1 / 10

Yacov Balash, Doron Merims and Nir Giladi MDU, Department of Neurology TASMC

Acute depression induced by deep brain stimulation of the subthalamic nuclei in patient with advanced PD. Case report. Yacov Balash, Doron Merims and Nir Giladi MDU, Department of Neurology TASMC. Condition before DBS.

yule
Download Presentation

Yacov Balash, Doron Merims and Nir Giladi MDU, Department of Neurology TASMC

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Acute depression induced by deep brain stimulation of the subthalamic nuclei in patient with advanced PD. Case report Yacov Balash, Doron Merims and Nir Giladi MDU, Department of Neurology TASMC

  2. Condition before DBS • Pt. SL, 48-year-old, right handed, married female, from Ashkenazi Jewish family who is treated in the Movement Disorders Unit of TASMC within 3 years • Seven years she has advanced Parkinson’s disease with bilateral asymmetric rest tremor and rigidity, peak of dose dyskinesias, “wearing offs” prolonged OFF states with akinesia and dystonia. H&Y at OFF= 3, H&Y at ON= 2.5 • DBS of the STN was undertaken because of young age, normal cognitive and affective functions, apparent influence of the L-dopa, lack of speech disorders.

  3. Medication before DBS • 1) DOPICAR 250 mg (1/4 tab x 12/d); • 2) ENTACAPONE 200 mg x 6/d; • 3) SINEMET CR 200/50 1 tab in evening; • 4) ROPINIROLE 3 mg x 3/d; • 5) AMANTADINE 100 mg x 3/d; • 6) CABERGOLINE 1.0 mg x 1/d; • 7) SELEGILINE (JUMEX )5 mg x 2/d; • 8)CITALOPRAM 20 mg x 1/d; • 9) TRIHEXYPHENIDYL 2 mg x 2/d;

  4. Rapid effects of the DBS • She was operated in 26 th of May 2003 -- bilateral DBS of the subthalamic nucleus was performed. • “Kinetra” TM Neurostimulator was launched on 02/06/03 • Stimulation parameters were:  • Rt STN = 2.2 V, 60 ms, 130 Hz; Lt STN = 3.1 V, 60 ms, 130 Hz; • Dramatic improvement in her physical state and mood followed by 2-3 weeks. L-dopa, Comtan, Amantadine, Selegiline, Trihexiphenidil treatment was discontinued because of the enhancement of dyskinesias, and supporting dose of the Ropinirole (2-4 mg/d) only was keeped.

  5. Dynamics of the UPDRS score changes after the operation UPDRS items Before DBS After DBS (April 2003) (August 2003) • Mentation, Behavour, Mood 4 2 • Activities of Daily Living 25 13 • Motor examination 32 7 • Complication of therapy 15 4 • Total: 76 26

  6. Remote effects of the DBS- cont • In two month the Pt developed “diphasic dyskinesiasias”in the Rt extremities probably due to overstimulation of the Lt STN. • At the 30 th of September 2003, and the voltage of STN stimulation was decreased as follows: Rt STN = 2.3 V, 60 ms, 130 Hz; Lt STN = 2.3 V, 60 ms, 130 Hz; • Ropinirole treatment was stopped.

  7. DBS induced changes in the motor and affective state • During 24 hours after these changes the dyskinesias greatly improved. But mood has been abruptly and severely worsened (within) with appearance of severe persistent depression.

  8. Profile of depression in the Pt 1.     Depressed Mood: Extreme despair • 2.      Guilt:No, but unwillingness to be the burden for her family • 3.      Suicide=Intention, farewell letter, search for gun • 4.      Insomnia= Middle of night, horror to live one more day • 5. Interests= Apathy, incredible energies to make usual kinds ADL • 6.      Distrust= to cognitive treatment , convictions, absolute confidence impossibility to help • 7.      Agitation= General restlessness • 8.      Insight: No loss • 9.      Obsessions: No, except for the suicidal intentions

  9. Antidepressant effect of the dopaminergic drugs 10/10/03 • Due to severe depression with impending suicide the Pt was hospitalized at the psychiatry clinic and treated by Prozac and Efexor. Ropinirole was restarted and switched to Cabergoline (3.5 mg) afterwards with the modest atnidepresive effect. 10/12/03 • Restarting Dopicar at the dose of 500 mg/d (1/4 of the pill, 8-10 times/day) had cut off all depression symptoms in 4-6 hours. • She’s motor condition now is excellent, with very mild dyskinesias in her Rt. extremities (fragment).

  10. Resume and discussion points • 1)Obvious and rapid benefit of the DBS of the STN on the motor state, flattening of the motor fluctuations , theoretic possibility to stop dopaminergic drugs et all after the operation. • 2) Growing oversensitivity of the output basal ganglia due to diminished stimulation from the STN; appearance of “diphasic dyskinesias” as a result of overstimulation of the STN. • 3) Acute development and immediate resolving of depression after withdrawal/restarting of dopaminergic stimulation and decreasing/increasing of electric stimulation of the STN . • 4)Pharmacological vs. electrical ways to treat depression

More Related