MRgFUS Pallidothalamic Tractotomy for Chronic Therapy-Resistant Parkinson's Disease in 51 Consecutive Patients: Single Center Experience
MRgFUS Pallidothalamic Tractotomy for Chronic Therapy-Resistant Parkinson's Disease in 51 Consecutive Patients: Single Center Experience
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DOI：
10.3389/fsurg.2019.00076
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发表时间：
2020-01-14
影响因子：
1.8
通讯作者：
Jeanmonod, Daniel
中科院分区：
文献类型：
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作者：
Gallay, Marc N.;Moser, David;Jeanmonod, Daniel
背景资料：从20世纪40年代开始，对苍白球传出纤维进行消融性神经外科手术以治疗帕金森病（PD）患者有着悠久的历史。自20世纪90年代初，我们进行了再实现的方法，丘脑底区，并提出，在组织学的基础上，专门针对苍白球丘脑束在水平的Forel的字段H1。自2011年以来，使用MR引导聚焦超声（MRgFUS）技术进行了这种干预，即苍白球丘脑束切开术（PTT）。最近，我们将对苍白球丘脑束组织学的重新评估与使用热剂量控制的损伤策略的优化相结合。目的：本研究旨在证明MRgFUS PTT治疗慢性难治性PD的疗效和风险特征。方法：该连续病例系列反映了我们目前的治疗常规，并在2017年至2018年期间收集。纳入了47例患者的52项干预措施。15例患者接受了双侧PTT。中位随访时间为12个月。结果如下：将统一帕金森病评定量表（UMRS）停药后评分与基线用药评分进行比较，结果显示震颤平均降低84%，强直降低70%，远端运动迟缓降低73%，所有数值均为治疗侧的数值。轴向项目（语音、躯干和步态）没有显著改善。PTT实现了100%抑制药物治疗中的运动障碍以及疼痛（p < 0.001）、肌张力障碍（p < 0.001）和REM睡眠障碍（p < 0.01）的减轻。左旋多巴的平均摄入量减少了55%。患者报告手术侧平均震颤缓解率为88%，平均总体症状缓解率为82%，全身平均总体症状改善率为69%。认知功能无明显改变。1年随访时，一小组双侧PTT显示出与单侧PTT相似的结果，但此时无法得出确切结论。结论：MRgFUS PTT被证明是一种安全有效的PD患者干预措施，可解决所有症状，有效性各不相同。我们讨论了需要整合术前状态的丘脑皮质网络以及心理情绪方面。
Background: There is a long history, beginning in the 1940s, of ablative neurosurgery on the pallidal efferent fibers to treat patients suffering from Parkinson's disease (PD). Since the early 1990s, we undertook a re-actualization of the approach to the subthalamic region, and proposed, on a histological basis, to target specifically the pallidothalamic tract at the level of Forel's field H1. This intervention, the pallidothalamic tractotomy (PTT), has been performed since 2011 using the MR-guided focused ultrasound (MRgFUS) technique. A reappraisal of the histology of the pallidothalamic tract was combined recently with an optimization of our lesioning strategy using thermal dose control. Objective: This study was aimed at demonstrating the efficacy and risk profile of MRgFUS PTT against chronic therapy-resistant PD. Methods: This consecutive case series reflects our current treatment routine and was collected between 2017 and 2018. Fifty-two interventions in 47 patients were included. Fifteen patients received bilateral PTT. The median follow-up was 12 months. Results: The Unified Parkinson's Disease Rating Scale (UPDRS) off-medication postoperative score was compared to the baseline on-medication score and revealed percentage reductions of the mean of 84% for tremor, 70% for rigidity, and 73% for distal hypobradykinesia, all values given for the treated side. Axial items (for voice, trunk and gait) were not significantly improved. PTT achieved 100% suppression of on-medication dyskinesias as well as reduction in pain (p < 0.001), dystonia (p < 0.001) and REM sleep disorders (p < 0.01). Reduction of the mean L-Dopa intake was 55%. Patients reported an 88% mean tremor relief and 82% mean global symptom relief on the operated side and 69% mean global symptom improvement for the whole body. There was no significant change of cognitive functions. The small group of bilateral PTTs at 1 year follow-up shows similar results as compared to unilateral PTTs but does not allow to draw firm conclusions at this point. Conclusion: MRgFUS PTT was shown to be a safe and effective intervention for PD patients, addressing all symptoms, with varying effectiveness. We discuss the need to integrate the preoperative state of the thalamocortical network as well as the psycho-emotional dimension.