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PubMed2004

Improvement of sleep quality in patients with advanced Parkinson's disease treated with deep brain stimulation of the subthalamic nucleus.

Most Parkinson's patients complain about sleep problems. The subjective effect of deep brain stimulation (DBS) of the subthalamic nucleus (STN) on nocturnal disabilities and sleep quality was elucidated by the recently established Parkinson's disease sleep scale (PDSS). The DBS-treated group obtained significant improvement of motor function assessed by the Unified Parkinson's Disease Rating Scale. The mean total PDSS improved significantly after surgery whereas no change was found for the control group. Significant improvements of individual questions were obtained for overall sleep quality and motor symptoms whereas nocturia and daytime sleepiness did not change despite significant reduction of parkinsonian medication.

Adult↗

PubMed1981

Iontophoretic studies on pallidal neurones and the projection from the subthalamic nucleus.

The predominant response of pallidal neurones to gamma-aminobutyric acid (GABA), glycine and dopamine when applied iontophoretically, was inhibition of firing rate. With dopamine some excitatory responses were observed, this never being the case with GABA or glycine. Picrotoxin reversibly blocked neuronal responses to GABA but not glycine in fourteen cases. Strychnine abolished glycine evoked inhibitions in seventeen cells while not affecting GABA responses. A number of cells were responsive to a stimulus delivered to the subthalamic nucleus (s.t.n.), an electrode array being used to establish the specificity of response to s.t.n. stimulation. In eight out of fourteen cases there was a reduction of 40% or more in the inhibitory responses following stimulation, with picrotoxin applied iontophoretically. Strychnine, conversely, had no effect on the synaptically evoked inhibition at doses that exceeded those required to antagonize iontophoretically applied glycine. Similarly, fluphenazine and naloxone administered iontophoretically or intraperitoneally (I.P.) had no effect on eight cells. The results indicate the existence of a 'GABA-ergic' link in the projection from the subthalamic nucleus to the globus pallidus, though other transmitters, but not glycine or dopamine, may contribute to the observed synaptic responses.

Animals↗

PubMed2004

Pseudobulbar crying induced by stimulation in the region of the subthalamic nucleus.

We describe a case of pseudobulbar crying associated with deep brain stimulation (DBS) in the region of the subthalamic nucleus (STN). Patients with pseudobulbar crying show no other evidence of subjective feelings of depression such as dysphoria, anhedonia, or vegetative signs. This may be accompanied by other symptoms of pseudobulbar palsy and has been reported to occur with ischaemic or structural lesions in both cortical and subcortical regions of the brain. Although depression has been observed to result from DBS in the region of the STN, pseudobulbar crying has not been reported. A single patient who reported the symptoms of pseudobulbar crying after placement of an STN DBS was tested in the off DBS and on DBS conditions. The patient was tested using all four DBS lead contacts and the observations and results of the examiners were recorded. The Geriatric Depression Scale was used to evaluate for depression in all of the conditions. The patient exhibited pseudobulbar crying when on monopolar stimulation at all four lead contacts. The pseudobulbar crying resolved off stimulation. This case describes another type of affective change that may be associated with stimulation in the region of or within the STN. Clinicians should be aware of this potential complication, the importance of differentiating it from stimulation induced depression, and its response to a serotonin reuptake inhibitor, such as sertraline.

Crying↗

PubMed2003

Deep brain stimulation of the subthalamic nucleus: effectiveness in advanced Parkinson's disease patients previously reliant on apomorphine.

OBJECTIVES: To assess the efficacy of bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) in patients with advanced Parkinson's disease previously reliant on apomorphine as their main antiparkinsonian medication. METHODS: Seven patients with motor fluctuations despite optimal medical treatment given as predominantly apomorphine infusion (n=6), or intermittent apomorphine injections (n=1) underwent bilateral STN DBS using frameless stereotactic surgery. Standard assessments of parkinsonism and motor fluctuations, using Unified Parkinson's Disease Rating Scale (UPDRS) were performed before and six months after surgery. Assessments were performed both on and off medication, and postoperative with the stimulators switched on and off. RESULTS: Bilateral STN DBS improved motor scores (UPDRS III) by 61% when off medication (p<0.05). Clinical fluctuations (UPDRS IV items 36-39) were reduced by 46.2% (p<0.05). Total daily apomorphine dose was reduced by 68.9% (p<0.05) and apomorphine infusion via a pump was no longer required in four patients. There were no operative complications. Two patients required treatment for hallucinations postoperatively but there was no significant change in mini-mental state examination. CONCLUSIONS: In patients with advanced Parkinson's disease, previously reliant on apomorphine, bilateral STN DBS is an effective treatment to reduce motor fluctuations and enable a reduction in apomorphine use.

Aged↗

PubMed2004

Subcellular and subsynaptic localization of group I metabotropic glutamate receptors in the monkey subthalamic nucleus.

Both subtypes of group I metabotropic glutamate receptor, mGluR1 and mGluR5, are expressed postsynaptically in neurons of the subthalamic nucleus (STN), and their activation induces different physiological responses. To test whether these effects could be explained by a differential localization of the two group I mGluRs, we analyzed the subcellular and subsynaptic distribution of mGluR1a and mGluR5 in the monkey STN. Double-immunofluorescence and light microscopic analyses revealed that both group I mGluR subtypes were strongly coexpressed in the neuropil and neuronal perikarya. Astrocytic perikarya exhibited intense mGluR1a, but no detectable mGluR5, immunoreactivity. At the electron microscopic level, immunoperoxidase labeling for both mGluR1a and mGluR5 was localized mainly in dendrites. A significant proportion of the total pool of mGluR1a-immunoreactive elements was accounted for by glial cell processes, whereas glial cell labeling was much less frequently encountered in sections immunostained for mGluR5. Preembedding immunogold labeling in STN dendrites revealed that 60-70% of the gold labeling for both mGluR subtypes was intracellular, whereas 30-40% was apposed to the plasma membrane. Of the plasma membrane-apposed particles, more than 90% were extrasynaptic; fewer than 10% were associated with symmetric or asymmetric synapses. Most of the synapse-associated labeling was found at the edges of both asymmetric and symmetric postsynaptic specializations. Some extrasynaptic gold particles were aggregated on parts of the plasma membrane tightly apposed by glial processes. These findings demonstrate that mGluR1a and mGluR5 exhibit a similar pattern of subsynaptic localization in monkey STN neurons, with both receptor subtypes exhibiting substantial extrasynaptic and perisynaptic localization.

Animals↗

PubMed2004

Effects of subthalamic nucleus stimulation and medication on resting and postural tremor in Parkinson's disease.

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) and antiparkinsonian medication have proved to be effective treatments for tremor in Parkinson's disease. To date it is not known how and to what extent STN DBS alone and in combination with antiparkinsonian medication alters the pathophysiology of resting and postural tremor in idiopathic Parkinson's disease. The purpose of this study was to examine the effects of STN DBS and antiparkinsonian medication on the neurophysiological characteristics of resting and postural hand tremor in Parkinson's disease. Resting and postural hand tremor were recorded using accelerometry and surface electromyography (EMG) from 10 Parkinson's disease patients and 10 matched control subjects. The Parkinson's disease subjects were examined under four treatment conditions: (i) off treatment; (ii) STN DBS; (iii) medication; and (iv) medication plus STN DBS. The amplitude, EMG frequency, regularity, and 1-8 Hz tremor-EMG coherence were analysed. Both STN DBS and medication reduced the amplitude, regularity and tremor-EMG coherence, and increased the EMG frequency of resting and postural tremor in Parkinson's disease. STN DBS was more effective than medication in reducing the amplitude and increasing the frequency of resting and postural tremor to healthy physiological levels. These findings provide strong evidence that effective STN DBS normalizes the amplitude and frequency of tremor. The findings suggest that neural activity in the STN is an important modulator of the neural network(s) responsible for both resting and postural tremor genesis in Parkinson's disease.

Adult↗

PubMed2005

Stimulation of the subthalamic nucleus in Parkinson's disease: a 5 year follow up.

BACKGROUND: The short term benefits of bilateral stimulation of the subthalamic nucleus (STN) in patients with advanced levodopa responsive Parkinson's disease (PD) are well documented, but long term benefits are still uncertain. OBJECTIVES: This study provides a 5 year follow up of PD patients treated with stimulation of the STN. METHODS: Thirty seven consecutive patients with PD treated with bilateral STN stimulation were assessed prospectively 6, 24, and 60 months after neurosurgery. Parkinsonian motor disability was evaluated with and without levodopa treatment, with and without bilateral STN stimulation. Neuropsychological and mood assessments included the Mattis Dementia Rating Scale, the frontal score, and the Montgomery-Asberg Depression Rating Scale (MADRS). RESULTS: No severe peri- or immediate postoperative side effects were observed. Six patients died and one was lost to follow up. Five years after neurosurgery: (i) activity of daily living (Unified Parkinson Disease Rating Scale (UPDRS) II) was improved by stimulation of the STN by 40% ("off" drug) and 60% ("on" drug); (ii) parkinsonian motor disability (UPDRS III) was improved by 54% ("off" drug) and 73% ("on" drug); (iii) the severity of levodopa related motor complications was decreased by 67% and the levodopa daily doses were reduced by 58%. The MADRS was unchanged, but cognitive performance declined significantly. Persisting adverse effects included eyelid opening apraxia, weight gain, addiction to levodopa treatment, hypomania and disinhibition, depression, dysarthria, dyskinesias, and apathy. CONCLUSIONS: Despite moderate motor and cognitive decline, probably due to disease progression, the marked improvement in motor function observed postoperatively was sustained 5 years after neurosurgery.

Activities of Daily Living↗

PubMed2006

Experimental manipulations of the subthalamic nucleus fail to suppress tonic seizures in the electroshock model of epilepsy.

Recently, it has been shown that the subthalamic nucleus (STN) has anticonvulsant effects on epileptic seizures originating from the forebrain. The aim of the present study was to determine whether the anticonvulsant properties of the STN extend to the suppression of tonic seizures originating from the brainstem elicited by electroshock in rats. Three different procedures were used to manipulate activity in the STN and in each case the duration of tonic hindlimb extension elicited by electroshock was used as a measure of seizure-severity. Under general anesthesia, two groups of rats received chronic implants of either bilateral stainless steel guide cannulae or bilateral bipolar stimulating electrodes stereotaxically implanted and aimed at the STN. After 3 days of recovery, each rat in the first group was tested with electroshock on three consecutive days after having received 220 nl bilateral microinjections into the STN of either 200 or 400 pmol of muscimol (a GABA agonist) dissolved in saline or the same volume of normal saline. In the second group the electroshock test was conducted, again on three consecutive days, immediately following high frequency electrical stimulation (HFS) of the STN at 130 or 260 Hz or a no current control condition. In the third group, rats were tested with electroshock before and after bilateral excitotoxic lesions of the STN with either kainic or ibotenic acids. None of these manipulations produced significant suppression of the tonic hind limb extension elicited by electroshock compared with the relevant control conditions. This suggests that, within the limitations of the current procedures, the anticonvulsant properties of the STN appear to be ineffective against tonic seizures originating in the brainstem.

Animals↗

PubMed2005

Effect of bilateral subthalamic nucleus stimulation on balance and finger control in Parkinson's disease.

We aimed to quantify the effects of bilateral subthalamic nucleus (STN) stimulation in Parkinson's disease (PD) on stance and gait ("axial"motor control), and related this to effects on finger movements ("appendicular" motor control). Fourteen PD patients and 20 matched controls participated. Subjects completed several balance and gait tasks (standing with eyes open or closed, on a normal or foam surface; retropulsion test; walking with eyes closed; walking up and down stairs; Get Up and Go test). Postural control was quantified using trunk sway measurements (angle and angular velocity) in the roll and pitch directions. Subjects further performed a pinch grip reaction time task, where we measured isometric grip forces, as well as movement and reaction times. Patients were examined with STN stimulators switched on or off (order randomised across patients), always after a supramaximal levodopa dosage. STN stimulation improved postural control, as reflected by a reduced trunk sway tremor during stance, a reduced duration for all gait tasks, an increased trunk pitch velocity while rising from a chair, and improved roll stability. STN stimulation also improved finger control, as reflected by a reduced time to reach maximum grip force, without altering reaction times and maximum force levels. Improvements in finger control timing did not correlate with reduced task durations during gait. We conclude that STN stimulation affords improvement of postural control in PD, over and above optimal drug treatment. STN stimulation also provides a simultaneous effect on distal and axial motor control. Because improvements in distal and axial motor control were not correlated, we assume that these effects are mediated by stimulation of different structures within the STN.

Adult↗

PubMed2002

Dependence of subthalamic nucleus oscillations on movement and dopamine in Parkinson's disease.

Local field potentials and pairs of neurones in the subthalamic nucleus (STN) of patients with Parkinson's disease show high-frequency oscillations (HFOs) at 15-30 Hz. This study explores how these HFOs are modulated by voluntary movements and by dopaminergic medication. We examined 15 patients undergoing implantation of bilateral deep brain stimulating electrodes using microelectrode recordings of pairs of STN neurones (eight patients) and macroelectrode recordings of local field potentials from the STN (14 patients). Synchronized HFOs between STN neurones were observed in 28 out of 37 pairs in five patients who had tremor in the operating room and none of 45 pairs in three patients who did not. In two of the three non-tremulous patients, HFOs in the frequency spectra of local field potentials were detected but were weaker than in those patients with tremor. Active movement suppressed synchronized HFOs in three out of five pairs of neurones, independent of changes in firing rate. HFOs observed in the local field potentials in nine out of 14 patients were reduced with voluntary movement in six of the eight patients tested. Dopaminergic medication decreased the incidence of synchronized HFOs in STN neurone pairs, reduced HFO synchrony in a pair of tremor cells concurrent with a reduction in firing rate and limb tremor, and decreased HFOs of local field potentials in the STN. These results demonstrate that HFO synchronization in the STN is reduced by voluntary movements and by exogenous dopaminergic medication. A mechanism for neuronal oscillatory synchronization in basal ganglia is proposed. It is suggested that the firing of STN neurones can be synchronized by 15-30 Hz cortical beta oscillatory activity, particularly when dopamine deficiency results in a higher background firing rate of STN neurones, and that this synchronization contributes to parkinsonian pathophysiology.

Action Potentials↗

PubMed2005

Pallidal vs subthalamic nucleus deep brain stimulation in Parkinson disease.

BACKGROUND: Deep brain stimulation (DBS) of the globus pallidus interna (GPi) and subthalamic nucleus (STN) has been reported to relieve motor symptoms and levodopa-induced dyskinesia in patients with advanced Parkinson disease (PD). Although it has been suggested that stimulation of the STN may be superior to stimulation of the GPi, comparative trials are limited. OBJECTIVE: To extend our randomized, blinded pilot comparison of the safety and efficacy of STN and GPi stimulation in patients with advanced PD. DESIGN: This study represents the combined results from our previously published, randomized, blinded, parallel-group pilot study and additional patients enrolled in our single-center extension study. SETTING: Oregon Health and Science University in Portland.Patients Twenty-three patients with idiopathic PD, levodopa-induced dyskinesia, and response fluctuations were randomized to implantation of bilateral GPi or STN stimulators. Patients and evaluating clinicians were blinded to stimulation site. All patients were tested preoperatively while taking and not taking medications and after 3, 6, and 12 months of DBS. MAIN OUTCOME MEASURES: Postoperatively, response of symptoms to DBS, medication, and combined medication and DBS was evaluated. Twenty patients (10 in the GPi group and 10 in the STN group) completed 12-month follow-up. RESULTS: Off-medication Unified Parkinson's Disease Rating Scale motor scores were improved after 12 months of both GPi and STN stimulation (39% vs 48%). Bradykinesia tended to improve more with STN than GPi stimulation. No improvement in on-medication function was observed in either group. Levodopa dose was reduced by 38% in STN stimulation patients compared with 3% in GPi stimulation patients (P = .08). Dyskinesia was reduced by stimulation at both GPi and STN (89% vs 62%). Cognitive and behavioral complications were observed only in combination with STN stimulation. CONCLUSION: Stimulation of either the GPi or STN improves many features of advanced PD. It is premature to exclude GPi as an appropriate target for DBS in patients with advanced disease.

Activities of Daily Living↗

PubMed1983

The fine structure of the rat subthalamic nucleus: an electron microscopic study.

The normal ultrastructure of the rat subthalamic nucleus (STH) was studied. The STH consisted of tightly packed neurons distributed within a neuropil filled with large numbers of blood vessels and thinly myelinated fibers. The somata of STH neurons (diameters, D, between 10 and 25 micron) contained abundant organelles but had only a small amount of both smooth and rough endoplasmic reticulum. The nuclei had deeply invaginated nuclear envelopes and pale nucleoplasm with little heterochromatin. STH neurons often were tightly apposed without any intervening glial membranes. Similar appositions were also found between somata and dendrites, dendrites and dendrites, and dendrites and initial axon segments. Although puncta adhaerentia were often observed, no gap junctions were found on any of these membrane appositions. In the neuropil, the dendrites were mostly smooth and thin (D between 0.5 and 1 micron) with an occasional stubby spine or thin dendritic appendage. At least two types of axon terminals were identified. Type 1 terminals (D up to 1 micron) contained medium-sized round vesicles (D about 45 nm) and formed asymmetrical synapses. Type 2 terminals were often large (D up to 5 micron) and contained both round and slightly flattened vesicles (D up to 50 nm). The type 2 terminals frequently formed adherens junctions with their postsynaptic targets in addition to forming relatively symmetrical synaptic junctions. The remaining axon terminals included a small number of terminals with various morphological characteristics and possibly some tangentially sectioned type 1 and type 2 terminals. Therefore they have not been classified as individual types in this study. A quantitative analysis indicated that the type 1 terminals formed synapses mainly with thin dendrites whereas the type 2 terminals formed synapses mainly with somata and larger dendrites.

Animals↗

PubMed1998

The subthalamic nucleus and tremor in Parkinson's disease.

The role of the subthalamic nucleus (STN) in the origin of parkinsonian tremor is discussed. Previous studies in monkeys made parkinsonian by MPTP (1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine) administration suggested a direct participation of the STN in the pathophysiology of tremor. We recorded tremor-related activity in the STN in 12 patients with Parkinson's disease (PD) and found that microstimulation of the sensorimotor region of the nucleus, where these neurons are present, stopped the tremor with a very short latency. Long-term treatment by means of bilateral deep-brain stimulation (DBS) in the same 12 patients led to a significant reduction of tremor as well as other cardinal features of PD. This effect was blindly assessed at 3 months after implantation. In another group of seven patients, a unilateral lesion of the STN was performed. Both postural and resting tremor were significantly improved on the limbs contralateral to the lesion side. In three patients, tremor disappeared completely after 12 months of follow up. The electrophysiologic data and therapeutic effect of inactivating the STN strongly indicated that this structure is directly involved in the origin of parkinsonian tremor, as suggested by the MPTP model.

Adult↗

PubMed1995

Effect of subthalamic nucleus lesion on mitochondrial enzyme activity in rat basal ganglia.

The subthalamic nucleus (STN) plays a major role in the control of basal ganglia output, and its overactivity may be central to the symptoms of Parkinson's disease. In order to elucidate the functional relationship between STN and its projection nuclei, we studied the short-term (1 week) effect of a selective lesion of STN on the activity of succinate dehydrogenase (SDH) and cytochrome oxidase (CO), two markers of neuronal activity, in the basal ganglia of rats. STN ablation induced a discrete reduction of oxidative metabolism, ipsilaterally to the lesion, in substantia nigra pars reticulata and globus pallidus, the rodent homologue of lateral globus pallidus. Such changes, ascribable to the interruption of the STN excitatory output to these nuclei, were present after 24 h and remained stable, or increased, throughout the observation period. A transitory, ipsilateral decrease was also observed in the caudate-putamen and the somato-sensory cortex, likely due to involvement of polysynaptic pathways. SDH and CO activity were always altered in the same areas, but SDH changes were more pronounced and occurred more rapidly. These results shed further light on the role played by STN in the control of basal ganglia output.

Animals↗

PubMedDate not supplied

Raphe neurons and barbiturate induced rhythmic activity in the subthalamic nucleus and ventral tegmental area.

A continuous rhythmic discharge in the subthalamic nucleus (STN), lateral habenular nucleus, and ventral tegmental area (VTA) is associated with tremor in cats lightly anesthetized with barbiturate. The pontine raphe nuclei centralis superior and inferior also show barbiturate dependent slow wave and unitary activity. Stimulation of the raphe region produces evoked potentials and synchronization of the oscillatory activity in STN and VTA. The latency of the evoked response is shortest in STN. Extensive raphe lesions abolish the rhythmic activity in STN and VTA, but lesions which do not completely destroy nuclei centralis superior and inferior are not effective. In single cell recordings 81% of 142 cells in the pontine raphe region and medial reticular formation are inhibited following VTA stimulation. Fifty-four percent of 129 cells in the same region were inhibited when tested with STN stimulation. Forty-seven raphe paramedian reticular formation cells showed convergence of inhibitory input from STN, VTA, and contralateral sciatic nerve (Group II and III fibers). Depletion of serotonin with rho-chlorophenylalanine did not affect the appearance of barbiturate rhythmic activity. It is concluded that the pontine raphe region is not essential for maintenance of the oscillatory activity in STN and VTA, and that the raphe region is on the output side of the system.

Animals↗

PubMed1999

Comparative effects of unilateral and bilateral subthalamic nucleus deep brain stimulation.

OBJECTIVE: To compare the effects of unilateral subthalamic nucleus (STN) deep brain stimulation (DBS) with bilateral STN DBS in advanced PD. METHODS: Our initial 10 consecutive patients with medication-refractory motor fluctuations and levodopa-induced dyskinesias undergoing chronic bilateral STN DBS underwent a standardized evaluation of unilateral and bilateral STN DBS in the medication-off state 6 to 18 months after electrode implantation. RESULTS: Bilateral STN DBS improved the mean total Unified Parkinson's Disease Rating Scale motor score by 54%, whereas unilateral stimulation improved motor scores only 23%. Unilateral STN DBS improved postural stability and gait 14%, other axial motor features 19%, and overall parkinsonism in limbs contralateral to stimulation by 46%, including an 86% improvement in contralateral tremor. However, bilateral STN DBS resulted in greater improvement in each of these domains, including limb function, i.e., the reduction in scores from the limbs on one side was greater with bilateral than with unilateral stimulation of the contralateral STN. CONCLUSIONS: Bilateral STN DBS improves parkinsonism considerably more than unilateral STN DBS; bilateral simultaneous electrode implantation may be the most appropriate surgical option for patients with significant bilateral disability. Unilateral STN DBS results in moderate improvement in all aspects of off-period parkinsonism and improves tremor as much as is typically reported with DBS of the ventral intermedius nucleus of the thalamus (Vim). For this reason, STN DBS may be a more appropriate choice than Vim DBS or thalamotomy for parkinsonian tremor. Some patients with highly asymmetric tremor-dominant PD might be appropriately treated with unilateral instead of bilateral STN DBS.

Aged↗

PubMed2003

Subthalamic nucleus stimulation in Parkinson's disease: correlation of active electrode contacts with intraoperative microrecordings.

BACKGROUND/AIMS: The most effective site for subthalamic nucleus (STN) stimulation has remained unclear. The position of active contacts relative to the dorsal margin of the STN was determined. METHODS: Electrodes (n = 49) were implanted following STN mapping by microrecording and microstimulation along five tracks (n = 25 patients). The stereotactic position of active contacts was determined and correlated with microrecordings using an algorithm for direct three-dimensional comparisons (n = 37). RESULTS: Most active contacts were detected within +/-1.0 mm from the dorsal margin of the STN as defined by microrecording (32.4%) or farther dorsal in the subthalamic area (37.8%), and only 29.7% were localized to the STN proper. This was consistent with the average stereotactic coordinates of the active contacts in these three groups. CONCLUSION: Our data suggest that the dorsal border area of the STN is the most effective target. Besides the dorsolateral STN (sensorimotor part) this may include projections from/to STN, the zona incerta, and pallidofugal projections in the fields of Forel.

Electric Stimulation Therapy↗

PubMed2001

Safety and efficacy of pallidal or subthalamic nucleus stimulation in advanced PD.

The authors retrospectively compared 1-year results of bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN; n = 16) and internal pallidum (GPi) (n = 11) in advanced PD and found about equal improvements in "off" period motor symptoms, dyskinesias, and fluctuations. STN stimulation reduced medication requirements by 65% and required significantly less electrical power. These advantages contrasted with a need for more intensive postoperative monitoring and a higher incidence of adverse events related to levodopa withdrawal.

Activities of Daily Living↗