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ABSTRACT: The effect of subthalamic nucleus deep brain stimulation (STN DBS) on impulse control and related behaviors (ICRB) in patients with Parkinson's disease (PD) is conflicting. We evaluated ICRB before and after bilateral STN DBS in patients with PD. A total of 89 patients with PD treated with bilateral DBS of STN underwent retrospective assessment of ICRB before and after DBS. Of the 89 patients studied, 20 patients (22.5%) had ICRB in the preoperative period. In 13 of those 20 patients (65%), preoperative ICRB improved, including resolution in six patients. Nine patients developed de novo ICRB after DBS, thus 23 patients (25.8%) had ICRB in the postoperative period. There was no demographic difference between the patients with or without ICRB in the preoperative state. In the postoperative state, the patients with ICRB had higher levodopa equivalent daily dose (LEDD) levels and lower Mini-Mental State Examination (MMSE) scores than the patients without ICRB. However, postoperative worsening or de novo ICRB did not correlate with LEDD levels or MMSE scores. Severity of ICRB worsened more after DBS in older patients. Patients with worsened or de novo ICRB after surgery had a greater decrease in Beck Depression Index scores after surgery compared with patients whose ICRB improved. In conclusion, ICRB may resolve or improve, or new ICRB may appear, after bilateral STN DBS. The difference in risk factors for preoperative vs. postoperative ICRB suggests that the pathogenesis of those conditions is different, at least in part.
Journal of Clinical Neuroscience 05/2013; · 1.25 Impact Factor
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Sun Ha Paek,
Ji Young Yun,
Sang Woo Song,
In Kyeong Kim,
Jae Ha Hwang,
Jin Wook Kim,
Han-Joon Kim, Hee Jin Kim,
Young Eun Kim,
Yong Hoon Lim,
Mi-Ryoung Kim,
Jae Hyuk Huh,
Keyoung Min Lee,
Sue K Park,
Cheolyoung Kim,
Dong Gyu Kim,
Beom Seok Jeon
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ABSTRACT: Few studies have analyzed the clinical impact of subthalamic nucleus (STN) deep brain stimulation (DBS) as a function of the positioning of the inserted electrode. We investigated retrospectively the three-year outcomes in Parkinson's disease (PD) patients following bilateral STN DBS in terms of the electrode positions. Forty-one advanced PD patients were followed up for over three years following bilateral STN DBS. Patients were evaluated with the Unified Parkinson's Disease Rating Scale (UPDRS), Hoehn and Yahr staging, Schwab and England Activities of Daily Living (ADL), and the Short Form-36 Health Survey (SF-36) before surgery and one, two, and three years after surgery. The patients were divided into two groups according to the electrode position based on the fused preoperative MRI and postoperative CT images: group I included patients who had both electrodes in the STN (n=30) while group II included patients who had one of the electrodes in the STN (n=11). The UPDRS, the Hoehn & Yahr staging, the Schwab and England ADL, and the SF-36 scores showed significant improvements with decreased l-dopa equivalent daily doses (LEDDs) in both groups as well as in the group as a whole for up to three years following bilateral STN DBS. However, the off-medication UPDRS total and motor (part III) scores significantly deteriorated with increased LEDDs for patients in group II three years after STN DBS compared to that of the group I patients. We conclude that more accurate electrode positioning in the STN leads to better long-term outcomes in advanced PD patients following DBS.
Journal of the neurological sciences 02/2013; · 2.32 Impact Factor
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ABSTRACT: OBJECTIVE: The aim of this study was to investigate whether specific neuropsychiatric domains could predict a conversion to dementia in those patients either with amnestic subtype of mild MCI (aMCI) or subcortical vascular MCI (svMCI). METHODS: At baseline, all subjects underwent neuropsychological tests, Neuropsychiatric Inventory (NPI), and MRI. We compared the baseline NPI scores between converters (CV) and non-converters (NCV) both in the aMCI and svMCI groups. RESULTS: The mean follow-up duration was 16.74±8.02 months (range: 4.2-43.9). At the second time point, about 30% of aMCI and svMCI patients converted to dementia with 7.5% of aMCI patients exhibiting improvement to normal cognitive state. In female aMCI patients, those who later improved to normal cognition exhibited higher baseline depression scores than the CV group. However, baseline depression scores were higher in the CV group than the NCV group in svMCI patients, and this difference was significant only in males. CONCLUSION: Our results suggest that depression might serve as a predictive marker of conversion to dementia in patients with svMCI, albeit only in males. On the other hand, patients who later improved to normal cognition showed higher scores of depression at baseline in female aMCI patients, suggesting that longer follow-ups are warranted in female patients with aMCI and depression.
Clinical neurology and neurosurgery 01/2013; · 1.30 Impact Factor
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ABSTRACT: Prior research has shown that the total amount of white matter ischemia had no significant correlation with cognitive deficits. We compared the association of white matter hyperintensities (WMHs) of total as well as cholinergic pathways with clinical dementia severity and investigated whether cholinergic ischemic burden had an independent predictive value with respect to cognitive decline in subcortical vascular cognitive impairment (SVCI). Forty-eight patients underwent detailed neuropsychological tests and brain magnetic resonance imaging. Quantification of WMH in the total white matter and in cholinergic pathways was achieved using the visual Scheltens scale and Cholinergic Pathway HyperIntensity Scale (CHIPS), respectively. We explored the association between WMH scores and clinical dementia rating scale (CDR). To assess the relation between WMH and cognitive scores, multiple linear regression analysis was used. The CHIPS score was higher in subcortical vascular dementia compared to subcortical vascular MCI, while this difference was not found with the total TMHs (TWMH) score. The TWMH score had a positive correlation with CHIPS, however only CHIPS scores positively correlated with sum of box scores of CDR scale (CDR SB; ρ = .474, P = .001). Higher CHIPS scores were associated with lower performance on the semantic word fluency test (β = -.447, P = .036), whereas the TWMH scores had no independent predictive value with respect to cognitive impairment, after controlling for CHIPS score. Our data confirmed the association of ischemic damage within cholinergic pathways with dementia severity, independent of TWMH in SVCI. In addition, this cholinergic deficit is clinically relevant to cognitive deterioration, especially with frontal dysfunction.
Journal of Geriatric Psychiatry and Neurology 06/2012; 25(2):122-7. · 3.07 Impact Factor
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ABSTRACT: Antecollis is a frequent complication in multiple system atrophy but is rare in Parkinson's disease (PD). We report an 80-year-old patient with a four-year history of PD who developed antecollis six weeks after taking pramipexole (1 mg/day). When assessed in the outpatient clinic, she had antecollis, cogwheel rigidity on the right side, and mild bradykinesia. We found no evidence of myopathic or neurogenic changes in the neck muscles on needle electromyography. We withdrew the pramipexole immediately, and, one week later, her antecollis improved dramatically. This report emphasizes the importance of considering dopamine agonists as a possible cause of antecollis and shows that immediate withdrawal of these drugs may reverse the symptoms.
Journal of Clinical Neuroscience 02/2012; 19(6):903-4. · 1.25 Impact Factor
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ABSTRACT: The data regarding whether parkin genotype attributes phenotypic variation are conflicting. Since the incidence of parkin mutations is very low in patients with an age at onset (AAO) of >40 years, previous studies have unfairly compared phenotypes of two early onset Parkinson's disease (EOPD) groups with different AAOs. Thus, we compared the clinical features between patients with and without parkin mutations in EOPD with an AAO of ≤40 years. Of the 124 patients with EOPD with an AAO of ≤40 years who were recruited and screened for parkin mutations, 84 completed assessments for comparison of the phenotype according to parkin genotype. Fourteen of the 84 subjects carried two parkin mutations; 6, a single mutation; and 64, no mutations. Patients with two mutations had significantly younger AAOs, longer duration of PD, and more common family history than patients without parkin mutations. Otherwise, motor and nonmotor symptoms did not differ between them. Subgroup analysis of EOPD with an AAO of ≤35 years revealed similar results. Phenotype of EOPD may depend on early AAOs rather than presence of parkin mutations.
Journal of Neurology 05/2011; 258(12):2260-7. · 3.47 Impact Factor
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ABSTRACT: We report on a clinicoanatomical analysis of five patients with structural midbrain lesions who shared severe nigrostriatal dopaminergic denervation but presented different involuntary movements. The main clinical phenotype was parkinsonism in only one case; it was choreoballism in three cases and tremor and dystonia in one case. Structural midbrain lesions are likely to involve structures additional to nigral dopaminergic neurons. The extent of extranigral involvement may determine the diverse clinical manifestations associated with the structural midbrain lesions.
Acta Neurovegetativa 02/2011; 118(8):1209-13. · 2.73 Impact Factor
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Ji Young Yun,
Woong-Woo Lee, Hee Jin Kim,
Ji Seon Kim,
Jong-Min Kim,
Han-Joon Kim,
Sung Yeun Kim,
Ji Yeon Kim,
Sung Sup Park,
Yu Kyeong Kim,
Sang Eun Kim,
Beom S Jeon
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ABSTRACT: We examined the relative significance of SCA2, SCA3 and SCA17 in Koreans patients with parkinsonism and ataxia. We recruited patients with either parkinsonism (n = 524; PD = 386 and MSA = 138) or ataxia (n = 44) as their main clinical feature for two years. These patients were screened for SCA2, SCA3 and SCA17. Six cases carried SCA2; one, SCA3; and eight, SCA17. In SCA2 patients, one patient exhibited MSA-P phenotype, and the other five exhibited ataxia. The single patient with SCA3 showed ataxia. In SCA17 patients, one patient presented ataxia, the other seven patients showed parkinsonism (three PD and four MSA-P). Dopamine transporter (DAT) imaging was performed in a subset of ataxic or parkinsonian SCA2 or SCA17, all of whom showed decreased DAT binding. In Korean population, the mutation frequencies of SCA2 and SCA17 were similar. SCA2 was a more significant cause of ataxia, whereas SCA17 was a more significant cause of parkinsonism. Contribution of SCA3 to parkinsonism was insignificant.
Parkinsonism & Related Disorders 02/2011; 17(5):338-42. · 3.80 Impact Factor
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ABSTRACT: We compared the electrode positions of subthalamic nucleus (STN) deep brain stimulation (DBS) estimated at the immediate postoperative period with those estimated 6 months after surgery.
Brain CT scans were taken immediately and 6 months after bilateral STN DBS in 53 patients with Parkinson's disease. The two images were fused using the mutual information technique. The discrepancies of electrode positions in three coordinates were measured in the fused images, and the relationship with the pneumocephalus was evaluated.
The average discrepancy of x- and y-coordinates of electrode positions at the level of STN (3.5 mm below the anterior commissure-posterior commissure line) were 0.6 ± 0.5 mm (range, 0~2.1 mm) and 1.0 ± 0.8 mm (range, 0~5.2 mm), respectively. The average discrepancy of z-coordinates of the electrode tips of the fused images was 1.0 ± 0.8 mm (range, 0.1~4.0 mm). The volume of pneumocephalus (range, 0~76 ml) was correlated with the y-coordinate discrepancies (p < 0.005).
The electrode positions in the immediate postoperative CT might have significant discrepancies with those in the CT taken at a stable period after STN DBS especially when there is a large amount of pneumocephalus.
Acta Neurochirurgica 12/2010; 152(12):2037-45. · 1.52 Impact Factor
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ABSTRACT: Previous studies have shown that subthalamic nucleus (STN) deep brain stimulation (DBS) improves tremor in Parkinson disease (PD). However, the patients included in those studies were unselected for tremor severity.
We specifically assessed the effect of STN DBS on tremor in selected PD patients with severe tremor.
Seventy-two PD patients who had received bilateral STN DBS were included. The effects of STN DBS on the off-medication tremor, the on-medication tremor, and the off-medication action tremor in patients selected as the worst one-third in each category at baseline were evaluated after a mean duration of > 2 years.
In patients with severe off-medication tremor, off-medication tremor score improved from 12.28 +/- 2.80 at baseline to 1.93 +/- 2.85 at the last follow-up (P < .001). The off-medication tremor in the off-stimulation state at the last follow-up was less severe than the preoperative off-medication tremor. In patients with severe on-medication tremor, on-medication tremor score improved from 6.17 +/- 2.45 to 1.35 +/- 2.58 (P < .001). In patients with severe off-medication action tremor, off-medication action tremor score improved from 5.08 +/- 1.35 to 1.24 +/- 1.42 (P < .001).
STN DBS is effective for severe off- and on-medication tremor and off-medication action tremor in PD. Our findings suggest that STN DBS reduces PD tremor through, at least in part, its effect on the tremor-generating mechanism independent of dopaminergic transmission and that long-term electrical stimulation of STN might induce a structural or neurochemical change leading to the improvement of tremor.
Neurosurgery 09/2010; 67(3):626-32; discussion 632. · 2.79 Impact Factor
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ABSTRACT: Spinocerebellar ataxia type 6 (SCA6) manifests a wide spectrum of non-cerebellar system involvements. The objective of this study was to examine the presence of nigrostriatal dopaminergic system derangement in SCA6. Eight patients with SCA6 who underwent a regular follow-up for at least 2 years participated in this study. A detailed neurological examination was performed and striatal dopamine transporter (DAT) was evaluated using [(99m)Tc]-TRODAT-1 SPECT. The main clinical feature of SCA6 was cerebellar ataxia with impaired eye movements. However, a wide spectrum of non-cerebellar system involvements, such as autonomic dysfunction, and pyramidal and extrapyramidal signs, was also observed. Two patients had bradykinesia. l-dopa was tried in one patient without benefit. Of the two patients with bradykinesia, DAT density was reduced to the Parkinson's disease (PD) range with a rostrocaudal gradient typical of PD in one patient (CAG repeats 13/22) and was mildly decreased in the other patient (12/25). Of the four patients without extrapyramidal signs, three (12/22, 11/25, 17/22) showed mild to severe reduction of DAT density and one (13/22) had a normal density. This study shows that SCA6 has a varying degree of nigrostriatal dopaminergic derangement. Two patients manifested mild bradykinesia, emphasising the need to screen for SCA6, even in patients with progressive ataxia and parkinsonism. Further histopathological studies would be helpful to determine the nigrostriatal dopaminergic damage in SCA6.
Journal of neurology, neurosurgery, and psychiatry 05/2010; 81(5):529-32. · 4.87 Impact Factor
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Movement Disorders 03/2010; 25(7):957-9. · 4.51 Impact Factor
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ABSTRACT: The G2385R (SNP accession no. rs34778348) and R1628P (rs33949390) variants of leucine-rich repeat kinase 2 (LRRK2, PARK8) are emerging as an important risk factor for Parkinson's disease (PD) in the ethnic Chinese and Japanese populations. The purpose of this study was to investigate whether these variants are a genetic risk factor in sporadic PD patients in the Korean population. A total of 923 patients and 422 healthy subjects were included. The variants were screened by a SNaPshot assay. The LRRK2 G2385R variant was detected in 82 PD patients (8.9%, two homozygous and 80 heterozygous) and in 21 normal controls (5.0%, all heterozygous). The frequency of the LRRK2 G2385R variant in PD was significantly higher than in normal controls (adjusted odds ratio 1.83, p = 0.0170, 95% confidence interval 1.11-3.00). There were no differences in the mean age at onset or gender between the G2385R carriers and the non-carriers in PD patients. The LRRK2 R1628P variant was very rare (0.78% in patients versus 0.26% in controls) in the tested 384 patient-control pairs, and was not a significant risk factor. This study supports that the LRRK2 G2385R variant may be a genetic risk factor for sporadic PD in the Korean population.
Parkinsonism & Related Disorders 10/2009; 16(2):85-8. · 3.80 Impact Factor
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ABSTRACT: We aimed to assess whether allelic variants of dopamine receptor, glutamate receptor, and serotonin transporter genes are associated with the appearance of impulse control and related behaviors (ICRB) in Parkinson's disease (PD) with dopamine replacement therapy (DRT). We surveyed ICRB in consecutive Korean patients with PD who were treated with stable DRT using modified Minnesota Impulsive Disorders Interview over a period of 4 months. In the 404 patients who completed the interview and the 559 Korean healthy normal controls, genotyping was performed for variants of the DRD3 p.S9G, DRD2 Taq1A, GRIN2B c.366C>G, c.2664C>T and c.-200T>G, and the promoter region of the serotonin transporter gene (5-HTTLPR). Behavioral abnormalities suggestive of ICRB including compulsive buying, gambling, sexual behavior and eating, and punding, were present in 14.4% of the patients. Variants of DRD2 and 5-HTTLPR were not associated with the risk of developing ICRB. However, the AA genotype of DRD3 p.S9G and the CC genotype of GRIN2B c.366C>G were more frequent in patients with ICRB than in nonaffected patients (odds ratio [OR] = 2.21, P = 0.0094; and 2.14, P = 0.0087, after adjusting for age and sex). After controlling for clinical variables in the multivariate analysis, carriage of either AA genotype of DRD3 or CC genotype of GRIN2B was identified as an independent risk factor for ICRB (adjusted OR: 2.57, P = 0.0087). Variants of DRD3 p.S9G and GRIN2B c.366C>G may be associated with the appearance of ICRB in PD.
Movement Disorders 07/2009; 24(12):1803-10. · 4.51 Impact Factor
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ABSTRACT: The diagnosis of multiple system atrophy (MSA) is mainly based on the clinical criteria, which are often of little assistance in the early stages of the disease. Positional downbeat nystagmus (pDBN) and perverted head-shaking nystagmus (pHSN), possible signs of cerebellar dysfunction, may be useful in differentiating MSA from other parkinsonian disorders. To investigate the occurrences of pDBN and pHSN in patients with MSA compared with those in patients with Parkinson's disease (PD). A total of 127 consecutive patients with MSA and 274 patients with PD underwent a video-oculographic recording of head-shaking and positional nystagmus over a year. The occurrences of pDBN and pHSN were higher in MSA than in PD. pDBN was more frequently observed in MSA with overt cerebellar signs than in those without, but the occurrence of pHSN did not differ between the MSA groups. pHSN was more frequently observed in MSA-p without overt cerebellar signs than in PD, but there was no difference in the occurrence of pDBN between them. The presence of pHSN and pDBN may be a clue for the diagnosis of MSA, and pHSN may be helpful in differentiating MSA-p from PD when the patients do not have overt cerebellar features.
Movement Disorders 06/2009; 24(9):1290-5. · 4.51 Impact Factor
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Sun Ha Paek, Hee Jin Kim,
Ji Young Yoon,
Jae Heok Heo,
Cheolyoung Kim,
Mi Ryoung Kim,
Yong Hoon Lim,
Keyong Ran Kim,
Jin Wook Kim,
Jung Ho Han,
Dong Gyu Kim,
Beom S Jeon
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ABSTRACT: To propose fusion image-based programming to adjust patients with advanced Parkinson disease (PD) effectively after subthalamic nucleus (STN) deep brain stimulation (DBS).
Between January 2007 and July 2008, 38 patients with advanced PD were consecutively treated with STN DBS. The electrode positions and information regarding their contacts with STN were determined via fusion of the images of preoperative magnetic resonance imaging (MRI) and of postoperative computed tomography (CT) obtained 1 month after STN DBS. Postoperative programming was performed using the information of electrode positions based on the fused images. All patients were evaluated with a prospective protocol of the Unified Parkinson Disease Rating Scale (UPDRS), Hoehn and Yahr Staging, Schwab and England Activities of Daily Living (SEADL), levodopa equivalent daily dose (LEDD), short-form-36 health survey (SF-36), and neuropsychological tests before and at 3 months and 6 months after surgery.
There was a rapid and significant improvement of motor symptoms, especially tremor and rigidity, after STN stimulation, with low morbidity. Stimulation led to an improvement in the off-medication UPDSR III scores of the patients of approximately 55% at 3 months and 6 months after STN DBS. Dyskinesia was significantly improved (74% at 3 months and 95% at 6 months) after STN DBS. In addition, LEDD values decreased to 50% of the level observed before surgery within 1 month after STN DBS.
Programming based on fused images of preoperative MRI and postoperative CT after STN DBS was performed quickly, easily, and efficiently.
World Neurosurgery 75(3-4):517-24. · 0.68 Impact Factor
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