British Journal of Neurosurgery (1991) 5, 505-508

SHORT REPORT

Long-term abolition of Parkinsonian tremor following attempted ventriculography

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P. V. MARKS,’ A. M. WILD2 & J. R. W. GLEAVE2 ‘Department of Neurosurgery, Auckland Hospital, Park Road, Auckland I , New Zealand; 2Department of Neurological Surgery, Addenbrooke’s Hospital, Hills Road, Cambridge C B 2 2 Q Q UK

Abstract Three patients are described who were selected for stereotactic thalamotomy to alleviate the tremor and rigidity of Parkinson’s disease but in whom these symptoms were abolished whilst attempting ventriculography. Discrete deep brain lesions were seen on post-operative CT scan and the basis for their relieving the patients’ symptoms is discussed. Although the tremor and rigidity was abolished in these cases and a favourable result ensued, ventriculography is an invasive and potentially dangerous procedure and it is therefore recommended that CT-derived thalamic targets should be employed for functional stereotaxy. Key words: Parkinson’s disease, stereotacric surgery, venmculography.

Introduction The majority of neurosurgeons who carry out functional stereotactic surgery for movement disorders such as Parkinson’s disease rely on intra-operative ventriculography to visualize the anterior and posterior commissures prior to calculation of the appropriate thalamic targets. Three cases are presented in which during the course of attempting ventriculography deep brain targets were fortuitously needled thereby resulting in abolition of the tremor. Case reports

Case 1 A 73-year-old man presented with an 8-year history of Parkinson’s disease which had started as a resting tremor of the left hand. After 2 years he developed bradykinesia and

was treated with Madopar which improved this symptom but had no effect upon his tremor. The tremor became progressively worse and he was referred for consideration of surgical treatment. Examination revealed a man with typical Parkinsonian facies and a resting tremor affecting the left hand with associated cogwheel rigidity. Having undergone psychometry, speech, occupational and physiotherapy assessment, he was felt to be a suitable candidate for thalamic surgery. At operation, the Leksell stereotactic frame was attached and a right frontal burr hole made under local anaesthetic. Two attempts were made to needle the ventricle, but after the second, it was noted that the tremor had been abolished and that the associated rigidity had gone. As the tremor had disappeared, the procedure was abandoned at this stage.

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P. V. Marks, A. M. Wild &J. R. W.Gleave

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A C T scan was performed later that day and showed the presence of two discrete highdensity lesions within the head of the right caudate nucleus (Fig. 1). The patient remains well and free of tremor 15 months postoperatively.

FIG.1. Postoperative CT scan of case 1 showing two small high-density lesions within the head of the right caudate nucleus (arrows).

junction of the thalamus and internal capsule (Fig. 2). The patient remains free of his rightsided tremor 24 months post-operatively.

FIG.2. CT scan showing a discrete high-density lesion at the junction of the left thalamus and internal capsule (arrow).

Case 3 Case 2

A 53-year-old man was a typical case of

Parkinson’s disease which initially presented with tremor of the right hand but soon spread to involve the left. The right-sided tremor increased in severity and was unaffected by anticholinergic drugs or dopaminergic agonists. He was referred for surgery and it was decided to treat the right-sided tremor by a left-sided thalamotomy. During the operative procedure ,difficulty was encountered in tapping the ventricle and after the third attempt, it was noted that the patient’s tremor has stopped. The procedure was curtailed at this juncture and a C T scan demonstrated the presence of a small haemorrhagic lesion at the

A 60-year-old woman presented with a 5-year history of paralysis agitans which had started as a tremor of her left upper limb and soon spread to involve the left leg. Examination revealed an obvious resting tremor of the left hand and an expressionless face. Marked rigidity was present in the left upper limb, but her gait was normal apart from her not swinging the left arm. She was felt to be a suitable candidate for surgery and right-sided stereotactic thalamotomy was planned. During ventriculography, the tremor was abolished on the first pass of the needle. The procedure was abandoned and a C T scan showed a discrete haemorrhagic lesion within the posterior limb of the right

Long-term abolition of Parkinsonian tremor

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internal capsule (Fig. 3). Her tremor and rigidity remain absent 24 months after the procedure.

FIG. 3. CT scan from case 3 showing a small haemorrhagic lesion within the posterior limb df the right internal capsule (arrow).

Discussion Ablation of a variety of subcortical centres has been found to alleviate the tremor and rigidity of Parkinson’s disease. Meyers’ destroyed the anterior two-thirds of the caudate nucleus thereby abolishing the tremor of post-encephalitic parkinsonism. Cooper’s work initially centred upon ablation of the pallidum or its outflow but later focused upon the ventrolateral thalamic nuclear complex (VL).293 Lesions in that portion of the internal capsule adjacent to the pallidum which encroach upon the fasciculus lenticularis are also effective and not attended by hemipare~is.~ Laitinen’s survey of the preferred targets of 16 practising stereotactic neurosurgeons has

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demonstrated a considerable variation in choice.s Although there was a concentration of target selection within the VL nucleus of the thalamus, the sites were separated by up to 7 mm. Other surgeons placed lesions either within the fields of Fore1 or in the subthalamic white matter inferior to VL. Laitinen concluded that successful surgery for Parkinson’s disease requires the interruption of the pallidothalamocortical fibres that transmit tremor and rigidity impulses towards the motor cortex, but their precise point of severance is not relevant. The variety of targets in our cases would support this view. Since its introduction into human stereotactic surgery by Spiegel and Wycis? ventriculography has been regarded as the ‘gold standard’ for target derivation and although some surgeons have employed CT, this has been as an adjunct rather than a replacement for ventriculography.’ The majority of neurosurgeons until recently have eschewed target coordinates derived solely from CT studies.* But now, an increasing number of surgeons are performing functional neurosurgery on CT-derived coordinates without recourse to ventriculography and claim good result^.^.'^ It has also been shown that CT-derived coordinates are as accurate as those obtained with ventriculography.8 Although, in the cases presented, various deep brain targets were lesioned inadvertently whilst attempting ventricular cannulation and a satisfactory physiological result ensued, this investigation must be regarded as invasive and potentially dangerous. This is especially true when the ventricles are of normal size,” and moreover, air ventriculography causes dilatation and slight anterior displacement of the third ventricle which can result in alteration of the anatomical target site.6 In view of the cases described and the increasing body of evidence in favour of CTderived coordinates, the principal author has abandoned ventriculography altogether in favour of CT-derived coordinates. It must, however, be emphasized that whatever radiological method is employed for anatomical target determination, it is imperative that physiolog-

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ical confirmationof the target is sought prior to lesioning.

Address for correspondence: Mr Paul Marks, Consultant Neurosurgeon, Auckland Hospital, Park Road, Auckland 1, New Zealand.

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References

5 Laitinen LV. Brain targets in surgery for Parkinson’s disease. Results of a survey of neurosurgeons. J Neurosurg 1985; 62:349-51. 6 Spiegel EA, Wycis HT, Marks M, Lee AJ. Stereotaxk apparatus for operations on the human brain. Science 1947; 106~349-50. 7

Kelly PJ, Kall B, Goerss S. Functional stereotactic surgery utilizing C T data and computer generated stereotactic atlas. Acta Neurochir, Suppl 1984;

33577-83. 8 Hariz, M.1, Bergenheim AT. A comparative study on

ventriculographic and computerized tomographicguided determinations of brain targets in functional stereotaxis. J Neurosurg 1990; 73:565-71. 9 Aziz T, Torrens M. CT-guided thalamotomy in the treatment of movement disorders. Br J Neurosurg

1 Meyers R. The modification of alternating tremor, rigidity and festination by surgery of the basal ganglia. Res Pub1 Assoc Res New Ment Dis 1942; 21:602-5. 2 Cooper IS, Poloukhine N. Chemopallidectomy: a 1989; 3~333-6. neurosurgical technique useful in geriatric Parkinso- 10 Laitinen LV. CT guided ablative stereotaxis without nians. J Am Geriatr SOC1955; 11:839-59. ventriculography. Appl Neurophysiol 1985; 48:18-21. 3 Cooper IS. Chemopallidectomy and chemothalamec- 11 Moseley IF. Pneumoencephalography. In: du Boulay tomy for Parkinson’s Disease and dystonia. Proc R SOC GHL, ed. A textbook of radiological diagnosis, Vol. 1. Med 1959; 5247-60. The head and central nervous system, 5th edn. 4 Gillingham FJ. Small localised surgical lesions of the London: H.K. Lewis 1984. internal capsule in the treatment of the dyskinesias. Confin Neurol 1962; 22:385-92.

Long-term abolition of parkinsonian tremor following attempted ventriculography.

Three patients are described who were selected for stereotactic thalamotomy to alleviate the tremor and rigidity of Parkinson's disease but in whom th...
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