Abstract & Commentary
Source: Houeto JL, et al. J Neurol Neurosurg Psychiatry. 2002;72:701-707.
This important surgical, neurological, and psychiatric report derives from an excellent study from the Centre d’Investigation Clinique, Hospital de la Salpetriere of Paris. Twenty-four patients volunteered in advance to accept the surgical procedure with detailed intellectual and sturdy physical capacities as well as psychological testing in advance and after operation. The aims of the effort were explicitly discussed with the patients, first to appraise the intended neurological effects of the surgical steps and subsequently to improve physical behavior by the self-improvement of function. This was attained by permanent attachment of electrodes in the subthalamic nucleus (STN) for indefinite stimulation. This greatly improved parkinsonian motor disability by approximately 69%. Reduction of levodopa daily dosage by 60% was appropriate. Complications of surgery were absent except by one patient who suffered a brief postoperative state of confusion. Average age at time of surgery was 59 years.
At publishing time, the present study averaged 19 months (range, 3-38) after electrodes were placed in all 24 patients. Postoperative evaluation of behavioral functions included: intellectual, personality, psychiatric disturbances, emotional changes, and blunted effect. Cognitive functions evaluated before and 6 months after surgery remained steady by the Matis dementia scale fixed at 140. Social adjustments included evaluation by each patient’s before surgery and postoperative behavior.
MINI international neuropsychiatric inventory is a structured interview that can be applied and evaluated for before surgery and after surgery. A variety of "scales" include behavioral control, goal direction, decision, emotion, interpersonal relations, insight, vanity, frugality, or manipulativeness. Items of the MINI are grouped together in major mood disorders; behavioral disability, and psychosis.
Social adjustment scale: Two patients resumed work; 8 adjusted to an excellent level; 14 were relatively good; and 2 were depressed. Age of onset of the disease as well as treatment was associated with "a poor, . . .global social adaptation."
Neuropsychiatric profile: Half the patients had depressive episodes preoperation, 5 after surgery; Suicidal thoughts: 3 preop, 4 postop; Hypomania: 1 post-op, 18 high euphoria postop; Agoraphora: 4 patients before surgery, 2 postop bouts of freezing; Anxiety: 17 preop, 18 following STN stimulation apparently frightened by possible failure of the stimulator. Drug addiction: Two before and after. Psychosis: 2 patients, both following cerebral drugs.
Commentary
This report provides a triumph of neurosurgical adeptness but emphasizes that more than half the patients who regained motor activity retained severe anxiety. Intelligence did not dwindle, but 6 patients broke their marriages in recovering their man-of-the-house behavior. Others found it impossible to associate with "new" families or activities. Overall, severe anxiety and emotional feelings gnawed consistently at time and events past, present, and "where am I going." Eight of the 24 patients, although they also improved from their sustained postoperative motor parkinsonism, they increased the expression of the following personality defects. These included: irritability, 1.7; lack of initiative, 2.6; perseveration, 1.8; lack of persistence, 2.5; lack of planning, 2.4; inflexibility, 1.4; poor judgment, 1.3; insensitivity, 1.4; impatience, 1.3; indecisiveness, 1.6.
Houeto and colleagues deserve strong praise for this report. Their functions emphasize, however, that bilateral STN therapy for PD in patients older than 70 is unwise. As this study indicates, it was the older patients in whom behavior filled with strong anxiety did the worst. Overall, 2 patients regained work and married life. Life was good or excellent in 11 patients, but moderately impaired in 12, and abnormally severe in one. —Fred Plum
Dr. Plum, Professor and Chairman, Department of Neurology and Neuroscience, Weill-Cornell Medical College, is Editor of Neurology Alert.
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