Zusammenfassung
Die tiefe Hirnstimulation des Nucleus subthalamicus wurde vor 15 Jahren in die Behandlung der fortgeschrittenen Parkinson-Krankheit eingeführt. Seither ist ihre klinische Wirksamkeit in zahlreichen Studien belegt worden und sie hat einen festen Platz im Therapiealgorithmus des Morbus Parkinson erobert. Die aktuellen Leitlinien der Deutschen Gesellschaft für Neurologie sehen eine Indikation für eine tiefe Hirnstimulation bei schwerem Tremor, hypokinetischen Wirkfluktuationen oder Dyskinesien, wenn die Optimierungsmöglichkeiten der oralen Medikation erschöpft sind. Obgleich diese Definition für den Patienten und den behandelnden Neurologen einen sehr breiten Ermessensspielraum lässt, welcher Schweregrad der Symptome eine Operationsindikation bedingt, und wieweit die medikamentösen Optimierungsversuche getrieben werden müssen, wird die Operation heute allgemein als „Ultima-Ratio”-Behandlung angesehen. Entsprechend ist das mittlere Alter der Patienten bei einer tiefen Hirnstimulation in den meisten Zentren zwischen 55 und 65 Jahre und die Krankheitsdauer um die 15 Jahre. In diesem Artikel werden wir verschiedene Faktoren diskutieren, die einen Einfluss auf das Ergebnis einer subthalamischen Neurostimulation haben. Das Alter des Patienten und das Krankheitsstadium spielen dabei neben einer eingehenden Prüfung der psychosozialen Motivation für einen operativen Eingriff die entscheidende Rolle.
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus has gained a firm place in the treatment algorithm of Parkinson's disease (PD) after having been introduced into the treatment of advanced PD 15 years ago. The clinical efficacy has been proven in numerous studies. The current treatment guidelines of the German Association of Neurology suggest an indication for DBS in cases of severe tremor, hypokinetic fluctuations or dyskinesia, if oral medication can no longer be optimised. Nevertheless, surgery is still regarded a „last resort treatment”, although this definition leaves a broad scope of discretion for the patient and the treating neurologist about the severity of symptoms that justify surgery, and the medication adjustments that should have been tried. Currently, the average age of patients undergoing DBS is between 55 and 65 years and the disease duration is around 15 years in most centres. In this article we will discuss several factors that have an impact on the outcome after deep brain stimulation. The age of the patient, the stage of the disease and the psychosocial motivation for surgery play a paramount role.
Schlüsselwörter
Parkinson - tiefe Hirnstimulation - Tremor
Key words
Parkinson's disease - deep brain stimulation - tremor
Literatur
-
1
Kleiner-Fisman G, Herzog J, Fisman D N. et al .
Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes.
Mov Disord.
2006;
21 (Suppl. 14)
S290-304
-
2
Schupbach W M, Chastan N, Welter M L. et al .
Stimulation of the subthalamic nucleus in Parkinson's disease: a 5 year follow up.
Journal of neurology, neurosurgery, and psychiatry.
2005;
76
1640-1644
-
3
Krack P, Batir A, Van Blercom N. et al .
Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson's disease.
The New England journal of medicine.
2003;
349
1925-1934
-
4
Voges J, Hilker R, Botzel K. et al .
Thirty days complication rate following surgery performed for deep-brain-stimulation.
Mov Disord.
2007;
22
1486-1489
-
5
Montaurier C, Morio B, Bannier S. et al .
Mechanisms of body weight gain in patients with Parkinson's disease after subthalamic stimulation.
Brain.
2007;
130
1808-1818
-
6
Mallet L, Schupbach M, N'Diaye K. et al .
Stimulation of subterritories of the subthalamic nucleus reveals its role in the integration of the emotional and motor aspects of behavior.
Proc Natl Acad Sci U S A.
2007;
104
10 661-10 666
-
7
Houeto J L, Mesnage V, Mallet L. et al .
Behavioural disorders, Parkinson's disease and subthalamic stimulation.
Journal of neurology neurosurgery and psychiatry.
2002;
72
701-707
-
8
Deuschl G, Schade-Brittinger C, Krack P. et al .
A Randomized Trial of Deep-Brain Stimulation for Parkinson's Disease.
New England Journal of Medicine.
2006;
355
896-908
-
9
Visser-Vandewalle V, Temel Y, Colle H. et al .
Bilateral high-frequency stimulation of the subthalamic nucleus in patients with multiple system atrophy – parkinsonism. Report of four cases.
J Neurosurg.
2003;
98
882-887
-
10
Krack P, Pollak P, Limousin P. et al .
Stimulation of subthalamic nucleus alleviates tremor in Parkinson's disease.
Lancet.
1997;
350
1675
-
11
Charles P D, Van Blercom N, Krack P. et al .
Predictors of effective bilateral subthalamic nucleus stimulation for PD.
Neurology.
2002;
59
932-934
-
12
Russmann H, Ghika J, Villemure J G. et al .
Subthalamic nucleus deep brain stimulation in Parkinson disease patients over age 70 years.
Neurology.
2004;
63
1952-1954
-
13
Derost P P, Ouchchane L, Morand D. et al .
Is DBS-STN appropriate to treat severe Parkinson disease in an elderly population?.
Neurology.
2007;
68
1345-1355
-
14
Ory-Magne F, Brefel-Courbon C, Simonetta-Moreau M. et al .
Does ageing influence deep brain stimulation outcomes in Parkinson's disease?.
Mov Disord.
2007;
22
1457-1463
-
15
Saint-Cyr J A, Trepanier L L, Kumar R. et al .
Neuropsychological consequences of chronic bilateral stimulation of the subthalamic nucleus in Parkinson's disease.
Brain.
2000;
123 (Pt 10)
2091-2108
-
16
Volkmann J.
Update on surgery for Parkinson's disease.
Curr Opin Neurol.
2007;
20
465-469
-
17
Schrag A, Banks P.
Time of loss of employment in Parkinson's disease.
Mov Disord.
2006;
21
1839-1843
-
18
Schrag A.
Quality of life and depression in Parkinson's disease.
J Neurol Sci.
2006;
248
151-157
-
19
Braak H, Del Tredici K.
Invited Article: Nervous system pathology in sporadic Parkinson disease.
Neurology.
2008;
70
1916-1925
-
20
Kempster P A, Williams D R, Selikhova M. et al .
Patterns of levodopa response in Parkinson's disease: a clinico-pathological study.
Brain.
2007;
130
2123-2128
-
21
Wolters E, Lees A J, Volkmann J. et al .
Managing Parkinson's disease with continuous dopaminergic stimulation.
CNS Spectr.
2008;
13
1-14; quiz 15–16
-
22
Schupbach M, Gargiulo M, Welter M L. et al .
Neurosurgery in Parkinson disease: a distressed mind in a repaired body?.
Neurology.
2006;
66
1811-1816
-
23
Agid Y, Schupbach M, Gargiulo M. et al .
Neurosurgery in Parkinson's disease: the doctor is happy, the patient less so?.
J Neural Transm Suppl.
2006;
70
409-414
Prof. Dr. Jens Volkmann
Neurologische Klinik, Universitätklinikum Schleswig-Holstein, Campus Kiel
Arnold-Heller-Str. 3, Haus 41
24105 Kiel
eMail: j.volkmann@neurologie.uni-kiel.de
