視床手術、視床破壊

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2015/10/03 06:44:14」(JST)

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First introduced in the 1950s, thalamotomy is an invasive procedure, primarily effective for tremors such as those associated with Parkinson's disease (PD), where a selected portion of the thalamus is surgically destroyed (ablated). Neurosurgeons use specialized equipment to precisely locate an area of the thalamus, usually choosing to work on only one side (the side opposite that of the worst tremors). Bilateral procedures are poorly tolerated because of increased complication and risk, including vision and speech problems. The positive effects on tremors are immediate. Other less destructive procedures are sometimes preferred, such as subthalamic deep brain stimulation (DBS), since this procedure can also improve tremors and other symptoms of PD.^[1]^[2]^[3]

Subthalamotomy

Subthalamotomy is a type of brain surgery in which the subthalamic nucleus is destroyed in attempt to help alleviate movement disorders often associated with Parkinson’s disease.^[4] This surgery has been most widely researched at Havana’s International Center for Neurological Restoration (CIREN) located in Cuba. This center has assumed a leading role in developing a surgical procedure that provides significant relief for patients experiencing the slowness of movement, tremor and muscle rigidity in middle to late stages of PD. Similar to the thalamotomy, this procedure can be repeated on both sides of the brain bilaterally, but is not recommended due to a large increase in the risk of speech and cognitive problems post-surgery.^[5] The aim of subthalamotomies is to reduce symptoms of PD and the uncontrolled movements that can happen to someone who has been taking the drug levodopa for a long period of time.^[6]

Surgical procedures

Frame for Stereotactic Thalamotomy on display at the Glenside Museum

Prior to the operation, a neurosurgeon will use stereotactic technology to identify the exact part of the brain that needs treatment by putting in place a frame on the patient’s head with four pins to keep it still. The doctor will then take a detailed brain scan using computed tomography (CT scan) or magnetic resonance imaging (MRI) in order to identify the precise location for operation as well as a path through the brain to get to that specific spot. During the surgery the patient is awake, however, the area on the scalp where the surgical tools are inserted is numbed with an anesthetic. The surgeon makes a cut (about 2 inches long) then inserts a hollow probe through a small hole drilled in the skull to the specific location. Different methods can be used to kill the brain cells, including circulating liquid nitrogen inside the probe destroying the targeted brain tissue, or by inserting an electrode heated up to near 200° Fahrenheit to burn the cells.^[6] Although the surgery usually requires only about a 2-day hospital stay, full recovery generally takes about 6 weeks.^[5]

Complications

Some of the patients in Cuban studies developed complications from the surgery, including severe involuntary movements, but the symptoms abated (to the point where patients could tolerate them) after three to six months.^[5] Subthalamotomy is not reversible because the brain cells are permanently destroyed. Most common complications include a risk of stroke, confusion, speech and/or visual problems.^[7] Although there are risks with unilateral subthalamotomy, the risks are greatly increased with bilateral subthalamotomy.

Studies

One study followed 89 patients with PD who were treated with unilateral subthalamotomy. Sixty-eight patients were available for evaluations after 12 months, 36 after 24 months and 25 patients after 36 months. The Unified Parkinson’s Disease Rating Scale motor scores improved significantly and levodopa daily doses were significantly reduced by 45%, 36% and 28% at 12, 24 and 36 months post-surgery. Unilateral subthalamotomy was associated with significant motor benefit contralateral to the lesion. Further work is needed to ascertain what factors led to severe, persistent chorea-ballism in a subset of patients.^[8] In an earlier study, 18 advanced PD patients received staged or simultaneous bilateral subthalamotomies. One patient subsequently developed multiple system atrophy (MSA) signs and was excluded from further analysis. Motor improvements compared to baseline were 58% in the off state and 63% in the on state. Daily levodopa dose was reduced by a mean of 72%, with 5 patients receiving none. Three patients developed severe chorea post-operatively, which improved spontaneously at 3–6 months.^[9] In a third study, microelectrode mapping (guided stereotactic surgery on the subthalamic nucleus) was performed in eight patients with PD and the findings indicated that subthalamotomy can ameliorate the cardinal symptoms of PD, reduce the dosage of levodopa, diminish complications of the drug therapy, and improve the quality of life.^[10] Havana’s International Center for Neurological Restoration reported at the American Neurological Association meeting in October 2002 that two years after undergoing a bilateral dorsal subthalamotomy, 17 Cuban patients improved by an average of 50% on movement tests, and they could dramatically reduce their daily ingestion of the Parkinson’s drug levodopa.^[5]

Subthalamotomy could be a preferred option for people with PD who have trouble affording either the medication or deep-brain stimulation needed to moderate symptoms.

References

^ Julie A. Fields, Alexander I. Tröster, Cognitive Outcomes after Deep Brain Stimulation for Parkinson's Disease: A Review of Initial Studies and Recommendations for Future Research, Brain and Cognition, Volume 42, Issue 2, March 2000, Pages 268-293, ISSN 0278-2626, 10.1006/brcg.1999.1104.
^ Bruce BB, Foote KD, Rosenbek J, Sapienza C, Romrell J, Crucian G, Okun MS: Aphasia and Thalamotomy: Important Issues. Stereotact Funct Neurosurg 2004;82:186-190 doi:10.1159/000082207
^ Justin S. Cetas, Targol Saedi, and Kim J. Burchiel. Destructive procedures for the treatment of nonmalignant {}pain: a structured literature review. J Neurosurg 109:000–000, 2008
^ Subthalamotomy. National Parkinson Foundation. Retrieved from http://www.parkinson.org/Parkinson-s-Disease/Treatment/Surgical-Treatment-Options/Subthalamotomy.aspx
^ ^a ^b ^c ^d Stix, Gary. (2003). Sustainable Surgery. Scientific American. Retrieved from http://www.scientificamerican.com/article.cfm?id=sustainable-surgery
^ ^a ^b Subthalamotomy. BootsWebMD. Retrieved from http://www.webmd.boots.com/a-to-z-guides/parkinsons-disease-subthalamotomy
^ Subthalamotomy for Parkinson's Disease. (2004). National Institute for Health and Clinical Excellence. ISBN 1-84257-657-7. Retrieved from http://www.nice.org.uk/nicemedia/live/11102/31038/31038.pdf
^ L Alvarez, R Macias, N Pavón, G López, M C Rodríguez-Oroz, R Rodríguez, M Alvarez, I Pedroso, J Teijeiro, R Fernández, E Casabona, S Salazar, C Maragoto, M Carballo, I García, J Guridi, J L Juncos, M R DeLong, J A Obeso. (2009). Therapeutic efficacy of unilateral subthalamotomy in Parkinson’s disease: results in 89 patients followed for up to 36 months. Journal of Neurology, Neurosurgery, and Psychiatry with Practical Neurology, Volume 80, Issue 9. Retrieved from http://jnnp.bmj.com/content/80/9/979.full
^ L Alvarez, R Macias, G Lopez, E Alvarez, C Maragoto, JA Obeso, N Pavon, MC Rodriguez-Oroz, J Juncos, J Guridi, ES Tolosa, W Koller, MR DeLong. (2002). Bilateral Subthalamotomy for PD. Movement Disorder Virtual University. Retrieved from http://www.mdvu.org/emove/article.asp?ID=531
^ Philip C. Su, M.D., Ham-Min Tseng, M.D., Hon-Man Liu, M.D., Ruoh-Fang Yen, M.D., and Horng-Huei Liou, M.D., Ph.D. (2002). Subthalamotomy for advanced Parkinson disease. Journal of Neurosurgery, volume 97. Retrieved from http://thejns.org/doi/abs/10.3171/jns.2002.97.3.0598?journalCode=jns

UpToDate Contents

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1. 本態性振戦の外科治療 surgical treatment of essential tremor
2. 頭蓋に対する定位手術的照射 stereotactic cranial radiosurgery
3. ジストニアの治療 treatment of dystonia
4. Symptomatic (secondary) myoclonus
5. 舞踏病の概要 overview of chorea

English Journal

Thalamic Connectivity in Patients with Essential Tremor Treated with MR Imaging-guided Focused Ultrasound: In Vivo Fiber Tracking by Using Diffusion-Tensor MR Imaging.

Wintermark M1, Huss DS, Shah BB, Tustison N, Druzgal TJ, Kassell N, Elias WJ.Author information 1From the Department of Radiology, Neuroradiology Division (M.W., N.T., T.J.D.), Department of Neurosurgery (D.S.H., N.K., W.J.E.), and Department of Neurology (B.B.S.), University of Virginia, 1215 Lee St, New Hospital, 1st Floor, Room 1011, Charlottesville, VA 22908-0170; and Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland (M.W.).AbstractPurpose To use diffusion-tensor (DT) magnetic resonance (MR) imaging in patients with essential tremor who were treated with transcranial MR imaging-guided focused ultrasound lesion inducement to identify the structural connectivity of the ventralis intermedius nucleus of the thalamus and determine how DT imaging changes correlated with tremor changes after lesion inducement. Materials and Methods With institutional review board approval, and with prospective informed consent, 15 patients with medication-refractory essential tremor were enrolled in a HIPAA-compliant pilot study and were treated with transcranial MR imaging-guided focused ultrasound surgery targeting the ventralis intermedius nucleus of the thalamus contralateral to their dominant hand. Fourteen patients were ultimately included. DT MR imaging studies at 3.0 T were performed preoperatively and 24 hours, 1 week, 1 month, and 3 months after the procedure. Fractional anisotropy (FA) maps were calculated from the DT imaging data sets for all time points in all patients. Voxels where FA consistently decreased over time were identified, and FA change in these voxels was correlated with clinical changes in tremor over the same period by using Pearson correlation. Results Ipsilateral brain structures that showed prespecified negative correlation values of FA over time of -0.5 or less included the pre- and postcentral subcortical white matter in the hand knob area; the region of the corticospinal tract in the centrum semiovale, in the posterior limb of the internal capsule, and in the cerebral peduncle; the thalamus; the region of the red nucleus; the location of the central tegmental tract; and the region of the inferior olive. The contralateral middle cerebellar peduncle and bilateral portions of the superior vermis also showed persistent decrease in FA over time. There was strong correlation between decrease in FA and clinical improvement in hand tremor 3 months after lesion inducement (P < .001). Conclusion DT MR imaging after MR imaging-guided focused ultrasound thalamotomy depicts changes in specific brain structures. The magnitude of the DT imaging changes after thalamic lesion inducement correlates with the degree of clinical improvement in essential tremor. © RSNA, 2014.
Radiology.Radiology.2014 Mar 9:132112. [Epub ahead of print]
Purpose To use diffusion-tensor (DT) magnetic resonance (MR) imaging in patients with essential tremor who were treated with transcranial MR imaging-guided focused ultrasound lesion inducement to identify the structural connectivity of the ventralis intermedius nucleus of the thalamus and determine
PMID 24620914

Structural changes in cerebellar outflow tracts after thalamotomy in essential tremor.

Buijink AW1, Caan MW2, Contarino MF1, Schuurman PR3, van den Munckhof P3, de Bie RM4, Olabarriaga SD5, Speelman JD4, van Rootselaar AF6.Author information 1Department of Neurology and Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Brain Imaging Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.2Brain Imaging Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.3Department of Neurosurgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.4Department of Neurology and Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.5Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.6Department of Neurology and Clinical Neurophysiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands; Brain Imaging Center, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands. Electronic address: a.f.vanrootselaar@amc.uva.nl.AbstractBACKGROUND: This study set out to determine whether structural changes are present outside the thalamus after thalamotomy in patients with essential tremor (ET), specifically in the cerebellorubrothalamic tracts. We hypothesized that diffusion tensor imaging (DTI) would detect these changes.
Parkinsonism & related disorders.Parkinsonism Relat Disord.2014 Mar 5. pii: S1353-8020(14)00073-X. doi: 10.1016/j.parkreldis.2014.02.020. [Epub ahead of print]
BACKGROUND: This study set out to determine whether structural changes are present outside the thalamus after thalamotomy in patients with essential tremor (ET), specifically in the cerebellorubrothalamic tracts. We hypothesized that diffusion tensor imaging (DTI) would detect these changes.METHODS:
PMID 24637119

Women pioneers in basal ganglia surgery.

Hariz GM1, Rehncrona S2, Blomstedt P3, Limousin P4, Hamberg K5, Hariz M6.Author information 1Department of Clinical Neuroscience, Umeå University, Umeå, Sweden; Department of Community Medicine and Rehabilitation, Occupational Therapy, Umeå University, Umeå, Sweden.2Department of Neurosurgery, Lund University, Lund, Sweden.3Department of Clinical Neuroscience, Umeå University, Umeå, Sweden.4UCL Institute of Neurology, Queen Square, London, UK.5Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden.6Department of Clinical Neuroscience, Umeå University, Umeå, Sweden; UCL Institute of Neurology, Queen Square, London, UK. Electronic address: m.hariz@ucl.ac.uk.AbstractBACKGROUND: Stereotactic functional neurosurgery on basal ganglia has a long history and the pioneers are mostly men. We aimed at finding out if there were women who have contributed pioneering work in this field.
Parkinsonism & related disorders.Parkinsonism Relat Disord.2014 Feb;20(2):137-41. doi: 10.1016/j.parkreldis.2013.11.002. Epub 2013 Nov 10.
BACKGROUND: Stereotactic functional neurosurgery on basal ganglia has a long history and the pioneers are mostly men. We aimed at finding out if there were women who have contributed pioneering work in this field.METHODS: The literature was searched to identify women who have been first to publish i
PMID 24262870

Japanese Journal

パーキンソン病に対する外科治療

佐藤澄人,隈部俊宏
北里医学 = Kitasato medicine 43(2), 95-104, 2013-12
NAID 40019954338

パーキンソン病以外の運動機能異常症状に対する機能的外科治療の位置づけ

平孝臣
臨床神経学 53(11), 966-968, 2013
パーキンソン病や本態性振戦（ET）のような不随意運動疾患以外にも，重度の痙縮，運動麻痺回復などが外科治療の対象となる．ETではposterior subthalamic areaが新たなターゲットとして注目を浴びている．また低侵襲的治療としてMRI内でおこなう経頭蓋集束超音波照射治療が注目されている．全身性ジストニアでは淡蒼球内節のDBSが確立されている．書痙や音楽家の動作特異性局所ジストニアも視 …
NAID 130004505484

ジストニアの外科治療

平孝臣
臨床神経学 52(11), 1077-1079, 2012
… I have treated more than 100 patients with TSFHD with modern stereotactic thalamotomy of the nucleus ventro-oralis (Vo). … Stereotactic Vo thalamotomy is effective and safe for of task-specific focal hand dystonia. … Not only DBS but thalamotomy and other neurosurgical procedures play an important role in management of dystonias. …
NAID 130004505063