DBS efficacia, complicanze in cronico e nuovi orizzonti terapeutici

Transcription

1 DBS efficacia, complicanze in cronico e nuovi orizzonti terapeutici

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3 TECNICHE DI NEUROMODULAZIONE Invasiva: odeep Brain Stimulation Non Invasiva: o Transcranial Magnetic Stimulation (TMS) o Transcranial Current Stimulation (tcs)

4 STIMOLAZIONE CEREBRALE PROFONDA (DBS)

5 NEUROMODULAZIONE L alterazione della attività neurale attraverso l utilizzo di una stimolazione elettrica o chimico-farmaceutica a livello di siti selezionati. ANATOMIA FUNZIONALE

6 Parkinson's Disease Common Movement Disorder ~7 million people worldwide

7 BASAL GANGLIA CORTICAL-STRIATAL-THALAMIC NETWORK ANATOMIA FUNZIONALE MC CEREBELLO-THALAMIC-CORTICAL NETWORK STRIATUM TH CRB SN GPe STN GPi CPGs CPGs CPGs Spine PARKINSON HEALTHY CONDITION DISEASE

8 Lozano AM. et al. (2017) What Have We Learned About Movement Disorders from Functional Neurosurgery?. Annual review of neuroscience, 40,

9 Steigerwald F. et al. (2008) Neuronal activity of the human subthalamic nucleus in the parkinsonian and nonparkinsonian state. Journal of neurophysiology 100.5:

10 Pozzi NG. et al. (2016) Distinctive neuronal firing patterns in subterritories of the subthalamic nucleus. Clin. Neurophysiol :

11 Canessa A. et al. (2016) Striatal dopaminergic innervation regulates subthalamic Beta-oscillations and cortical-subcortical coupling during movements: Preliminary evidence in subjects with Parkinson s disease.. Front- Human Neuroscience

12 Tinkhauser G. et al. The modulatory effect of adaptive deep brain stimulation on beta bursts in Parkinson s disease 2017 Brain

13 BASAL GANGLIA CORTICAL-STRIATAL-THALAMIC NETWORK MC CEREBELLO-THALAMIC-CORTICAL NETWORK STRIATUM TH CRB SN GPe STN GPi CPGs CPGs CPGs Spine PARKINSON SYMPTOM CONTROL DISEASE

14 COME FUNZIONA??

15 Benabid AL, Pollak P et al. Combined (thalamotomy and stimulation) stereotactic surgery of the VIM thalamic nucleus for bilateral Parkinson s disease Appl Neurophysiol. 50(1-6): FUNZIONA? Benabid AL, Limusin P et al. Chronic eletrical stimulation of the ventralis intermedius nucleus of the thalamus as a treatment of movement disorders (tremor, ndr) J. Nuerosurg. 84: Limousin P, et al. Electrical stimulation of the subthalamic nucleus in advanced Parkinson s disease N Engl J Med. 339(16): Coubes P et al. Treatment of DYT1-generalised dystonia by stimulation of the internal globus pallidus Lancet. 355(9222): Stimulation for Parkinson's Disease Study Group. Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson's disease N Engl J Med : 956. Follett KA et al (CSP 468 Study Group). Pallidal versus subthalamic deep-brain stimulation for Parkinson s disease N Engl J Med. 362(22): Vidailhet M et al Bilateral deep-brain stimulation of the globus pallidus in primary generalized dystonia N. Engl. J. Med. 352: Volkmann J et al. Safety and efficacy of pallidal or subthalamic nucleus stimulation in advanced Parkinson s Disease. Neurology 56:48-51 Deuschl G et al. A randomized trila of Deep Brain Stimulation in Parkinson s Disease N. Engl. J. Med. 355: Volkmann J et al. Pallidal neurostimulation in patients with medication-refractory cervical dystonia: a randomised, sham-controlled trial Lancet 13:875-84

16 Koller WC, et al. (2001) Long term safety and efficacy of unilateral deep brain stimulation of the thalamus in essential tremor." Movement disorders 16.3: Baizabal-Carvallo JF, et al. (2014) The safety and efficacy of thalamic deep brain stimulation in essential tremor: 10 years and beyond. JNNP 85.5 : pt 49pt 25pt

17 Moro, E., et al. (2017) Efficacy of pallidal stimulation in isolated dystonia: a systematic review and meta analysis. European journal of neurology.

18 Benabid AL., et al., Deep brain stimulation of the subthalamic nucleus for the treatment of Parkinson's disease. Lancet Neurol, (1): p % 50%

19 Schuepbach W.M.M. et al. (2013) Neurostimulation for Parkinson s Disease with Early Motor Complications. N. Engl. J. Med. 368: % -26% 123pt 120pt

20 WHAT IF, ALL THAT GLITTER ISN T GOLD? RISCHI CHIRURGICI AE STIMOLAZIONE INDOTTI

21 RISCHI CHIRURGICI Fenoy A. J. & Simpson Jr R. K. (2014) Risks of common complications in deep brain stimulation surgery: management and avoidance: Clinical article. Journal of neurosurgery, 120(1),

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24 AE STIMOLAZIONE INDOTTI - ACUTI Motori

25 AE STIMOLAZIONE INDOTTI - ACUTI Non-Motori Voon V, et al. (2006) Deep brain stimulation: neuropsychological and neuropsychiatric issues." Movement Disorders 21.S14.

26 AE STIMOLAZIONE INDOTTI TIME? Volkmann, J. et al, (2010) Neuropsychiatric effects of subthalamic neurostimulation in Parkinson disease. Nature Reviews Neurology, 6(9), p.487.

27 SINTOMI ASSIALI Pötter Nerger M. & Volkmann J. (2013) Deep brain stimulation for gait and postural symptoms in Parkinson's disease Movement Disorders, 28(11), Paradosso terapeutico: marcato miglioramento clinico UPDRS o Kin, ma self-percieved peggioramento nel 42% dei pazienti

28 DETERMINANTS Fasano A. (2015) Axial disability and deep brain stimulation in patients with Parkinson disease Nature reviews Neurology, 11(2),

29 BASAL GANGLIA CORTICAL-STRIATAL-THALAMIC NETWORK MC CEREBELLO-THALAMIC-CORTICAL NETWORK STRIATUM TH CRB DBS GPe GPi PPN MLR STN RF SN LOCOMOTOR NETWORK CPGs CPGs CPGs CPGs

30 DBS: ALTERAZIONE DELLA MARCIA Favilla C. G. et al. (2013) Worsening essential tremor following deep brain stimulation: disease progression versus tolerance. Brain, aws subject with ET, 36 months follow-up, stim-on and stim-off, but only for 30 min!

31 DBS: ALTERAZIONE DELLA MARCIA Reich M. M., Brumberg J.B. et al. (2016) Progressive gait ataxia following deep brain stimulation for essential tremor: adverse effect or lack of efficacy? Brain, 139(11),

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33 FOCUSED STIMULATION Reich M. M. et al. (2017) Progressive gait ataxia following deep brain stimulation for essential tremor: adverse effect or lack of efficacy? Brain, 139(11),

34 CONCLUSION

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