1834
LETTER Pramod K. Pal* Department of Neurology National Institute of Mental Health and Neuro Science Bangalore 560 029 Karnataka, India *E-mail:
[email protected] N. Shivashankar Speech Pathology and Audiology National Institute of Mental Health and Neuro Science Bangalore 560 029 Karnataka, India
References 1. Schott GD. Mirror writing: neurological reflections on an unusual phenomenon. J Neurol Neurosurg Psychiatry 2007;78:5–13. 2. Tashiro K, Matsumoto A, Hamada T, et al. The aetiology of mirror writing: a new hypothesis. J Neurol Neurosurg Psychiatry 1987;50: 1572-1578. 3. Jedynak PC, Tranchant C, de Beyl DZ. Prospective clinical study of writer’s cramp. Mov Disord 2001;16(3):494-499. 4. Schott GD, Schott JM. Mirror writing, left-handedness, and leftward scripts. Arch Neurol 2004;61:1849-1851. 5. Chan JL, Ross ED. Left-handed mirror writing following right anterior cerebral artery infarction: evidence for nonmirror transformation of motor programs by right supplementary motor area. Neurology 1988;38:59-63. 6. Berardelli A, Rothwell JC, Hallett M, et al. The pathophysiology of primary dystonia. Brain 1998;121 (Pt 7):1195-1212.
Occipital Pseudoaneurysm as a Complication of Extension Channel Placement for DBS in Parkinson’s Disease Deep brain stimulation (DBS) of the subthalamic nucleus (STN) in patients with advanced Parkinson’s disease (PD) has demonstrated beneficial reduction of disability as assessed by Unified Parkinson’s Disease Rating Scale (UPDRS) motor scores in the medication-off condition ranging from 28 to 71%.1 Complications related to DBS procedures have been analyzed by several centers.2–5 In a recent series of 81 consecutive patients, Lyons et al. reported a 1.2% frequency of surgical complications, including bleeding, 4.9% aborted procedures, 1.2% postoperative seizures, 3.7% infections, and 12.5% misplaced leads.6 Iatrogenic pseudoaneurysms of the extracranial vessels have been reported as a complication of craniotomy,7 secondary to placement of external ventricular drainage catheters8 or of a pin-type head-holder device.9 We describe the first report of an occipital artery pseudoaneurysm as a complication of neurosurgical device placement for subthalamic DBS implantation.
Published online 26 June 2007 in Wiley InterScience (www. interscience.wiley.com). DOI: 10.1002/mds.21491
Movement Disorders, Vol. 22, No. 12, 2007
CASE REPORT A 68-year-old woman, affected by idiopathic PD since she was 57, underwent stereotactic surgery for STN stimulation for important dyskinesias uncontrolled by pharmacological treatment consisting of levodopa, dopamine agonists, and COMT inhibitor (entacapone) in November 2004. Her preoperative UPDRS motor score (part III) was 57 (off-condition) and 22 (on-condition), Hoehn & Yahr score was 4 with 25% dopaminergic responsiveness (L-dopa). Post-operative (1 year later) UPDRS motor score (part III) was 27 (offcondition, DBS-on) and 17 (on-condition, DBS-on) and dopaminergic responsiveness was 25% (L-dopa). The pulse generator was implanted three days after surgery with the quadripolar connector (Kinetra, Medtronic Inc., MN) tunnelled subcutaneously reaching the generator. The immediate postoperative phase was free of complications. Two weeks after completion of DBS surgery, she was admitted to our clinic for progressively increasing, intense pain exacerbated by tactile, temperature, and pain sensory loss over the left parietal-occipital region. On examination she had a pulsatile mass in synchrony with the heartbeat. Compression of the artery proximal to the mass diminished the pulsations. Pseudoaneurysm was clinically suspected. The minimally invasive surgical technique of endovascular treatment by angiographic embolization of the pseudoaneurysm with short-lasting anesthesia in the on-condition of stimulation was chosen. A digital selective subtraction angiography of the left external carotid, introducing a 5F sheath, was performed, demonstrating a giant pseudoaneurysm of the distal occipital artery, without any direct arteriovenous fistula, near the extension channel of the electrocatheter (Fig. 1A). A super selective catheterism was performed in the neck of the pseudoaneurysm. A total of 0.5 ml of acrylic glue (Glubran 2, GEM, Italy) and 0.5 ml of Lipiodol was injected to obtain complete occlusion of the terminal branch of the occipital artery. At the end of the procedure control angiographic visualization did not show any dilation (Fig. 1B). No complications such as bleeding occurred. After the procedure, the mass, without pulse, progressively disappeared within one month.
CONCLUSION DBS of the STN has been established as a safe and efficacious treatment for advanced PD patients with disabling motor fluctuations and dyskinesias. However, it is important to recognize that the procedure is not without surgical and hardware complications. In PD, device-related complications rarely occurred,1 although extracranial vessel pseudoaneurysm is a complication of device placement under the superficial skull tissues. Although an overall complication rate between 0 and 11.8% has been reported for all stereotactic operation, only single case reports are available specifically in stereotactic and shunt surgery and there are no data up to now in PD.10 The main objectives of any extracranial pseudoaneurysm treatment are to reduce the risk of hemorrhage, relieve headache, and resolve any cosmetic defects.11 Surgical ligation with resection of the lesion is considered the treatment of choice.12 In contrast, endovascular embolization has a low incidence of recanalization, allergic reac-
PSEUDOANEURYSM FOLLOWING DEEP BRAIN STIMULATION
1835
particular, in our patient, pain and discomfort of soft tissues of the parietal-occipital region and subsequent interventional angiography did not seem to induce any changes in the DBS program. Acknowledgments: We thank Dr. A. Avogadro (Medtronic Italia SpA) for technical support. Nicola Tambasco, MD, PhD* Neurology Department University of Perugia Perugia, Italy *E-mail:
[email protected] Mohamed Hamam, MD Interventional Angiography, Neuroradiology Department Ospedale S. Maria Della Misericordia Perugia, Italy Corrado Castrioto, MD Neurosurgery Department Ospedale S. Maria Della Misericordia Perugia, Italy Paolo Calabresi, MD Aroldo Rossi, MD Neurology Department University of Perugia Perugia, Italy
References
FIG. 1. A: Subtracted angiography of the left external carotid showing pseudoaneurysm of the terminal branch of the occipital artery near the extension channel. Electrocatheters (black arrow) and extension channel (white arrow) can be observed. B: Postinjection angiography.
tions, and, in our case, external channel dislocation. Selective angiography is necessary for the evaluation of superficial pseudoaneurysm. Thus, endovascular treatment using a microcoil or, more recently, glue may be commonly used as a therapeutic tool in a single stage.13 To our knowledge, this is the first report of the development of occipital pseudoaneurysm following device placement in DBS neurosurgery. Although our patient had significant benefit from the DBS procedure in line with the literature,1,14 she developed discomfort from 2 weeks following surgery until complete pseudoaneurysm removal. In
1. Krack P, Batir A, Van Blercom N, et al. Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson’s disease. N Engl J Med 2003;349:1925–1934. 2. Beric A, Kelly PJ, Rezai A, et al. Complications of deep brain stimulation surgery. Stereotact Funct Neurosurg 2001;77:73–78. 3. Oh MY, Abosch A, Kim SH, Lang AE, Lozano AM. Long-term hardware-related complications of deep brain stimulation. Neurosurgery 2002;50:1268 –1276. 4. Umemura A, Jaggi JL, Hurtig HI, et al. Deep brain stimulation for movement disorders: morbidity and mortality in 109 patients. J Neurosurg 2003;98:779 –784. 5. Joint C, Nandi D, Parkin S, Gregory R, Aziz T. Hardware-related problems of deep brain stimulation. Mov Disord 2002;17 (Suppl 3):S175–S180. 6. Lyons KE, Wilkinson SB, Overman J, Pahwa R. Surgical and hardware complications of subthalamic stimulation: a series of 160 procedures. Neurology 2004;63:612– 616. 7. Lee GY, Daniel RT, Halcrow S. Postoperative pseudoaneurysm of the superficial temporal artery. J Neurol Neurosurg Psychiatry 2002;72:553–554. 8. Angevine PD, Connolly ES Jr. Pseudoaneurysms of the superficial temporal artery secondary to placement of external ventricular drainage catheters. Surg Neurol 2002;58:258 –260. 9. Fernandez-Portales I, Cabezudo JM, Lorenzana L, et al. Traumatic aneurysm of the superficial temporal artery as a complication of pin-type head-holder device. Case report. Surg Neurol 1999;52: 400 – 403. 10. Sahrakar K, Boggan JE, Salamat MS. Traumatic aneurysm: a complication of stereotactic brain biopsy: case report. Neurosurgery 1995;36:842– 846. 11. De Vogelaere K. Traumatic aneurysm of the superficial temporal artery: case report. J Trauma 2004;57:399 – 401.
Movement Disorders, Vol. 22, No. 12, 2007
1836
LETTERS TO THE EDITOR
12. Lalak NJ, Farmer E. Traumatic pseudoaneurysm of the superficial temporal artery associated with facial nerve palsy. J Cardiovasc Surg (Torino) 1996;37:119 –123. 13. Hong JT, Lee SW, Ihn YK, et al. Traumatic pseudoaneurysm of the superficial temporal artery treated by endovascular coil embolization. Surg Neurol 2006;66:86 – 88. 14. Deuschl G, Schade-Brittinger C, Krack P, et al., for the German Parkinson Study Group. Neurostimulation Section. A randomized trial of deep-brain stimulation for Parkinson’s disease. N Engl J Med 2006;355:896 –908.
Efficacy of rTMS in the Treatment of CoMorbid Anxiety in Depressed Patients with Parkinson’s Disease There have been a few published studies evaluating the effectiveness of rTMS for treatment of depression in Parkinson’s Disease.1,2 This pilot study investigates the effectiveness and tolerability of rTMS in the treatment of anxiety and depression in patients with idiopathic Parkinson’s Disease. An Investigational Device Exemption (IDE) from the FDA and approval from Washington University School of Medicine (WUSM) Institutional Review Board (IRB) were obtained. Informed consent was obtained on all subjects. Oversight was provided by the members of the Electroconvulsive and rTMS Committee at WUSM Department of Psychiatry. Inclusion criteria were: men or women, 40 yr of age or older; diagnosis of idiopathic Parkinson’s Disease regardless of Hoehn and Yahr Stage; DSM-IV diagnoses of Major Depression or Bipolar I Disorder; able to discontinue antidepressant and anti-anxiety medications, maintain stable anti-Parkinson medication regimen. Atypical antipsychotic medications for drug-induced psychosis or psychotic depression, and the use of Zolpidem (ⱕ10 mg/day) to manage insomnia were permitted. Eight subjects were enrolled but one subject excluded during screening process due to an abnormal MRI report. Seven subjects participated in the study: 5 men, 2 women, ages 62 to 79 yr. Psychiatric diagnosis was determined by administration of a Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) by the PI. The Hamilton Rating Scale of Depression (HAMD-21) was completed by the PI at the beginning of the study, once during treatment, posttreatment, at follow-up, and if the subject qualified for the weekly Extension Phase. The Beck Depression Inventory II (BDI-II) and the State and Trait Anxiety Scales were completed by the subjects. Treatment was delivered using the NEOPULSE TMS system. Subjects received a total of 10 treatments in 2 wk. Subjects received stimulation to the left DLPFC at settings of Hz 20, 80% of motor threshold, On for 2 s; Off for 28 s for 25 min. These parameters delivered 2,000 pulses per treatment session. Efficacy was measured by a decrease in the Hamilton Depression scale by at least 50% from baseline and was considered a Responder to treatment. If the subject achieved efficacy
Published online 19 June 2007 in Wiley InterScience (www. interscience.wiley.com). DOI: 10.1002/mds.21613
Movement Disorders, Vol. 22, No. 12, 2007
during the 2 wk of treatment, the subject entered the Extension Phase to receive four treatments scheduled once a week. Subjects were followed-up at 1 and 6 mo posttreatment. All subjects were diagnosed with at least one DSM-IV Anxiety Disorder in addition to Major Depression. Three had additional diagnoses of Panic Disorder with Mild Agoraphobia and one had panic attacks but did not meet criteria for Panic Disorder. Five subjects were diagnosed with Generalized Anxiety Disorder and five subjects were diagnosed with Social Phobia (two general, three specific), a life long problem, independent of diagnosis of Parkinson’s Disease. Trait anxiety describes general proneness to anxiety whereas state anxiety reflects current anxiety. In this study, both the trait and state anxiety scores show a downward trend after treatment. The mean Trait Anxiety Pre-Treatment Score of the Responders was 50.5 and Post-Treatment score of 41.33. One month follow-up on five Responders was 40.6 and at the 6 mo follow-up on 4 subjects were 43. The only Non-Responder showed a decrease in both trait and state anxiety. State Anxiety Mean score of the Responders at pretreatment was 44.33 and 33.17 at posttreatment. At 1 mo and 6 mo mean scores were 40.4 and 40.25, respectively. Six of the 7 subjects were Responders within 2 wk as determined by greater than 50% decrease in the HAMD-21 (Pre-Treatment Mean Score ⫽ 21.83 and Post-Treatment Mean Score ⫽ 6.00). Follow-up data is available on only five of the Responders at 1 mo posttreatment (Mean Score ⫽ 5) and on three Responders at 6 mo posttreatment (Mean Score ⫽ 6.66). The BDI-II scores of the Responders also followed the same downward trend demonstrating that the subject’s self rating scores corresponded with the investigator’s scores. Correlation of the six post-test BDI and HAM-D scores showed a mutual trend toward decreased depressive symptoms; however, results were not statistically significant due to small sample size (Pearson r ⫽ 0.47, P ⫽ 0.18, one-tailed; Kendall’s Tau B ⫽ 0.21, P ⫽ 0.280, one-tailed). Developing alternative treatment methods for depression and anxiety in PD patients is important, given the shortcomings of current therapies. Although the study has limitations, such as small sample size, open-label design, and the PI performing all outcome ratings, the efficacy results are as favorable as larger published randomized studies with the additional finding of the effectiveness of rTMS to treat comorbid anxiety in PD. The study also reflects that high intensity rTMS with the delivery of 2,000 pulses per treatment is well tolerated by this population. Theresa C. Kormos, MSN, RN, BC, AP/MHCNS St Louis Psychiatric and Psychological Services LLC St Louis, Missouri, USA *E-mail:
[email protected]
References 1. Dragasˇevic N, Potrebi c´ A, Damjanovi c´ A, Stefanova E, Kosti c´ VS. Therapeutic efficacy of bilateral prefrontal slow repetitive transcranial magnetic stimulation in depressed patients with Parkinson’s disease: an open study. Mov Disord 2002;17(3):528-532. 2. Fregni F, Santos CM, Myczkowski ML, et al. Repetitive transcrianial magnetic stimulation is as effective as fluoxetine in the treatment of depression in patients with Parkinson’s disease. J Neurol Neurosurg Psychiatry 2004;75:1171-1174. in Wiley Interscience (www.interscience.wiley.com)
