Malignant neuroleptic syndrome following deep brain stimulation surgery: a case report

<p>Abstract</p> <p>Background</p> <p>The neuroleptic malignant syndrome is an uncommon but dangerous complication characterized by hyperthermia, autonomic dysfunction, altered mental state, hemodynamic dysregulation, elevated serum creatine kinase, and rigor. It is most often caused by an adverse reaction to anti-psychotic drugs or abrupt discontinuation of neuroleptic or anti-parkinsonian agents. To the best of our knowledge, it has never been reported following the common practice of discontinuation of anti-parkinsonian drugs during the pre-operative preparation for deep brain stimulation surgery for Parkinson's disease.</p> <p>Case presentation</p> <p>We present the first case of neuroleptic malignant syndrome associated with discontinuation of anti-parkinsonian medication prior to deep brain stimulation surgery in a 54-year-old Caucasian man.</p> <p>Conclusion</p> <p>The characteristic neuroleptic malignant syndrome symptoms can be attributed to other, more common causes associated with deep brain stimulation treatment for Parkinson's disease, thus requiring a high index of clinical suspicion to timely establish the correct diagnosis. As more centers become eligible to perform deep brain stimulation, neurologists and neurosurgeons alike should be aware of this potentially fatal complication. Timely activation of the deep brain stimulation system may be important in accelerating the patient's recovery.</p

Percutaneous Endoscopic Gastro-Jejunostomy (PEGJ): Could Drug Administation be the Only Indication for Insertion? The Levodopa/Carbidopa Infusion Treatment Experience. A Retrospective Evaluation of the Method

Enteral feeding is the preferred means of nutritional support in patients unable to eat normally. Percutaneous endoscopic gastro-jejunostomy (PEGJ) is widely used in such cases. It is also accepted that medication will be administered through the tube. In patients with severe Parkinson’s disease, a continuous delivery system of levodopa/carbidopa, formulated as a gel suspension (Duodopa®), reaches the small intestine through a jejunostomy and represents an alternative treatment method. The continuous release results in less variability in levodopa serum concentrations and fewer motor fluctuations and dyskinesias compared to oral administration. The method requires a very good collaboration between neurologists and gastroenterologists and is used in specializing centers in patients as mentioned with severe disease. A modified percutaneous endoscopic gastrostomy (PEG) kit is placed under sedation. This allows the passage of a pig tail catheter which is advanced to the jejunum and a portable pump is attached on it through a specially designed tubing system. This is the only case, known to us, where PEGJ is inserted for drug administration. We present our experience of nine cases (7 males, 2 females, mean age 72.4 years) with a follow up of up to five years. In three patients the tubing system had to be changed; the first it was accidentally pulled out, the second because of bezoar formation around the intragastric part of the tube and the third because of knot formation at the intragastric part of the jejunal tube. At the end of this five year period, all patients agreed that the neurological benefit was welcome and they had all come in terms with the undoubted difficulties the procedure causes

The Insertion of Electrodes in the Brain for Electrophysiological Recording or Chronic Stimulation Is Not Associated With Any Biochemically Detectable Neuronal Injury

ObjectiveThe aim of this study was to evaluate the degree of brain tissue injury that could be potentially induced by the introduction of a) microrecording electrodes, b) macrostimulation electrodes, or c) chronic stimulation electrodes. We aimed to evaluate whether the use of five simultaneous microrecording tracks is associated with any brain injury not detectable by conventional imaging such as CT or MRI. Materials and MethodsThe study included 61 patients who underwent surgery for implantation of 121 DBS leads. In all cases, five simultaneous tracts were utilized for microelectrode recordings. All patients underwent measurements of serum S-100b at specific time points as follows: a) prior to the operation, and b) intraoperatively at specific stages of the procedure: 1) after opening the burr hole, 2) after the insertion of microrecording electrodes, 3) during macrostimulation, 4) at the end of the operation, and 5) on the first postoperative day. ResultsThe levels of serum S-100B protein remained within the normal range during the entire period of investigation in all patients with the exception of two cases. In both patients, the procedure was complicated by intraparenchymal hemorrhage visible in neuro-imaging. The first patient developed a small intraparenchymal hemorrhage, visible on the postoperative MRI, with no neurological deficit. The second patient experienced a focal epileptic seizure after the insertion of the right DBS chronic lead and the postoperative CT scan revealed a right frontal lobe hemorrhage. ConclusionThese results strongly indicate that the insertion of either multiple recording electrodes or the implantation of chronic electrodes in DBS does not increase the risk of brain hemorrhage or of other intracranial complications, and furthermore it does not cause any biochemically detectable brain tissue damage

Constant-Current Deep Brain Stimulation of the Globus Pallidus Internus in the Treatment of Primary Dystonia by a Novel 8-Contact (Octrode) Lead

OBJECTIVE: To evaluate bilateral constant-current globus pallidus internus (GPi) deep brain stimulation using an 8-contact lead. METHODS: This prospective, open-label, single-center pilot study of 10 patients assessed the feasibility of delivering bilaterally constant-current GPi deep brain stimulation with a novel 8-channel lead to treat primary dystonia using standard scales as outcome measures. RESULTS: Patients included 4 men and 6 women with a mean age of 35.8 years +/- 9.2 (range, 27-49 years). Mean age of onset was 18.5 years +/- 9.1 (range, 8-35 years), and mean disease duration was 17.3 years (range, 7-27 years). All had primary dystonia (8 generalized dystonia, 1 segmental dystonia, 1 focal dystonia). The primary variable was determined as 50% reduction in dystonia symptoms from baseline to the 6-month follow-up, as defined by the Burke-Fahn-Marsden Dystonia Rating Scale. Six patients (60.0%) achieved &gt;50% reduction in Burke-Fahn-Marsden Dystonia Rating Scale score and were classified as responders at the 6-month follow-up. Five of these 6 responders (83.3%) sustained that response through the assessment at the end of the first year. Constant-current stimulation was associated with significant improvement in pain and quality of life in all patients. Nearly 84% of the overall improvement occurred by the end of first month after stimulation onset, documenting an early response to treatment. Axial symptoms responded the best. CONCLUSIONS: Constant-current GPi deep brain stimulation proved safe and efficacious for treatment of primary dystonia. Motor scores improved by 54%, mostly within the first month. No phenotype-specific stimulation could be achieved, despite the capability of the new lead to stimulate specific loci within the GPi

Treatment of idiopathic head drop (camptocephalia) by deep brain stimulation of the globus pallidus internus Case report

Deep brain stimulation of the globus pallidus internus has been shown to be beneficial in a small number of patients suffering from axial dystonias. However, it has not yet been reported as an effective treatment for the alleviation of idiopathic head drop. The authors describe a 49-year-old woman with idiopathic cervical dystonia (camptocephalia) who was unable to raise her head &gt; 30 degrees when standing or sitting; her symptoms would abate when lying down. This disabling neurological condition was treated successfully with bilateral chronic electrical stimulation of the globus pallidus internus. (DOI: 10.3171/2008.9.17659

Effect of constant-current pallidal deep brain stimulation for primary dystonia on cognition, mood and quality of life: Results from a prospective pilot trial

Objective: Knowledge on the effects of DBS on cognitive functions is limited and no data exists on the effects of constant-current DBS (CC-GPi-DBS), which appears to prevail over constant-voltage stimulation. Our aim was to prospectively assess the effect of Constant-Current-GPi-DBS, using an 8-contact lead, on cognition, mood and quality of life. Patients and Methods: Ten patients aged 27-49 underwent prospective neuropsychological assessment using dedicated tests. Various cognitive domains (intelligence, executive functions, memory, attention, visuo-spatial perception, verbal intelligence) as well as emotional state and quality of life were examined preoperatively and 1, 6 and 12 months after continuous constant-current DBS. Results: Patients performed preoperatively below average on information processing speed, phonemic verbal fluency and working memory. At 6-months there was an improvement in phonemic verbal fluency (p &lt; .05), which was retained at 12-months postoperatively (p = .05). Results also showed marginal improvement in the Trail Making-A test (p = .051) and the Stroop colour-word test (p &lt; .05). Despite improvement in Quality of Life (Physical and Mental Component improved by 32.42% and 29.46% respectively), patients showed no discernible change in anxiety and depression status. Conclusions: CC-GPi-DBS for primary dystonia has no discernible negative impact on cognition and mood. If anything, we noted an improvement of certain cognitive functions

Restoration of erect posture in idiopathic camptocormia by electrical stimulation of the globus pallidus internus

The authors report on 2 young patients who developed drug-resistant idiopathic dystonic camptocormia (bent spine) and were treated successfully by deep brain stimulation (DBS) of the globus pallidus internus (GPi). The first patient, a 26-year-old woman, suffered for 3 years from such severe camptocormia that she became unable to walk and was confined to bed or a wheelchair. The second patient, a 21-year-old man, suffered for 6 months from less severe camptocormia; he was able to walk but only for short distances with a very bent spine, the arms in a parallel position to the legs, and the hands almost approaching the floor to potentially support him in case of a forward fall. Within a few days following DBS, both patients experienced marked clinical improvement. At most recent follow-up (44 months in one case and 42 in the other), the patients’ ability to walk upright remained normal. Similar findings have only been reported recently in a few cases of camptocormia secondary to Parkinson disease or tardive dyskinesia. On the basis of the experience of these 2 idiopathic cases and the previously reported cases of secondary camptocormia with a favorable response to GPi DBS, the authors postulate that specific patterns of oscillatory activity in the GPi are vital for the maintenance of erect posture and the adoption of bipedal walking by humans. (DOI: 10.3171/2010.3.JNS09981