Pedunculopontine Nucleus Deep Brain Stimulation in a Patient with Primary Progressive Freezing Gait Disorder

Ostrem, Jill L.; Christine, Chadwick W.; Glass, Graham A.; Schrock, Lauren E.; Starr, Philip A.

doi:10.1159/000268742

Cited by 43 publications

(34 citation statements)

References 33 publications

(22 reference statements)

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“…Further, studies have used different landmarks when assessing their data, including the AC-PC or the B-F system. Another issue is that, even when electrodes were placed in apparently the same brainstem region, patients were stimulated through different contacts (some in the caudal PPN, others in the rostral PPN) [6,7,8,13,17,22,23,25,28,30,52,53]. …”

Section: Postoperative Imagingmentioning

confidence: 99%

Pedunculopontine Nucleus Region Deep Brain Stimulation in Parkinson Disease: Surgical Techniques, Side Effects, and Postoperative Imaging

Hamani

Lozano

Mazzone

et al. 2016

Stereotact Funct Neurosurg

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The pedunculopontine nucleus (PPN) region has received considerable attention in clinical studies as a target for deep brain stimulation (DBS) in Parkinson disease. These studies have yielded variable results with an overall impression of improvement in falls and freezing in many but not all patients treated. We evaluated the available data on the surgical anatomy and terminology of the PPN region in a companion paper. Here we focus on issues concerning surgical technique, imaging, and early side effects of surgery. The aim of this paper was to gain more insight into the reasoning for choosing specific techniques and to discuss shortcomings of available studies. Our data demonstrate the wide range in almost all fields which were investigated. There are a number of important challenges to be resolved, such as identification of the optimal target, the choice of the surgical approach to optimize electrode placement, the impact on the outcome of specific surgical techniques, the reliability of intraoperative confirmation of the target, and methodological differences in postoperative validation of the electrode position. There is considerable variability both within and across groups, the overall experience with PPN DBS is still limited, and there is a lack of controlled trials. Despite these challenges, the procedure seems to provide benefit to selected patients and appears to be relatively safe. One important limitation in comparing studies from different centers and analyzing outcomes is the great variability in targeting and surgical techniques, as shown in our paper. The challenges we identified will be of relevance when designing future studies to better address several controversial issues. We hope that the data we accumulated may facilitate the development of surgical protocols for PPN DBS.

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Section: Postoperative Imagingmentioning

confidence: 99%

Pedunculopontine Nucleus Region Deep Brain Stimulation in Parkinson Disease: Surgical Techniques, Side Effects, and Postoperative Imaging

Hamani

Lozano

Mazzone

et al. 2016

Stereotact Funct Neurosurg

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“…However, the amount of dual innervation has not been quantified. Besides, the case studies of PPN stimulation (as a single target) for FOG have shown benefit with bilateral stimulation [19,20]. We feel that bilateral surgery will offer additional benefits in patients compared to unilateral surgery.…”

Section: Discussionmentioning

confidence: 99%

“…It also has connections with the contralateral PPN [10,11,12]. Considering these observations, PPN stimulation has been performed with beneficial effects, improving gait and freezing in patients with Parkinson's disease [13,14,15,16,17,18] and primary freezing of gait (FOG) [19,20]. To date, results of the first open and blinded study series of Parkinson's disease patients treated with PPN deep brain stimulation (DBS) have shown promising results in improving gait and balance [14,16,17].…”

Section: Introductionmentioning

confidence: 99%

Bilateral Pedunculopontine Nucleus Stimulation for Progressive Supranuclear Palsy

Doshi

Desai

Karkera

et al. 2015

Stereotact Funct Neurosurg

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The pedunculopontine nucleus (PPN) is a potential target for gait disorders. We report 4 cases of bilateral PPN stimulation in progressive supranuclear palsy (PSP) patients with short-term (6 months) and long-term (18 months) follow-ups. Patients with PSP who had gait disturbances, but were able to walk with or without assistance, were selected. The patients' median age was 64 years and the disease duration 3 years. Bilateral PPN deep brain stimulation (DBS) was performed. The pacemaker was programmed using a bipolar mode and lower frequencies (20-45 Hz). The PSP rating scores (PSPRS) and their gait subscores (No. 25, 26, 27 and 28) along with PSP staging scores were used as primary end points. The total Unified Parkinson's Disease Rating Scale (UPDRS), UPDRS III and the 39-item Parkinson's Disease Questionnaire were considered as secondary end points. Video recordings of the gaits were performed before surgery and at the 6- and 18-month follow-ups. These were retrospectively reviewed by a blinded neurologist for the primary end points. At the 6- and 18-month follow-ups, the median change in PSPRS was from 33 (baseline) to 37.5 and 47, respectively. Similarly, the PSP staging changed from 3 to 2.5 and 3.5, item 25 from 1.5 to 2 and 3.5, item 26 from 2.5 to 2 and 3.5, item 27 from 3.5 to 3 and 3.5 and item 28 from 1.5 to 1.5 and 3. Two patients in the study with the PSP-parkinsonism phenotype experienced improvement in their gait until the last follow-up. Bilateral PPN DBS can be safely performed in PSP patients despite mid-brain atrophy.

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“…The influence of the PPTg on fastigial and interpositus nuclei may also play a role in the origin of gait and postural instability in advanced PD, a point at which patients are refractory to dopaminergic medication but are able to benefit from deep brain stimulation of the PPTg [29,[32][33][34][35]131]. This evidence has led some authors to consider gait and axial disturbances in PD as possible consequences of a disruption of ACh mechanisms in the brainstem rather than of the nigrostriatal dopaminergic system; and the severity of these motor disabilities has been directly related to the degree of ACh neuronal loss in the PPTg [132,133].…”

Section: Investigating Whether the Pptg Influences The Cerebral Cortementioning

confidence: 99%

Participation of the pedunculopontine tegmental nucleus in arousal-demanding functions

Vitale¹,

Capozzo²,

Mazzone³

et al. 2017

Transl Brain Rhythmicity

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The pedunculopontine tegmental nucleus (PPTg) is part of the locomotor mesencephalic region and the reticular activating system (RAS). As such, it is involved in regulating some aspects of the motor control and the wake/sleep cycle, but the way in which it operates is unclear. PPTg neurons respond to a variety of sensory stimuli and to cues that trigger the execution of goal-directed motor acts. In this paper, we discuss data that suggest that in addition to operating via thalamic nuclei, the PPTg may also operate by activating cerebellar nuclei, especially the dentate nucleus. In such a way, an intense and diffuse activation of the cerebral cortex may be achieved. In arousal-demanding reward-related tasks, separate populations of PPTg neurons modulate their discharge pattern to encode, in particular, expectancy and magnitude of reward. These neuronal responses, which should reach thalamic, basal ganglia, and cerebellar nuclei through ascending PPTg fibers are essential for the formation of stimuli-reward associations and action selection. In parallel, PPTg neurons, via descending fibers directed to lower brainstem and spinal motor structures, may automatically influence motor mechanisms and muscle tone in order to cause movements that are executed in a smooth and timely manner. In patients affected by Parkinson's disease, PPTg deep brain stimulation may increase arousal, thus making patients more attentive to behavioral stimuli that trigger motor act, while simultaneously facilitating movement.

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Pedunculopontine Nucleus Deep Brain Stimulation in a Patient with Primary Progressive Freezing Gait Disorder

Cited by 43 publications

References 33 publications

Pedunculopontine Nucleus Region Deep Brain Stimulation in Parkinson Disease: Surgical Techniques, Side Effects, and Postoperative Imaging

Pedunculopontine Nucleus Region Deep Brain Stimulation in Parkinson Disease: Surgical Techniques, Side Effects, and Postoperative Imaging

Bilateral Pedunculopontine Nucleus Stimulation for Progressive Supranuclear Palsy

Participation of the pedunculopontine tegmental nucleus in arousal-demanding functions

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