Combined (thalamotomy and stimulation) stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson disease

Stereotactic thalamotomy of the thalamic nucleus ventralis intermedius (VIM) is routinely used for movement disorders. During this procedure, it has been observed that high-frequency (100 Hz) stimulation of VIM was able to stop the extrapyramidal tremor. In patients with bilateral tremor of extrapyramidal origin, who were resistant to drug therapy, the therapeutic protocol associated (1) a radiofrequency VIM thalamotomy for the most disabled side, and (2) a continuous VIM stimulation for the other side using stereotactically implanted electrodes, connected to subcutaneous stimulators. VIM thalamotomy relieved the tremor in all operated cases. Side effects were mild and regressive. VIM stimulation strongly decreased the tremor but failed to suppress it as completely as thalamotomy did. This was due in part to the fact that programmable stimulator frequency rate is limited to 130 Hz, while it appeared that the optimal stimulation frequency was 200 Hz. This therapeutic protocol appears to be of interest for patients with bilateral extrapyramidal movement disorders.     

Absence attacks controlled by thalamic stimulation

Thalamic electrical stimulation in 3 patients alleviated chronic pain, absence attacks and spontaneously occurring delta and theta EEG discharges. It is suggested that diencephalic discharges may activate and/or lower the threshold for pain at the level of the diencephalon.     

Thalamic stimulation for chronic pain

Electrical stimulation of the thalamus was found to be effective for the treatment of chronic intractable pain of various etiologies. Diencephalic recordings revealed spontaneous focal electrical discharge patterns with relatively low activation thresholds. Localization of the optimum thalamic discharge site is used as a guide for the electrode implant to be used for chronic stimulation. The thalamic sites which most frequently displayed the low threshold spontaneous focal discharge activity were the CM-Pf complex and related intralaminar nuclear structures. Generation of diencephalic pain-reverberating circuits was discussed in relation to explaining the pain syndromes herein described. The applied electrical stimulation is thought to electrophysiologically 'jam' the low threshold discharging systems and thereby alleviate pain.     

刺激兔丘脑不同核团和胼胝体引起的膈神经放电效应

实验在33例清醒、肌肉麻痹和切断双侧迷走神经的家兔上进行,观察了刺激丘脑不同核团(VIL,VL,VPM 和 MI)和胼胝体纤维以激活皮层时膈神经的放电效应。当在吸气相(膈神经放电时)给予上述核团及胼胝体纤维电脉冲刺激,可使膈神经放电短暂抑制,随后的呼气相缩短、吸气相提前出现。如果在呼气相刺激上述核团,也能使该呼气时相缩短,随后的吸气时相提前出现。当在皮层接受 VL 投射的局部区域给予回苏灵后,再刺激 VL,皮层诱发电位增大,除使原先的膈神经放电效应更为明显外,还可在呼气相刺激时引起膈神经即刻的短暂放电。以上实验结果提示,当用回苏灵使皮层活动加强后,刺激丘脑 VL 引起的膈神经放电效应明显增强。损毁红核或切断皮层下行传导束但保留皮层脊髓束后,刺激丘脑引起的膈神经放电效应均不受影响,表明传入冲动激活皮层后引起的膈神经放电效应可能主要经皮层脊髓束下传,而皮层红核脊髓束不起重要作用。     

Thalamic lesions dissociate breathing inhibition by hypoxia and adenosine in fetal sheep

The effects of diencephalic lesions on respiratory responses to intra-arterially infused adenosine (ADO) were determined in chronically catheterized fetal sheep (>0.8 term). These studies were designed to test the hypothesis that the inhibitory effects of ADO on fetal breathing, like those of hypoxia, are mediated by the parafascicular nuclear complex (Pf) of the posteromedial thalamus. ADO inhibited breathing [control (C): 26 +/- 2.6, ADO: 4 +/- 1 min/h] in normal fetuses and in a fetus with a lesion that virtually destroyed the thalamus but left intact most of Pf. Neuronal lesions in the diencephalon, produced by injecting ibotenic acid, abolished the inhibitory effects of ADO on breathing (C: 31 +/- 5.1, ADO: 30 +/- 4.5 min/h) when the lesions encompassed Pf or the sector immediately rostral to Pf that retained the capacity to regulate hypoxic inhibition. Smaller lesions created by the insertion of needles also eliminated the depressant effects of ADO when disruptions were within Pf or a rostral component of the thalamic cortical activating system. It is concluded that 1) a medial thalamic sector is critically involved in ADO-induced apnea and 2) ADO-dependent and ADO-independent mechanisms mediate hypoxic inhibition.     

Diencephalic seizures. Case report

Intractable complex partial and diencephalic seizures in 1 patient are being treated effectively by intermittent daily electrical stimulation in the right thalamus in conjunction with phenytoin, 200 mg/day. Electrical stimulation in the right thalamus was found to suppress spike and sharp wave discharge activity temporarily in the right thalamus and in the left parietal and right scalp leads. It was postulated that beneficial effects from electrical stimulation were due to electrically 'jamming a low-threshold discharge system'.     

刺激下丘脑弓状核或垂体前叶对丘脑束旁核神经元伤害性反应的抑制

采用电生理学方法,观察电刺激大鼠下丘脑弓状核（ＡＲＣ）或垂体前叶（ＡＬ）,对丘脑束旁核（Ｐｆ）神经元伤害性反应的影响。实验结果表明,电刺激ＡＲＣ能抑制Ｐｆ神经元的伤害性放电,这种抑制很快出现,也很快恢复,称为即时抑制。电刺激Ａ辄能抑制Ｐｆ神经元的伤害性放电,这种抑制的出现有一定的潜伏期,并持续较长时间,称为延迟抑制。摘除垂体减弱刺激ＡＲＣ的即时抑制,而损毁ＡＲＣ则减弱刺激ＡＬ的延迟抑制。地塞米松预     

综述与专论: 外源节律性脑刺激技术在精神神经类疾病治疗中的应用

神经振荡是中枢神经系统中一种节律性神经活动模式，研究发现精神神经类疾病患者存在神经振荡异常。外源节律性刺激能够通过“夹带”效应以及可塑性变化机制有效调节异常的神经振荡，具有治疗精神神经类疾病的潜在可能性。目前，外源节律性脑刺激技术主要包括经颅交流电刺激、经颅时间相干刺激、节律性感觉刺激等方式。本文从外源节律性脑刺激技术原理以及目前不同技术在临床上治疗精神神经类疾病的刺激策略、研究进展以及治疗效果等角度展开综述，提出这一类调控技术可能成为未来临床治疗精神神经疾病症状的无创高效新型治疗方案，并对其未来的发展方向进行展望。     

Atypical Forms of Cerebral α-Activity in the Case of Lesions in Regulatory Structures of the Human Brain

The results of the EEG study of patients with tumor lesion of diencephalic (29 subjects) and limbic (25 subjects) structures with the focus on the analysis of structural and functional organization of α activity have been summarized. It has been found that diencephalic structure dysfunction is accompanied by disorder of α-rhythm spatial organization in the form of generalization or translocation of its focus to the frontal regions of the cerebral cortex. Distinctive features of “diencephalic” type alteration of α rhythm are determined by predominant integration of the thalamic or hypothalamic structures into the pathological process. Involvement of the limbic structures, especially at early stages of the disease, induces increase in α-rhythm intensity in the temporal region of the affected hemisphere. The nature of the response of the EEG pattern to the functional stress allows identifying it as a “hippocampal α rhythm”. Implementation of the automatic methods of analyzing plays an important role in the identification of these specified pathologic forms of the α rhythm that are often invisible during visual assessment. Detected atypical forms of α rhythm facilitates the interpretation of hemispheric asymmetry of the EEG in patients with cerebral pathology.     

Somatosensory evoked potential recovery (SEP-R) in various neurological disorders

Recovery functions of somatosensory evoked potentials were studied by the paired stimulation technique in 61 patients with various neurological disorders. A less suppressive or hyperexcitable phase at short intervals, which had been shown in myoclonic patients, was seen in 22 patients. This abnormality was observed even in patients without myoclonus or involuntary movements, which suggests that this phenomenon is not mainly due to some dysfunction causing myoclonus or movement disorders. Less suppression at short intervals was observed for both N20-P25 and P25-N33 components in most of them. Less suppressive recovery of the N20-P25 component with normal recovery of the P25-N33 component was shown only in 3 patients with subcortical lesions with relative sparing of the cortical elements (Binswanger's subcortical encephalopathy). We conclude that less suppressive recovery of only the N20-P25 component suggests the presence of subcortical lesions.     

Computer simulated discharges of thalamic ventrobasal neurones during sleep and wakefulness

A theoretical model is described which in response to combinations of poissonian pulse trains with different mean frequencies on three independent incoming lines, generated output signals simulating spontaneous discharges of thalamic ventrobasal (VB) neurones during sleep and wakefulness. Some dynamic neuronal properties as refractoriness, facilitation, short term memory were simulated and characteristics of response to single pulses on different lines properly selected to reproduce those exhibited by VB neurones upon artificial stimulation of thalamic afferent systems. The data obtained from the model are briefly discussed in relation to possible contributions of specific and nonspecific afferent systems in producing spontaneous VB discharges characteristic of different levels of vigilance.     

Evoked potentials to joint presentation of photic and acoustic stimuli in the human EEG

The results are outlined of a comparative estimation of averaged EP recorded in response to simultaneous and separate presentation of photic and acoustic stimuli on EEG of fifteen healthy subjects and twelve patients with focal lesions of the diencephalic structures. Investigation of the EP components and integral-temporal parameters has revealed that in healthy subjects EP to a combined heteromodal stimulation considerably exceeded by amplitude the one recorded in response to a separate presentation of stimuli. In case of lesion of the diencephalic formations, the converging effect of polysensory stimulation for the main waves of the response was less pronounced than in healthy subjects. At the same time, in pathological cases the summation effect of the afteraction potential (recorded after the main EP components as a slow negative oscillation) was manifested most distinctly, especially in the central zone of the cortex.     

Relative contributions of local cell and passing fiber activation and silencing to changes in thalamic fidelity during deep brain stimulation and lesioning: a computational modeling study

Deep brain stimulation (DBS) and lesioning are two surgical techniques used in the treatment of advanced Parkinson’s disease (PD) in patients whose symptoms are not well controlled by drugs, or who experience dyskinesias as a side effect of medications. Although these treatments have been widely practiced, the mechanisms behind DBS and lesioning are still not well understood. The subthalamic nucleus (STN) and globus pallidus pars interna (GPi) are two common targets for both DBS and lesioning. Previous studies have indicated that DBS not only affects local cells within the target, but also passing axons within neighboring regions. Using a computational model of the basal ganglia-thalamic network, we studied the relative contributions of activation and silencing of local cells (LCs) and fibers of passage (FOPs) to changes in the accuracy of information transmission through the thalamus (thalamic fidelity), which is correlated with the effectiveness of DBS. Activation of both LCs and FOPs during STN and GPi-DBS were beneficial to the outcome of stimulation. During STN and GPi lesioning, effects of silencing LCs and FOPs were different between the two types of lesioning. For STN lesioning, silencing GPi FOPs mainly contributed to its effectiveness, while silencing only STN LCs did not improve thalamic fidelity. In contrast, silencing both GPi LCs and GPe FOPs during GPi lesioning contributed to improvements in thalamic fidelity. Thus, two distinct mechanisms produced comparable improvements in thalamic function: driving the output of the basal ganglia to produce tonic inhibition and silencing the output of the basal ganglia to produce tonic disinhibition. These results show the importance of considering effects of activating or silencing fibers passing close to the nucleus when deciding upon a target location for DBS or lesioning.     

Non-Invasive Electrical Brain Stimulation Montages for Modulation of Human Motor Function

Non-invasive electrical brain stimulation (NEBS) is used to modulate brain function and behavior, both for research and clinical purposes. In particular, NEBS can be applied transcranially either as direct current stimulation (tDCS) or alternating current stimulation (tACS). These stimulation types exert time-, dose- and in the case of tDCS polarity-specific effects on motor function and skill learning in healthy subjects. Lately, tDCS has been used to augment the therapy of motor disabilities in patients with stroke or movement disorders. This article provides a step-by-step protocol for targeting the primary motor cortex with tDCS and transcranial random noise stimulation (tRNS), a specific form of tACS using an electrical current applied randomly within a pre-defined frequency range. The setup of two different stimulation montages is explained. In both montages the emitting electrode (the anode for tDCS) is placed on the primary motor cortex of interest. For unilateral motor cortex stimulation the receiving electrode is placed on the contralateral forehead while for bilateral motor cortex stimulation the receiving electrode is placed on the opposite primary motor cortex. The advantages and disadvantages of each montage for the modulation of cortical excitability and motor function including learning are discussed, as well as safety, tolerability and blinding aspects.     

Tremor disorders. Diagnosis and management.

Tremor is commonly encountered in medical practice, but can be difficult to diagnose and manage. It is an involuntary rhythmic oscillation of a body part produced by reciprocally innervated antagonist muscles. Tremors vary in frequency and amplitude and are influenced by physiologic and psychological factors and drugs. Categorization is based on position, posture, and the movement necessary to elicit the tremor. A resting tremor occurs when the body part is in repose. A postural tremor occurs with maintained posture and kinetic tremor with movement. Various pathologic conditions are associated with tremors. Essential tremor, which is the most common, is postural and kinetic, with a frequency between 4 and 8 Hz, and involves mainly the upper extremities and head. Essential tremor responds to treatment with primidone, beta-blockers, and benzodiazepines. Parkinson''s disease causes a 4- to 6-Hz resting tremor in the arms and legs that responds to the use of anticholinergics and a combination of carbidopa and levodopa. Tremor can also be a manifestation of Wilson''s disease, lesions of the cerebellum and midbrain, peripheral neuropathy, trauma, alcohol, and conversion disorders. Treatment should be directed to the underlying condition. Stereotactic thalamotomy of thalamic stimulation is a last resort.     

深部脑刺激作用机制的探讨

深部脑刺激器（deep brain stimulator）,也经常被称为脑起搏器,是可植入人体设备,并连续不断地传送刺激脉冲到深部脑组织的特定区域,即所谓的深部脑刺激（deep brain stimulation,DBS）.迄今为止,深部脑刺激是治疗严重顽固抗药性运动障碍疾病（如帕金森病,原发性震颤及肌张力异常等）的最有效的外科治疗手段之一.此外,广大的科研工作者也不断地探索应用DBS治疗其他神经及精神异常（如,癫痫和强迫症）的新的临床应用.尽管应用DBS治疗运动障碍非常有效,并也迅速被探索性地应用到其他神经障碍治疗中,但其作用机制仍然不是十分清楚,成为学者们争论的热点.DBS治疗效果的作用机制通常有两种基本的观点：高频刺激抑制学说及高频刺激兴奋学说.基于最近发表的关于中枢神经系统内的高频刺激效应的资料、数据及相关评论,两种机制共存并发挥作用的DBS作用假说被提出,认为DBS通过施加高频刺激干扰并控制了核团病理性紊乱随机活动,同时施加兴奋性刺激到其他基底节的网络,以实现对帕金森病的治疗.     

The role of monopolar stimulation during computed-tomography-guided stereotactic biopsies

44 patients underwent intraoperative stimulation with a monopolar electrode prior to computed tomography (CT)-guided stereotactic biopsy. Stimulation at 2-100 Hz resulted in functional responses in 6/21 patients with subcortical or callosal lesions, 4/6 with basal ganglion lesions, 8/10 with thalamic and 4/4 with brainstem lesions. In all but 2 patients with mesencephalic lesions, where limited biopsy sites were available, an alternative biopsy site was used if a functional response was obtained. No morbidity was seen among these patients, although postbiopsy CT scans demonstrated small 3- to 7-mm hematomas in 5/11 patients. Retrospective review of 79 patients who underwent biopsies without stimulation demonstrated hematomas in 6/10 patients and a 3.3% transient surgical morbidity. These data indicate that postbiopsy hematomas are a relatively common occurrence, that intraoperative electrical stimulation within abnormal lesions can identify functional potential, and that avoidance of biopsies within these functional areas may be associated with reduced morbidity.     

电刺激家兔大脑皮层感觉区对丘脑束旁核痛敏单位放电活动的影响

本工作目的在于探讨大脑皮层与丘脑束旁核痛觉信息活动之间的关系。用玻璃微电极记录了60只清醒麻痹状态下家兔束旁核痛敏单位的诱发放电活动。按其对外周伤害性刺激的反应型式而分成两类,分别称为痛兴奋单位和痛抑制单位。观察到在电刺激大脑皮层感觉区时,多数痛兴奋单位呈抑制性改变,并且有时施予皮层的每一单个刺激均能立即遏止一阵痛放电,少数呈易化性改变;痛抑制单位则对伤害性刺激呈现抑制反应解除,而施予皮层的每一单个刺激均可使之先有一阵短暂的放电,然后出现抑制的现象。本组实验观察过程,完整的总例数共32个单位,包括25个痛兴奋单位(18个呈抑制改变,7个呈易化改变)和7个痛抑制单位(全部呈易化改变)。实验结果表明,大脑皮层感觉区传出系统对机体的痛觉信息传递活动具有下行调制作用。由于皮层刺激对束旁核放电的影响是逐渐发展起耒的,因此考虑在上述过程中可能有体液因素的参与。     

Analysis of the effects of electrical stimulation of certain limbic structures

It has been established that stimulation of the structures of the limbic system (hippocampus, amygdaloid complex, septum) and the medial nucleic of the thalamus of rabbits in conditions of free behavior elicits four basic types of behavioral reactions: arousal, orientation-investigatory, aggressive-defensive and various epileptiform (convulsive) reactions. Activation of behavior, i.e., arousal and the orientation-investigatory reaction, constantly appear on stimulation of the unspecific thalamic nuclei. The aggressive-defense reaction is elicited by stimulating the nuclei of the amygdaloid complex of the ventral part of the hippocampus and the ventromedial nuclei of the thalamus. The epileptiform reactions are most readily reproduced on stimulation of the amygdaloid complex and the ventral part of the hippocampus. The threshold for the appearance of discharges of the aftereffect is very low. The latter are more sustained on stimulation of the basolateral part of the amygdala and the ventral part of the hippocampus. In rabbits as compared with higher animals the discharges on stimulation rapidly spread not only to the limbic system but also to the reticular formation and the neocortex.Kharkov Medical Institute. Translated from Neirofiziologiya, Vol. 1, No. 2, pp. 194–201, September–October, 1969.     

Abnormal oscillatory synchronisation in the motor system leads to impaired movement

Converging data suggest that abnormal synchronised oscillatory activity in the basal ganglia may contribute to bradykinesia in patients with Parkinson's disease. This synchrony preferentially occurs over 10-30 Hz, the so-called beta band. Correlative evidence has been supplemented by experiments in which direct stimulation of the basal ganglia in the beta band slows movement. Yet questions remain regarding the small scale of the latter effects and whether synchrony is an early or even obligatory feature of parkinsonism. Nevertheless, the principle that abnormally synchronised activity in the beta band can disrupt the function finds a precedent in the syndrome of cortical myoclonus. Here, pathologically synchronised discharges of pyramidal neurons are transmitted to the healthy spinal cord. The result is the synchronous discharge of motor units leading to rhythmic jerking.