DBS手术后病人管理

ChinaFebruary13,2007:DBSWilliamJ.Marks,Jr.,MDUniversityofCaliforniaSanFranciscoSanFrancisco,CAActivaTherapy/DeepBrainStimulation
Soletraisapprovedfor:–EssentialTremor(1997*)–Parkinson’sdisease(2002*)–Dystonia(2003*)
Kinetraisapprovedfor:–Parkinson’sdisease(2004*)*USAapprovalSoletra®Kinetra®30,000Introductions
Name
Role(neurologist,neurosurgeon,nurse,etc.)
Location
NumberofActivapatientsinpractice
CurrentlevelofinvolvementwithActivaTherapy
Challenges&issueswithActivaTherapyActiva®DBS

DBS
DBS
DBS

PD1.2.3.4.5.Activa:
DBS



0123DBS™*ThenegativeelectrodeexertsthetherapeuticeffectLeadElectrodes01230123offoff(-)off(+)positiveoffoff(+)(-)offRate(Hertz)numberofpulsespersecondPulseWidth(
sec)durationofeachstimulusAmplitude(Volts)intensityofstimulation**TheseparametersgenerallyprovidetherapeuticbenefitwithtwoappropriatelyplacedDBS™leadsfollowingaseriesofprogrammingsessions.::::135-185Hz135-185HzRate90-120
sec60-90
secPulseWidth2.5-3.6V2.0-3.6VAmplitudeGPiSTNParameterDeepBrainStimulation:ManagingParkinson’sDiseasePatientswithActiva®TherapyDeepBrainStimulationDBS:

––––
(e.g.,)–––

ImportanceofLeadLocationProperlyselectedelectrodeonaproperlylocatedDBS™leadprovidesoptimaltherapeuticbenefitwithminimalstimulation-inducedadverseeffects.((((((STNSensoryPathwaysMotorPathwaysThenegativeelectrodeexertsthetherapeuticeffect.ImportanceofLeadLocationImproperlyselectedelectrodeonaproperlylocatedDBS™leadfailstoprovideadequatestimulationtotheintendedtargetanddeliversstimulationtosensoryandmotorpathways,resultinginstimulation-inducedadverseeffectsandlessthanoptimalbeneficialeffects.STNSensoryPathwaysMotorPathwaysThenegativeelectrodeexertsthetherapeuticeffect.((((((ImportanceofLeadLocationAsub-optimallylocatedDBS™leaddoesnotallowstimulationoftheintendedtargetwithoutstimulatingadjacentstructures;stimulation-inducedadverseeffects,butnottherapeuticeffects,thuspredominate.((((((STNSensoryPathwaysMotorPathwaysThenegativeelectrodeexertsthetherapeuticeffect.STNThalamusSubstantiaNigradorsallateralmedialventral&/STNGPi:GPi

STN––()–
GPi––
––
–(e.g.,)….–STNManagingParkinson’sDiseasePatientswithActiva®TherapyDBS™LeadDetails
–•(spanning10.5mm,Model3387)•(spanning7.5mm,Model3389)–––DBS–MRI*orCT*PleaserefertolastslideforMRIinformationMRI*:STN*PleaserefertolastslideforMRIinformationMRI*:STN*PleaserefertolastslideforMRIinformation
––(e.g.,UPDRS*,,);
*UPDRS–UnifiedParkinson’sDiseaseRatingScaleManagingParkinson’sDiseasePatientswithActiva®Therapy
2-4()


–




Soletra–:impedance600-1300;currentdrain12-30
A–:impedance2000;currentdrain12
A–:impedance250;currentdrain500
A
:–(135-185Hz)–(60
sforSTN,90
sforGPi)
,“”–––(e.g.,/UPDRS-III)
(135-185Hz)(60
sforSTN,90
sforGPi)
:0-,1off,2off,3off,case+
0V0.1-0.2V

30)
0V
(1,2,and3)

STNGPi:Rigidity

Tremor()Bradykinesia



3.6V(Soletra)IPG
()
:–case(IPG)“off”–
*ItrelIIisnotapprovedforParkinson’sControlTherapy
/
IPG

IPG
:–()–(STN)–(–:
––––
MRI()
–/––
)STNPatients
GPiPatients
()

STN40-50%







–––


–––ManagingParkinson’sDiseasePatientswithActiva®Therapy


–––––
1.2.3.

1.
–––
VimDBS:Effect&Location
:–
:–
:–
:–Vo=ventraloral(pallidalrelay);Vim=ventralintermediate(cerebellarrelay);Vc=ventralcaudal(principlesomatosensorynucleus);IC=internalcapsuleSTNDBS:Effect&Location
:–
:–
:–()
:–
:–IC=internalcapsule;STN=subthalamicnucleus;RN=rednucleus;ML=mediallemniscusGPiDBS:Effect&Location
:–
:–
:–;0
:–GP=globuspallidus;IC=internalcapsule;OT=optictract


*PleaserefertolastslideforMRIinformation
–––––––
DBS–––––––
––––––
DBS––––––2.

MRI*––

–
–STN:2.5Vor–GPi:3.6Vor*PleaserefertolastslideforMRIinformation3.





/IPGIPGCommentsIPG(EOL)x-rayIPG100%IPGIPGIPGTreatmentDiagnosisProblem
Activa®PD:––––
–DBSPD–
STN
:
––
––––

()
ET:DBS
PD:––:/–:/
Dystonia:PD
STNStimulation––)–STN(ZI)–•STN••STN
GPiStimulation–PD
–––PD
–UPDRSIII–Timedtests–

1.2.3.


Activa®PD––DBS–––

ActivaPD1.PD•731311••“”“”“”,•2002“”200mg•200411“”2005“”50mgBid•200611“”40%“”60%“”•••••DBS1.PDShandongQiluHospDr.Liu,Yiming73yearsoldmale.Durationofsymptoms:13yearsBriefdescriptionofhistory:1.Startedwithrighthandrestingtremor(1993).Thetremorincreasedafterhisrectocancersurgery1995.Hewason“Artane”intheearlystage.Hebeganwith“Sinemet”in1999andgoodresponsetoSinemetfor3years.Hehadmotorfluctuationin2002andadded“Amantadine”.Healsoexperienced“wearingoff”“dystonia”since2004,thenheaddeddopamineagonistandthesymptomswerewellcontrolledtillNov.2006.2.SinceNov.2006,hehadseveremotorfluctuationanddyskinesia.Sometimesallthemedicationdidnotworkforhismotorproblemthewholeday.Wealsofindhehasmildcognitiveproblemrecently.3.HehasafamilyhistoyofPD.4.Latestmedication:Levodopais1000-1200mg/day,Trastal150mg/day,amantadine300mg/day).Issues/questions:ThepatienthasfamilyhistoryofPDandhadrectocancerhistory,IfDBSshouldbeperformedinthispatient?2.PDBeijingTiantanHosp
Male(WangJF)52yearsold,DurationofPDsymptoms:10yearsBriefdescriptionofhistory:1.Startedwithleftupperlimbrigidityandbradykinesia,thendevelopedwithhandsrestingandposturaltremor.2.Eyesclosedfrequentlyandaggravatedwithnervous.3.Beforeoper