의학강좌 백선하

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1 Continuing Education Column Sun Ha Paek, MD Department of Neurosurgery, Seoul National University College of Medicine E mail : paeksh@snu.ac.kr J Korean Med Assoc 2008; 51(2): Abstract Parkinson disease (PD) is the second most common degenerative disease in the central nervous system following the Alzheimer s disease. Although the specific progressive degenerative change of dopamine producing cells in the substantia nigra compacta has been well documented, neither the cause nor the underlying mechanism of degeneration has been identified. Long term use of L dopa causes dyskinesia, motor fluctuation, and other side effects, preventing the patients with advanced PD from further medication. Since deep brain stimulation (DBS) was introduced in the late 1980s by Dr. Benabid, it has become the standard surgical treatment for the patient with advanced PD who has developed drug-induced side effects or motor fluctuation after long term use of L dopa. Since DBS had been first reimbursed by the National Health Insurance System in January 2005 in Korea, many patients with advanced PD had a chance to be treated with DBS. The subthalamic nucleus (STN), globus pallidus interna (GPi), and thalamic VIM nucleus have been utilized as the target of DBS in the treatment of the patients with advanced PD. In this paper, the author briefly reviews the current methodology of surgical treatment of advanced PD, focusing on the STN DBS. Keywords : Advanced parkinson disease; Subthalamic nucleus; Deep brain stimulation 158

2 Brain stem / Spinal cord Brain stem / Spinal cord Indirect Indirect GPe STN D2 Cortex in Normal Putamen SNC GPi/SNr PPN Direct D1 Cortex in Parkinson Disease GPe STN D2 Putamen SNC GPi/SNr PPN Direct Figure 1. Basal ganglia circuit in normal (A) and Parkison disease (B). D1 CM/Pf VA/VL A CM/Pf VA/VL B 159

3 Pack SH Table 1. Hoehn and Yahr Staging: Five stage disability scale which represents disease progression status of Parkinson disease. Summary of the meaning of each stage Hoehn & Yahr stage 0: No visible symptoms of Parkinson's disease 1: Parkinson's disease symptoms just on one side of the body 2: Parkinson's disease symptoms on both sides of the body and no difficulty walking 3: Parkinson's disease symptoms on both sides of the body and minimal difficulty walking 4: Parkinson's disease symptoms on both sides of the body and moderate difficulty walking 5: Parkinson's disease symptoms on both sides of the body and unable to walk Figure 2. Parkinson diary example: The diary is divided into half hour time periods on which patients denote whether they are on with nontroublesome dyskinesia, or on with trouble some dyskinesia. The patient or caregiver should place 1 check mark in each half hour time slot to indicate the patient's predominant response during most of that period. 160

Table 2. Target points of subthalamic nucleus, internal globus pallidus, and VIM of the thalamus in the Atlas (Schaltenbrand Wahren Brain Atlas) Figure 3.

4 Table 2. Target points of subthalamic nucleus, internal globus pallidus, and VIM of the thalamus in the Atlas (Schaltenbrand Wahren Brain Atlas) Figure 3. Frequent errors of asymmetries of frame placement. Target point Description STN Vim GPI middle 1/3 of AC PC line 0~6 mm below AC/PC plane 10~14 mm from midline posterior 1/4 of AC PC length level of AC PC plane 15 mm from midline Rule of Tasker for Vim : width of Vim = 11.5 mm + (3 rd ventricle width)/2 2/3 of AC PC length in front of PC level of AC PC plane 20 mm from midline 161

5 Pack SH Figure 4. Brain area to be covered in MRI in T2 axial images (left) and T1 axial images (right). 162

6 Figure 5. Simultaneous 5 channel microelectrode recording and record sheet. 163

7 Pack SH Table 3. Symptoms indicating wrong placement of electrode during subthalamic nucleus stimulation Side Effect Stimulated Area Lead Speech arrest, dysarthria Internal capsule Lateral Limb tonic contraction Myoclonus Paresthesias Medial lemniscus Posterior Unilateral ocular deviation 3 rd cranial nerve Medial Mydriasis Other ocular signs RiMLF internal capsule/t.r Posteromedial Horner s sign, sweating STN/3rd CN/Internal capsule Variable Figure 6. Microelectrode recording during approach for subthalamic nucleus (SNr; substantia nigra pars reticulata, STN; subthalamic nucleus; Zi; zona incerta). 164

8 11. Nussbaum RL, Ellis CE. Alzheimer s disease and Parkinson s disease. N Engl J Med 2003; 348: Benabid AL, Benazzouz A, Hoffmann D, Limousin P, Krack P, Pollak P. Long term electrical inhibition of deep brain targets in movement disorders. Mov Disord 1998; 13: S Fraix V, Pollak P, Van Blercom N, Xie J, Krack P, Koudsie A, Benabid AL. Effect of subthalamic nucleus stimulation on levodopa induced dyskinesia in Parkinson's disease. Neurology 2000; 55: Olanow CW, Brin MF, Obeso JA. The role of deep brain stimulation as a surgical treatment for Parkinson s disease. Neurology 2000; 55: S Pollak P, Fraix V, Krack P, Moro E, Mendes A, Chabardes S, Koudsie A, Benabid AL. Treatment results: Parkinson s disease Mov Disord 2002; 17: S Carpenter MB, ed. Core text of neuroanatomy. 4th ed. Baltimore: Williams & Wilkins, 1991: Deep Brain Stimulation for Parkinson s Disease Study Group. Deep brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson's disease. N Engl J Med 2001; 345: Minguez Castellanos A, Escamilla Sevilla F, Katati MJ, Martin Linares JM, Meersmans M, Ortega Moreno A, Arjona V. Different patterns of medication change after subthalamic or pallidal stimulation for Parkinson s disease: target related effect or selection bias? J Neurol Neurosurg Psychiatry 2005; 76: Volkmann J, Allert N, Voges J, Weiss PH, Freund HJ, Stürm V. Safety and efficacy of pallidal or subthalamic nucleus stimulation in advanced PD. Neurology 2001; 56: Moro E, Scerrati M, Romito LM, Roselli R, Tonali P, Albanese A. Chronic subthalamic nucleus stimulation reduces medication requirements in Parkinson s disease. Neurology 1999: 53:

9 Pack SH 11. Fraix V, Pollak P, Moro E, Chabardes S, Xie J, Ardouin C, Benabid AL. Subthalamic nucleus stimulation in tremor dominant parkinsonian patients with previous thalamic surgery. J Neurol Neurosurg Psychiatry 2005; 76: Thobois S, Mertens P, Guenot M, Hernier M, Mollion H, Bouvard M, Chazot G, Broussolle E, Sindou M. Subthalamic nucleus stimulation in Parkinson's disease: clinical evaluation of 18 patients. J Neurol 2002; 249: Krack P, Batir A, Van Blercom N, Chabardes S, Fraix V, Ardouin C, Koudsie A, Limousin PD, Benazzouz A, LeBas JF, Benabid AL, Pollak P. Five year follow up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson s disease. N Engl J Med 2003; 349: Romito LM, Scerrati M, Contarino MF, Iacoangeli M, Bentivoglio AR, Albanese A. Bilateral high frequency subthalamic stimulation in Parkinson s disease: long term neurological follow up. J Neurosurg Sci 2003; 47: Rodriguez Oroz MC, Zamarbide I, Guridi J, Palmero MR, Obeso JA. Efficacy of deep brain stimulation of the subthalamic nucleus in advanced Parkinson s disease 4 years after surgery: double blind and open label evaluation. J Neurol Neurosurg Psychiatry 2004; 75: Godinho F, Thobois S, Magnin M, Guenot M, Polo G, Benatru I, Xie J, Salvetti A, Garcia Larrea L, Broussolle E, Mertens P. Subthalamic nucleus stimulation in Parkinson's disease: Anatomical and electrophysiological localization of active contacts. J Neurol 2006; 253: Benabid AL, Chabardes S, Seigneuret E. Deep brain stimulation in Parkinson's disease: long term efficacy and safety What happened this year? Curr Opin Neurol 2005; 18: Bejjani BP, Dormont D, Pidoux B, Yelnik J, Damier P, Arnulf I, Bonnet AM, Marsault C, Agid Y, Phlippon J, Cornu P. Bilateral subthalamic stimulation for Parkinson s disease by using three dimensional stereotactic magnetic resonance imaging and electrophysiological guidance. J Neurosurg 2000; 92: Benazzouz A, Breit S, Koudsie A, Pollak P, Krack P, Benabid AL. Intraoperative microrecordings of the subthalamic nucleus in parkinson s disease. Mov Disord 2002; 17: S Krack P, Fraix V, Mendes A, Benabid AL, Pollak P. Postoperative management of subthalamic nucleus stimulation for Parkinson s disease. Mov Disord 2002; 17: S

10 Peer Reviewer Commentary 167

975_983 특집-한규철, 정원호

975_983 특집-한규철, 정원호 Focused Issue of This Month Gyu Cheol an, MD Department of Otolaryngology ead & Neck Surgery, Gachon University of College Medicine E - mail : han@gilhospital.com Won-o Jung, MD Department of Otolaryngology