The behavioral complications of pallidal stimulation: a case report

We report a case of recurrent manic episodes associated with chronic deep brain stimulation (DBS) targeting globus pallidus (GP) in the treatment of Parkinson's disease (PD). Cardinal PD symptoms and dyskinesia improved with DBS, and neuropsychological testing found improvements in visuospatial measures associated with left DBS and in verbal memory with right DBS when compared to the patient's preoperative baseline. Under conditions of right, left, and bilateral DBS, the patient experienced bouts of mania and hypomania lasting several days at a time. Positron emission tomography (PET) with (15)O-labeled water was performed after his first manic episode under four conditions: no stimulation, right DBS, left DBS, and bilateral DBS. Although no manic switch occurred during the course of the PET study, all three DBS conditions were associated with decreases in regional flow in the left parahippocampus and hippocampus and right mid-cingulate gyrus. Increases in flow in left inferior frontal area, bilateral insula, dorsolateral prefrontal cortex, and cuneus were common to all DBS conditions. GP stimulation in PD may be associated with behavioral and cognitive effects. Distributed blood flow changes observed with pallidal DBS support a role for the pallidum in cognition and affective regulation.     

Neuropsychological Sequelae of Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease: A Critical Review

Neuropsychologists are increasingly involved in surgical candidacy evaluations and postoperative neurobehavioral assessments of patients with movement disorders, most notably those with disease (PD). We review here the initial studies regarding neuropsychological outcomes of deep brain stimulation (DBS) within the subthalamic nucleus (STN) for treatment of PD. Overall, these initial investigations provide preliminary support for the cognitive and neurobehavioral safety of STN DBS. Improvements in self-reported symptoms of depression and diminished verbal fluency were the most common findings, whereas changes in global cognitive abilities, memory, attention, and frontal/executive functions were inconsistent and most often described as nominal and/or transient. The generalizability of this literature is hindered by several methodological limitations, including small samples and the absence of appropriate control participants. The clinical and theoretical implications of these initial studies are highlighted and recommendations are offered to guide future research.     

Competition, inhibition, and semantic judgment errors in Parkinson's disease

Semantic processing errors are symptoms of an up-regulation (schizophrenia) or degradation (Parkinsonism) of dopaminergic pathways. A recent connectionist model attributed errors in the schizophrenic processing of context to increased gain in competitive neural processes. This study extends this "gain hypothesis" by comparing the sensitivity to reduced gain of a simulation of semantic route activation to characteristic semantic judgment errors made by Parkinson's patients in an open search task. Under normal gain conditions, the dominant sense of polysemous words "wins" through competition and lateral inhibition at the word sense level (beta(inh)). For words with very different sense frequencies, decreasing gain by increasing beta(inh) resulted in the dominant word sense winning; however, for words with similar sense frequencies, increasing beta(inh) resulted in the dominant word sense winning only for low to moderate values. At high levels, no clear winner emerged after 200 epochs, with the least dominant sense reaching the maximum activation value. These results are discussed in the context of the Yerkes-Dodson Law, which may provide a theoretical basis for understanding normal and impaired semantic performance in catecholaminergic disorders.     

Health-related quality of life in Parkinson's disease after pallidotomy and deep brain stimulation

This study explored the multidimensional outcome of three neurosurgical interventions for Parkinson's disease (PD): pallidotomy (N = 23), pallidal deep brain stimulation (DBS) (N = 9), and thalamic DBS (N = 7). All patients completed the Sickness Impact Profile (SIP) and the Beck Depression Inventory. Pallidotomy patients also completed the Profile of Mood States, the Beck Anxiety Inventory, and a disease-specific quality of life (QOL) measure, the Parkinson's Disease Questionnaire (PDQ-39). Three months after surgery, all neurosurgical groups showed significant improvements in mood and function, including physical, psychosocial, and overall functioning. Pallidal DBS and pallidotomy patients who completed additional QOL measures reported decreased anxiety and tension, increased vigor, improved mobility and ability to perform activities of daily living, and decreased perceived stigma. Psychosocial dysfunction scores from the SIP were related to depressed mood both at baseline (r = .42) and at followup (r = .45), but the physical dysfunction subscale was not related to mood at either time point, suggesting that disruption of social relationships due to PD may have more impact on affective distress than physical symptoms alone. Results suggest that neurosurgical interventions for PD improve disabling PD motor symptoms and also improve several domains of quality of life.     

Presurgical Coping, Depression, and Quality of Life in Persons with Parkinson's Disease

This study describes utilization of coping strategies and evaluates the interaction between coping strategies, depression, and quality of life (QOL) in patients with Parkinson's disease (PD) who are being considered for neurosurgical intervention. Eighty patients (mean age 61.7 years) with PD being evaluated for possible deep brain stimulation completed self-report instruments of coping strategies (Coping Responses Inventory), depression (Beck Depression Inventory), and disease-specific QOL (Parkinson's Disease Questionnaire-39). Analyses showed that patients with PD cope with the acute stressor of approaching neurosurgery through a variety of strategies, but particularly avoidant and behavioral strategies. When the correlated but apparently opposing effects of cognitive and behavioral strategies were teased apart, greater use of cognitive strategies was associated with more severe depressive symptomatology (and poorer QOL), while greater use of behavioral strategies appeared to be associated with less depression. Depressive symptomatology, in turn, was associated with poorer QOL. However, coping had minimal direct association with QOL. From this it was concluded that patients with advanced PD generate a variety of coping responses to an acute stressor such as surgery, and the use of behavioral strategies, in particular seeking of alternative enjoyable activities, may be associated with better mood if salutary effects are not overwhelmed by less helpful cognitive coping techniques. The minimization of depressive symptomatology, in turn, is associated with better QOL.     

Effect of speech task on intelligibility in dysarthria: a case study of Parkinson's disease

This study assessed intelligibility in a dysarthric patient with Parkinson's disease (PD) across five speech production tasks: spontaneous speech, repetition, reading, repeated singing, and spontaneous singing, using the same phrases for all but spontaneous singing. The results show that this speaker was significantly less intelligible when speaking spontaneously than in the other tasks. Acoustic analysis suggested that relative intensity and word duration were not independently linked to intelligibility, but dysfluencies (from perceptual analysis) and articulatory/resonance patterns (from acoustic records) were related to intelligibility in predictable ways. These data indicate that speech production task may be an important variable to consider during the evaluation of dysarthria. As speech production efficiency was found to vary with task in a patient with Parkinson's disease, these results can be related to recent models of basal ganglia function in motor performance.     

Neuronal changes in normal human aging and Alzheimer's disease

This article discusses age-related changes in brain weight, total number of cortical neurons, cortical dendrites, spine, and synapse density. The conclusion is that the present outlook is less grim than it was 30 years ago. Age-related reduction appears to be specific to brain region and cortical layer rather than a general feature. In addition, we describe a different pattern of changes that occur in Alzheimer's disease patients. This review concludes that the association cortices in particular are affected in aging and Alzheimer's disease and that the primary visual and somatosensory cortices are relatively spared.