct Neurosurg 2002;79:118–145.
  14. McIntyre CC, Grill WM, Sherman DL, Thakor NV: Cellular effects of deep brain stimulation: model-based analysis of activation and inhibition. J Neurophysiol 2004;91:1457–1469.
  15. Moro E, Lang AE, Strafella AP, Poon YY, Arango PM, Dagher A, Hutchison WD, Lozano AM: Bilateral globus pallidus stimulation for Huntington’s disease. Ann Neurol 2004;56:290–294.
  16. Diederich NJ, Kalteis K, Stamenkovic M, Pieri V, Alesch F: Efficient internal pallidal stimulation in Gilles de la Tourette syndrome: a case report. Mov Disord 2005;20:1496–1499.
  17. Mink JW, Thach WT: Basal ganglia motor control. 1. Nonexclusive relation of pallidal discharge to five movement modes. J Neurophysiol 1991;65:273–300.
  18. Wenger KK, Musch KL, Mink JW: Impaired reaching and grasping after focal inactivation of globus pallidus pars interna in the monkey. J Neurophysiol 1999;82:2049–2060.
  19. Inase M, Buford JA, Anderson ME: Changes in the control of arm position, movement, and thalamic discharge during local inactivation in the globus pallidus of the monkey. J Neurophysiol 1996;75:1087–1104.
  20. Chou KL, Hurtig HI, Jaggi JL, Baltuch GH: Bilateral subthalamic nucleus deep brain stimulation in a patient with cervical dystonia and essential tremor. Mov Disord 2005;20:377–380.
  21. Sun B, Li D, Sun C: Target selection for primary dystonia deep brain stimulation: GPI or STN. Proc Am Soc Stereotact Funct Neurosurg Quadrennial Meet, New York, 2003, p 91.
  22. Zhang JG, Zhang K, Wang ZC, Ge M, Ma Y: Deep brain stimulation in the treatment of secondary dystonia. Chin Med J (Engl) 2006;119:2069–2074.
  23. Kleiner-Fisman G, Liang GS, Moberg PJ, Ruocco AC, Hurtig HI, Baltuch GH, Jaggi JL, Stern MB: Subthalamic nucleus deep brain stimulation for severe idiopathic dystonia: impact on severity, neuropsychological status, and quality of life. J Neurosurg 2007;107:29–36.
  24. Soares J, Kliem MA, Betarbet R, Greenamyre JT, Yamamoto B, Wichmann T: Role of external pallidal segment in primate parkinsonism: comparison of the effects of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine-induced parkinsonism and lesions of the external pallidal segment. J Neurosci 2004;24:6417–6426.
  25. Zhang J, Russo GS, Mewes K, Rye DB, Vitek JL: Lesions in monkey globus pallidus externus exacerbate parkinsonian symptoms. Exp Neurol 2006;199:446–453.
  26. Alterman RL, Miravite J, Weisz D, Shils JL, Bressman SB, Tagliati M: Sixty hertz pallidal deep brain stimulation for primary torsion dystonia. Neurology 2007;69:681–688.
  27. Birdno MJ, Grill WM: Mechanisms of deep brain stimulation in movement disorders as revealed by changes in stimulus frequency. Neurotherapeutics 2008;5:14–25.