Trastornos del Movimiento y Neurocirugía Funcional


En esta sección se ponen a disposición de todos los usuarios y pacientes, una lista de publicaciones relacionadas con los Trastornos del Movimiento y Neurología Funcional en los que han participado activamente miembros del equipo médico de la Unidad de Neurocirugía

Estimulación subtalámica unilateral en el tratamiento de la enfermedad de Parkinson avanzada

V. Hernando-Requejo, J. Pastor, E. Peña, R. Carrasco-Moro, M. Pedrosa-Sánchez, P. Pulido-Rivas, R.G. Sola 

Resumen:

La estimulación subtalámica unilateral (ESTU) en el tratamiento de la enfermedad de Parkinson avanzada puede ser eficaz y presentar ventajas al comparar esta técnica con la estimulación subtálamica bilateral (ESTB). Pacientes y métodos. Estudiamos 35 pacientes consecutivos: 22 con ESTB y 13 con ESTU (seis izquierdos y siete derechos). Las características epidemiológicas y las escalas de evaluación funcional –Hoehn y Yahr, Schwab y England, y escala unifi- cada para la enfermedad de Parkinson (UPDRS) I a IV– no fueron significativamente diferentes en ambos grupos, excepto pa- ra Hoehn y Yahr en off (ESTU: 3,3 ± 0,3; ESTB: 4,1 ± 0,2; p = 0,004). Resultados. Los porcentajes globales de mejoría tras seis meses de cirugía fueron UPDRS I: 12%; II: 21,6%; III-off medicamentoso/on eléctrico: 30,6% (con respecto a off ini- cial); III-on/on: 8,8% (con respecto a on inicial); IV: 48,9%. Reducción de la dosis equivalente de levodopa: ESTU: 26,3%; ESTB: 17%. Estos porcentajes de mejoría no fueron significativamente diferentes en ambos grupos. Considerando la escala motora en off medicamentoso y on eléctrico en el sexto mes, y comparándola con la misma en off antes de la cirugía, los sínto- mas motores axiales mejoraron en un 17,1% (ESTU) y un 25% (ESTB); en las extremidades, ESTU: 39,1% en las contralatera- les al electrodo implantado; y 14,5% en las ipsilaterales; ESTB: extremidades derechas, 32,6%; izquierdas, 31,5%. No encon- tramos diferencias significativas al comparar la potencia eléctrica consumida por los electrodos en ambos grupos de pacientes en el sexto mes de tratamiento. Conclusiones. La ESTU resulta eficaz para la mejoría de los síntomas axiales. En nuestra serie, la reducción de la medicación tras la cirugía fue similar a los pacientes con ESTB. [REV NEUROL 2008; 46: 18-23]

Palabras clave. Enfermedad de Parkinson. Estimulación cerebral profunda. Estimulación subtalámica unilateral. Neurocirugía funcional. Resultados quirúrgicos. Trastornos del movimiento.
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Tratamiento de un caso de temblor esencial con estimulación subtalámica

V. Hernando-Requejo, J. Pastor, M. Pedrosa-Sánchez, A. Luengo-Dos Santos, R.García de Sola

Resumen:

Chronic stimulation of the subthalamic nucleus (STN) has proved itself to be useful in treating Parkin- son’ s disease and especially in dealing with the tremor suffered by patients. Yet there is very little experience to support the use of STN as an alternative therapy in non-Parkinsonian tremors. Case report. Our study considered the case of a patient who had been diagnosed as suffering from drug-resistant essential tremor which was predominant in the distal region of the upper right limb and was treated by unilateral stimulation of the STN. The patient’s clinical state improved significantly from the first weeks onwards. After a year and a half of therapy, the patient had achieved a stable improvement of 82.4% on the tremor scale and medication was reduced by 41.7%. Conclusions. SNT stimulation appears as a suitable target for the treatment of drug- resistant essential tremor. [REV NEUROL 2004; 38: 637-9].

Palabras clave. Deep brain stimulation. Essential tremor. Subthalamic nucleus.
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Tratamiento de un caso de distonía generalizada mediante estimulación subtalámica

J. Pastor-Gómez, V. Hernando-Requejo, A. Luengo-Dos Santos, M. Pedrosa-Sánchez, R.G. Sola

Resumen:

Generalised dystonia is an entity that does not usually respond well to medical treatment. Different surgical targets have therefore been used in the treatment of dystonia, including several thalamic nuclei or the internal globus pallidus. The subthalamic nucleus plays a fundamental role in the physiology of the basal ganglia. It could therefore be considered to be a good potential target for stimulation. Case report. A patient who was confined to a wheelchair and who had not responded to a number of different medical treatment protocols or to a bilateral thalamotomy was treated with bilateral deep brain stimulation in the subthalamic nucleus. Tetrapolar electrodes were placed in both subthalamic nuclei in two stages. The patient showed a significant improvement from the very beginning of the post-operative period. After six months’ progression, the patient was able to walk unaided and the dystonic seizures diminished significantly. Unfortunately, the patient died from choking. We used a bipolar stimulation protocol at 50 Hz with 210 μs pulses, which do not reach the levels of maximum charge density that are considered to be harmful. Conclusion. The subthalamic nucleus can be a good surgical target for deep brain stimulation in cases of generalised dystonia; it responds well to stimulation at intermediate frequencies with safe charge densities. [REV NEUROL 2003; 37: 529-31]

Palabras clave. Deep brain stimulation. Generalised dystonia. Subthalamic nucleus.
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La moderna psicocirugía: un nuevo enfoque de la neurocirugía en la enfermedad psiquiátrica

M. Pedrosa-Sánchez, R.G. Sola

Resumen:

To obtain an up-to-date review of the different possible surgical approaches in the management of certain psychiatric disorders that are refractory to conservative treatment (pharmacotherapy, psychotherapy, electroconvulsive ther- apy). Method. In order to conduct this research we reviewed the work published by centres with the most experience in this type of surgery, mainly in North America and Europe, since its beginnings in the 1930s, with the controversy concerning prefrontal leucotomy, until the appearance of modern stereotactic techniques. We analyse the anatomophysiological bases, their main clinical indications, the surgical techniques used and their results, as well as perspectives for the future of this neurosurgical treatment. Conclusions. The most noteworthy progress in psychosurgery in recent years has been the combination of a more rigorous selection of patients and the higher degree of specificity with which treatment is performed on the brain structures involved in psychiatric disease. The most widely employed psychosurgical procedures at present are cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leucotomy and postero-medial hypothalamotomy, with favourable responses in about 35-70% of cases. The psychiatric diagnoses where the best results are to be found are obsessive-compulsive disorder, chronic anxiety states and major depression. Current progress in neuroimaging techniques, increased neurophysiological knowledge and the revolutionary neuromodulation techniques, especially deep brain stimulation, offer an even more promising future for psychiatric neurosurgery. [REV NEUROL 2003; 36: 887-97]

Palabras clave. Capsulotomy. Cingulotomy. Deep brain stimulation. Hypothalamotomy. Limbic leucotomy. Obsessive-compulsive disorder. Psychosurgery. Subcaudate tractotomy.
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Psicocirugía y tratamiento neuroquirúrgico del dolor: revisión sistemática de la experiencia alcanzada en estos tipos de tratamiento

V. Hernando-Requejo, J. Pastor, E. García-Camba, R.G. Sola

Resumen:

Psychosurgery and the neurochemical treatment of pain (NTP) are therapeutic options restricted to patients who show resistance to medical treatments. Surgical techniques have been perfected over the last few decades. Aims. Our aim was to conduct a systematic review of the studies dealing with psychosurgery and NTP reported in the literature, based on the standards of quality used in evidence-based medicine. Development. Following screening and selection, nine of the 178 papers found (MEDLINE, 1990-2002) were selected for the study: three referring to the treatment of neuropathic pain and six about the treatment of obsessive-compulsive disorder (OCD). The objectives were the therapeutic results in all cases, the study of the anatomical-functional bases in three of them and the description of side effects in five. After adapting the standards of quality used in evidence-based medicine (there are no standards for papers about surgery), one was classified in group B, six in group C and two as C-D. The three papers about the treatment of pain reported a significant improvement in the pain scales in 40-77% of patients. As regards the treatment of OCD, results showed an overall improvement of the scales in 20.4-70% of the patients with an improvement above 50%. The side effects are also described. Conclusions. Data published support the indication of psychosurgery and NTP for selected patients with neuropathic pain and OCD. The methodological limitations of the papers prevent us from drawing conclusions about the other diseases for which these techniques have been indicated. [REV NEUROL 2004; 38: 949-56]

Palabras clave. Capsulotomy. Cingulotomy. Evidence based medicine. Leucotomy. Neuropathic pain. Obsessive-compulsive disorder. Systematic review.
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