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Neuronal degeneration in the basal ganglia and loss of pallido-subthalamic synapses in mice with targeted disruption of the Huntington's disease gene.

Huntington's disease (HD) is a progressive neurodegenerative disorder associated with CAG repeat expansion within a novel gene (IT15). We have previously created a targeted disruption in exon 5 of Hdh (Hdhex5), the murine homologue of the HD gene. Homozygotes for the Hdhex5 mutation exhibit embryolethality before embryonic day 8.5, while heterozygotes survive to adulthood and display increased motor activity and cognitive deficits. Detailed morphometric and stereological analyses of the basal ganglia in adult heterozygous mice were performed by light and electron microscopy. Morphometric analyses demonstrated a significant loss of neurons from both the globus pallidus (29%) and the subthalamic nucleus (51%), with a normal complement of neurons in the caudate-putamen and substantia nigra. The ultrastructural appearance of sporadic degenerating neurons in these regions indicated apoptosis. The highest frequency of apoptotic neurons was observed in the globus pallidus and subthalamic nucleus. Stereological analyses in the subthalamic nucleus revealed a significant decrease in the numerical density of symmetric synapses (43%), suggesting a relatively selective loss of inhibitory pallido-subthalamic afferents. Immunohistochemistry using antibodies against enkephalin and substance-P was unremarkable in heterozygotes, indicating a normal complement of enkephalin-immunoreactive striatopallidal afferents and substance-P-immunoreactive striatopeduncular and striatonigral afferents in these animals. These findings show that loss of an intact huntingtin protein is associated with significant morphological alterations in the basal ganglia of adult mice, indicating an important role for this protein during development of the central nervous system.

Afferent Pathways↗

Organization and efferent projections of nucleus tegmenti pedunculopontinus pars compacta with special reference to its cholinergic aspects.

In an attempt to evaluate the cellular organization and efferent projections of the nucleus tegmenti pedunculopontinus pars compacta, several experiments were performed in the rat. From measurements of neurons in the nucleus tegmenti pedunculopontinus pars compacta in Nissl-stained sections, the nucleus was observed to contain many large neurons which made it possible to demarcate this nucleus from surrounding pontomesencephalic reticular formation. Two other neuronal populations, medium and small neurons, were also seen in the nucleus tegmenti pedunculopontinus pars compacta. Detailed measurements showed that 90% by volume of all neurons in the nucleus tegmenti pedunculopontinus pars compacta were large and medium-sized neurons. After injections of [3]leucine into the nucleus tegmenti pedunculopontinus pars compacta, transported label was observed in dorsally and ventrally coursing ascending fibers. The dorsally coursing fibers entered the centrolateral nucleus and centre median-parafascicular complex of the thalamus. The ventrally coursing fibers produced accumulation of silver grains in the ventral tegmental area, substantia nigra pars compacta, subthalamic nucleus, zona incerta and lateral hypothalamus. Crossed fibers of the nucleus tegmenti pedunculopontinus pars compacta were observed sparsely at the levels of the thalamus and posterior commissure, and to a greater degree through the supraoptic commissure of Meynert. Much less anterograde labeling was seen in the equivalent terminal sites on the contralateral side of the brain. By electron microscopic autoradiography major terminal sites of axons of the nucleus tegmenti pedunculopontinus pars compacta were examined in rats injected with [3H]leucine in the nucleus tegmenti pedunculopontinus pars compacta and later injected with horseradish peroxidase in the striatum and pallidum. Statistical data showed preferential radiolabeling of terminals forming asymmetrical synaptic contact with dendrites in the centrolateral nucleus, centre median-parafascicular complex and subthalamic nucleus. Apparent terminations in the substantia nigra pars compacta proposed in earlier studies and shown in the present light microscopic autoradiograms were not supported by this ultrastructural analysis. Several radiolabeled terminals of the asymmetrical type contacting horseradish peroxidase labeled dendrites in the thalamus confirmed direct input from the nucleus tegmenti pedunculopontinus pars compacta to the thalamostriate projection neurons. [3H]choline injections into the thalamus and subthalamic nucleus produced retrograde perikaryal labeling of large neurons in the nucleus tegmenti pedunculopontinus pars compacta.

Animals↗

Increased m-CPP-induced oral dyskinesia after lesion of serotonergic neurons.

Peripheral administration of the 5-hydroxytryptamine (5-HT)(2C/1B) agonist 1-(m-chlorophenyl)piperazine (m-CPP) produces abnormal orofacial movements in rats. We have previously shown that this behavior is mediated by 5-HT(2C) receptors in the subthalamic nucleus [Neuroscience 72 (1996) 117]. The present studies examined this effect after serotonin depletion to determine whether removal of endogenous serotonin affected this behavioral response and/or subthalamic 5-HT(2C) receptors. Rats received an intraventricular infusion of the neurotoxin 5,7-dihydroxytryptamine (5,7-DHT, 100 mg/10 ml) or vehicle after desipramine pretreatment (25 mg/kg ip). The efficacy of serotonin depletion was confirmed by a decrease in serotonin uptake sites measured by autoradiography. Oral dyskinesia induced by peripheral administration of m-CPP (1.0 mg/kg ip) was markedly increased in lesioned rats compared to sham-operated controls 4 and 8 but not 12 days after the lesion. A subset of lesioned rats that displayed transient seizures after m-CPP injection did not prevent the measurement of oral dyskinesia during the observation period. No differences in 5-HT(2C) receptor levels were found with ligand-binding autoradiography in the subthalamic nucleus, or in other brain regions that express this receptor, in rats sacrificed 5 days following 5,7-DHT lesions. The data indicate that lesion of serotonergic neurons in adult rats induces a transient increase in motor responses mediated by subthalamic 5-HT(2C) receptors. These data suggest that functional alterations in serotonergic transmission in the subthalamic nucleus may be involved in the pathophysiology of hyperkinetic movement disorders.

5,7-Dihydroxytryptamine↗

Subthalamic projection to nucleus tegmenti pedunculopontinus in the rat.

A projection from the subthalamic nucleus to the nucleus tegmenti pedunculopontinus has been demonstrated in the rat using retrograde and anterograde transport of horseradish peroxidase. Small, well-localized injections of peroxidase in nucleus pedunculopontinus gave rise to retrogradely labelled cell bodies in the subthalamic nucleus. Injections of peroxidase restricted to the subthalamic nucleus gave terminal labelling in nucleus pedunculopontinus.

Animals↗

Levodopa-induced dyskinesias in Parkinson's disease: is sensitization reversible?

Levodopa-induced dyskinesias (LIDs) in patients with Parkinson's disease are considered to result from the severity of dopaminergic denervation in the striatum, which is an irrevocable phenomenon, and sensitization induced by long-term intermittent administration of levodopa. Taking advantage of the 64% reduction of levodopa treatment allowed in 12 Parkinson's disease patients by continuous high-frequency stimulation of the subthalamic nucleus, we evaluated the severity of parkinsonian motor disability and LIDs during two levodopa challenges performed before the surgical implantation of the stimulation electrodes and after 8.8 months of continuous bilateral subthalamic nucleus stimulation that was interrupted 2 hours before the levodopa test. Motor disability during the "off" and "on" drug periods was unchanged. The severity of LIDs during the "on" period and dystonia during the "off" period decreased by 54% and 62%, respectively. The reduced severity of LIDs in the absence of subthalamic nucleus stimulation demonstrates that the sensitization phenomenon resulting from long-term intermittent levodopa administration is partially reversible.

Adult↗

Effects of intrasubthalamic injection of dopamine receptor agonists on subthalamic neurons in normal and 6-hydroxydopamine-lesioned rats: an electrophysiological and c-Fos study.

Subthalamic neuronal activity is controlled by a dopaminergic innervation, which may act via D1 and D2 dopamine receptors. This study investigates the effect of apomorphine and the selective D1 and D2 agonists, SKF 82958 and quinpirole respectively, in normal and 6-hydroxydopamine-lesioned rats. The effect of microinjection of these drugs into the subthalamic nucleus was assessed by recording unit activity and the expression of the c-Fos-immunoreactive protein in the subthalamic nucleus. Dopaminergic agonists reduced the discharge rate and did not induce c-Fos expression in the normal rat. Apomorphine and quinpirole increased the discharge rate and induced a strong expression of c-Fos-like immunoreactive proteins, whereas SKF 82958 induced a decrease of the discharge rate and a slight expression of c-Fos in 6-hydroxydopamine-lesioned rats. The striking contrast in the changes obtained with apomorphine and quinpirole in normal and 6-hydroxydopamine-lesioned rats is discussed in relation to a hyperexpression of D2 dopaminergic receptors on the GABAergic terminals into the subthalamic nucleus. These results show that, in normal rats, dopamine agonists exert an inhibitory control on subthalamic neurons via D1 and D2 receptors. However, in 6-hydroxydopamine-lesioned rats, the hyperactivity of subthalamic neurons is also reduced by D1 receptor agonist but not by D2 dopamine agonists. This last result points out one aspect of the complex mechanisms underlying the physiopathology of Parkinson's disease.

Adrenergic Agents↗

Neuroprotection for the new millennium. Matchmaking pharmacology and technology.

A major theme of the 1990s in the pathophysiology of nervous system injury has been the multifactorial etiology of irreversible injury. Multiple causes imply multiple opportunities for therapeutic intervention--hence the abandonment of the "magic bullet" single pharmacologic agent for neuroprotection in favor of pharmacologic "cocktails". A second theme of the 1990s has been the progress in technology for neuroprotection, minimally- or non-invasive monitoring as well as treatment. Cardiac stenting has eliminated the need, in many cases, for open heart surgery; deep brain stimulation for Parkinson's disease has offered significant improvement in quality of life for many who had exhausted cocktail drug treatment for their disease. Deep brain stimulation of the subthalamic nucleus offers a novel treatment for Parkinson's disease where a technological advance may actually be an intervention with effects that are normally expected from pharmacologic agents. Rather than merely "jamming" the nervous system circuits involved in Parkinson's disease, deep brain stimulation of the subthalamic nucleus appears to improve the neurotransmitter imbalance that lies at the heart of Parkinson's disease. It may also slow the progression of the disease. Given the example of deep brain stimulation of the subthalamic nucleus for Parkinson's disease, in future one may expect other technological or "hardware" interventions to influence the programming or "software" of the nervous system's physiologic response in certain disease states.

Basal Ganglia↗

Ensemble recordings of human subcortical neurons as a source of motor control signals for a brain-machine interface.

OBJECTIVE: Patients with severe neurological injury, such as quadriplegics, might benefit greatly from a brain-machine interface that uses neuronal activity from motor centers to control a neuroprosthetic device. Here, we report an implementation of this strategy in the human intraoperative setting to assess the feasibility of using neurons in subcortical motor areas to drive a human brain-machine interface. METHODS: Acute ensemble recordings from subthalamic nucleus and thalamic motor areas (ventralis oralis posterior [VOP]/ventralis intermediate nucleus [VIM]) were obtained in 11 awake patients during deep brain stimulator surgery by use of a 32-microwire array. During extracellular neuronal recordings, patients simultaneously performed a visual feedback hand-gripping force task. Offline analysis was then used to explore the relationship between neuronal modulation and gripping force. RESULTS: Individual neurons (n = 28 VOP/VIM, n = 119 subthalamic nucleus) demonstrated a variety of modulation responses both before and after onset of changes in gripping force of the contralateral hand. Overall, 61% of subthalamic nucleus neurons and 81% of VOP/VIM neurons modulated with gripping force. Remarkably, ensembles of 3 to 55 simultaneously recorded neurons were sufficiently information-rich to predict gripping force during 30-second test periods with considerable accuracy (up to R = 0.82, R(2) = 0.68) after short training periods. Longer training periods and larger neuronal ensembles were associated with improved predictive accuracy. CONCLUSION: This initial feasibility study bridges the gap between the nonhuman primate laboratory and the human intraoperative setting to suggest that neuronal ensembles from human subcortical motor regions may be able to provide informative control signals to a future brain-machine interface.

Electrodes, Implanted↗

Neuropsychological assessment for management of patients with deep brain stimulation.

The inclusion of cognitive and behavioural criteria has been recommended for the management of patients with deep brain stimulation. A neuropsychological assessment may contribute to different issues: (1) selection of the best candidates for surgery, (2) evaluation of the consequences of surgery, (3) research of the best electrode implantation. Recent neuropsychological studies indicate that (1) with appropriate inclusion criteria, the effects of surgery on cognitive functions are limited; (2) an aggravation of behavioural disorders might be related to subthalamic nucleus (STN) stimulation and depend on electrode location; (3) subthalamic nucleus stimulation, but not the internal globus pallidus stimulation, improves psychomotor efficiency and working memory. These results would suggest that the implanted electrodes are not solely targeting the motor circuit and that the cognitive and motor circuits are not completely segregated.

Basal Ganglia↗

Tonic activation of presynaptic GABA(B) receptors on rat pallidosubthalamic terminals.

AIM: The subthalamic nucleus plays a critical role in the regulation of movement, and abnormal activity of its neurons is associated with some basal ganglia motor symptoms. We examined the presence of functional presynaptic GABA(B) receptors on pallidosubthalamic terminals and tested whether they were tonically active in the in vitro subthalamic slices. METHODS: Whole-cell patch-clamp recordings were applied to acutely prepared rat subthalamic nucleus slices. The effects of specific GABA(B) agonist and antagonist on action potential-independent inhibitory postsynaptic currents (IPSCs), as well as holding current, were examined. RESULTS: Superfusion of baclofen, a GABA(B) receptor agonist, significantly reduced the frequency of GABA(A) receptor-mediated miniature IPSCs (mIPSCs), in a Cd2+-sensitive manner, with no effect on the amplitude, indicating presynaptic inhibition on GABA release. In addition, baclofen induced a weak outward current only in a minority of subthalamic neurons. Both the pre- and post-synaptic effects of baclofen were prevented by the specific GABA(B) receptor antagonist, CGP55845. Furthermore, CGP55845 alone increased the frequency of mIPSCs, but had no effect on the holding current. CONCLUSION: These findings suggest the functional dominance of presynaptic GABA(B) receptors on the pallidosubthalamic terminals over the postsynaptic GABA(B) receptors on subthalamic neurons. Furthermore, the presynaptic, but not the postsynaptic, GABA(B) receptors are tonically active, suggesting that the presynaptic GABA(B) receptors in the subthalamic nucleus are potential therapeutic target for the treatment of Parkinson disease.

Animals↗

A lesioning and 2-deoxyglucose study of the hyperactivity produced by an intra-accumbens dopamine agonist.

Lesioning and 2-deoxyglucose (2-DG) autoradiographic studies were applied to the hyperactivity induced in rats by intra-accumbens treatment with the dopamine agonist 2-amino-6,7-dihydroxy-1,2,3,4-tetrahydro-naphthalene (ADTN). Lesions made in substantia innominata and rostro-ventral globus pallidus both attenuated the hyperactivity although no consistent changes in 2-DG uptake were recorded in these areas. Compared to normal rats, hyperactive rats showed greatly increased glucose utilization in the subthalamic nucleus and lateral habenula. Lesioning the subthalamic nucleus greatly reduced the hyperactivity, whereas a lateral habenula lesion was ineffective. Hyperactivity was associated with a discrete, bilateral area of increased 2-DG uptake in the reticular formation which corresponded to the description of the deep mesencephalic nucleus (DMN). Lesions made in the DMN greatly attenuated the hyperactivity response. The DMN may be a locomotor region in the rat.

Animals↗

The medial prefrontal cortex plays an important role in the excitation of A10 dopaminergic neurons following intravenous muscimol administration.

Intravenous muscimol administration increases the activity of dopaminergic neurons of the A10 cell group, located in the ventral tegmental area. Evidence suggests that this increase in activity is produced by disinhibition following the inhibition of GABAergic ("non-dopaminergic") cells in the ventral tegmental area. We hypothesized that the activation of A10 cells by muscimol is likely to be at least partly caused by the action of excitatory afferents. To verify this, A10 cells were isolated from ipsilateral afferent sources which utilise excitatory amino acids (which play an important role in the activity of these neurons), using hemisections at the level of the subthalamic nucleus (or just anterior to the subthalamic nucleus), electrolytic lesions of the pedunculopontine tegmental nucleus, or a combination of both. Following hemisections, and hemisections combined with lesions of the pedunculopontine tegmental nucleus, muscimol inhibited rather than excited A10 dopaminergic neurons. The pedunculopontine tegmental nucleus itself appeared to make little intrinsic contribution to muscimol-induced excitation, although the results suggested that part of the excitation which originates in the forebrain may be conducted to A10 cells via the pedunculopontine tegmental nucleus. The source of the effective forebrain excitation was investigated using electrolytic lesions of documented sources of excitatory amino acidergic afferents to the ventral tegmental area: the medial prefrontal cortex, certain nuclei of the amygdalar complex and the lateral habenular nucleus. In the medial prefrontal cortex-lesioned group, muscimol again produced inhibition, an effect qualitatively and quantitatively similar to that in the hemisected groups. Habenular lesions blocked muscimol-induced excitation without producing inhibition, whilst amygdalar lesions produced no significant change in the effects of muscimol. The results suggest that under normal circumstances, an active excitation counteracts and exceeds the direct inhibitory effects of muscimol on the activity of A10 dopaminergic neurons. Furthermore, this activation appears to be produced by the action of excitatory (probably excitatory amino acidergic) afferents arising from the medial prefrontal cortex, and possibly the lateral habenular nucleus. Insofar as the excitation of A10 dopaminergic neurons, which is produced by certain drugs of abuse, and which may play a crucial role in their sustained use, has its basis in excitation following disinhibition, this excitation may provide a novel target for therapeutic intervention in addiction.

Amygdala↗

STN stimulation alters pallidal-frontal coupling during response selection under competition.

To investigate the effects of bilateral subthalamic nucleus (STN) stimulation on patterns of brain activation during random number generation (RNG), a task that requires suppression of habitual counting and response selection under competition. We used H(2)(15)O positron emission tomography to investigate the changes of regional cerebral blood flow (rCBF) induced by bilateral STN stimulation during a RNG task, in six patients with Parkinson's disease. Paced RNG at 1 Hz was compared with a control counting task. Both tasks were performed off medication with deep brain stimulation on and off. Subthalamic nucleus stimulation had a negative effect on performance of fast-paced RNG, leading to reduced randomness and increased habitual counting. Subthalamic nucleus stimulation also induced a reduction of rCBF in the left dorsal frontal gyrus, inferior frontal gyrus, dorsolateral prefrontal cortex, posterior and right anterior cingulate, and an increase of rCBF in the right internal globus pallidum (GPi) during RNG. Stimulation of the STN significantly altered pallidal coupling with frontal and temporal areas compared with when the stimulators were off. In conclusion, during RNG: (i) STN stimulation activates its output neurons to the GPi; (ii) STN stimulation induces increased inhibition of a prefrontal-cingulate network. This is the first direct evidence that STN stimulation significantly alters pallidal coupling with prefrontal, cingulate, and temporal cortices during performance of a task that requires response selection under competition.

Cerebrovascular Circulation↗

Electrophysiological and Fos immunohistochemical evidence for the excitatory nature of the parafascicular projection to the globus pallidus.

Extracellular recordings and immunohistological detection of c-Fos-like immunoreactive proteins were used to determine the synaptic effect of the parafascicular projection to the globus pallidus. Electrical stimulation of the parafascicular neurons induced a single-spike excitatory response with a stable latency of 2.3 ms, suggesting a monosynaptically driven effect. Pharmacological stimulation of the parafascicular nucleus with carbachol increased tonically the pallidal discharge rate by 142%. The discharge rate of the pallidal neurons was described by 37% in parafascicular-lesioned rats. These results demonstrate the excitatory nature and the tonic action of the parafasciculopallidal projection. Carbachol activation of parafascicular neurons also induced the synthesis of c-Fos-like immunoreactive proteins in the pallidal neurons. Control experiments in subthalamic-lesioned rats showed that the parafascicular excitation of the pallidal neurons remained, but both electrophysiological and expression of c-Fos-like immunoreactive proteins were attenuated. This suggests that the direct parafascicular excitation of the pallidal neurons is indirectly reinforced by the previously described parafascicular excitatory input to the subthalamic nucleus. Conversely, the effect of this last input to the subthalamic nucleus is dramatically enhanced in rats with pallidal lesion. Our results demonstrate the complex role of the parafascicular nucleus in activating both the globus pallidus and the subthalamic nucleus, two closely related structures. These results illustrate the integrative capacities of the globus pallidus, whose activity is modulated by multiple afferents.

Animals↗

Experimental hemichorea/hemiballismus in the monkey. Studies on the intracerebral site of action in a drug-induced dyskinesia.

Antagonists of the neurotransmitter gamma aminobutyric acid (GABA) were injected at seventy intracerebral sites in the conscious monkey. Injections located in or near to the subthalamic nucleus provoked involuntary movements of the contralateral limbs. These movements had the characteristics of chorea and, when severe, resembled hemiballismus as seen following subthalamic nucleus lesions in man and monkey. Localized injections of GABA antagonists into the medial segment of the globus pallidus were without observable effect on motor activity. These observations are discussed with regard to the role of GABA in subthalamopallidal relations. Injection of GABA antagonists at some other sites provoked different forms of dyskinesia. Injections in or near the zona incerta adjacent to the subthalamic nucleus induced torticollis and circling behaviour either in isolation or in addition to contralateral limb dyskinesia. Injections at some sites located in the lateral segment of the globus pallidus or in the putamen induced choreoathetoid or myoclonic movements, respectively.

Animals↗

Future and current surgical therapies in Parkinson's disease.

PURPOSE OF REVIEW: The mainstay of treatment for Parkinson's disease remains medical therapy. With improved surgical precision and decreased morbidity, stereotactic lesioning and deep brain stimulation have become more popular. New therapies currently in clinical trials include gene therapy and direct drug delivery to the brain. The present review discusses surgical therapies for the treatment of Parkinson's disease and the status of experimental strategies currently in preclinical and clinical testing. RECENT FINDINGS: Both stereotactic ablation and deep brain stimulation of the thalamus, globus pallidus interna, and subthalamic nucleus are discussed and compared in the current literature. New therapies such as drug infusions into the brain, gene therapy, and neural transplantation are in clinical trials and have been tested extensively in animals. Safety and efficacy of such therapies are discussed in recent literature. SUMMARY: Although medication remains the first and main line of treatment and the mainstay for Parkinson's disease, advances in techniques and safety of operations have made surgical interventions more popular. Thalamic surgery remains helpful only in a limited subset of patients with predominent tremor that is unresponsive to medication. Bilateral subthalamic nucleus DBS holds the most promising results for patients with tremor, severe motor fluctuations and dyskinesias from L-dopa, with the best improvements seen in daily activities and quality of life. Newer therapies currently in clinical trial include gene therapy to replace lost gamma-aminobutyric acid inputs to the subthalamic nucleus and globus pallidus interna/substantia nigra pars reticulata, and infusion of recombinant glial derived neurotrophic factor to support at-risk nigrostriatal neurons. Further developments in these areas, along with evolution in stem cell science that hopefully will permit replacement of lost neurons, may alter the nature of surgical practice in Parkinson's disease patients in the not too distant future.

Corpus Striatum↗

Nigrostriatal lesions alter oral dyskinesia and c-Fos expression induced by the serotonin agonist 1-(m-chlorophenyl)piperazine in adult rats.

The loss of dopaminergic innervation of the basal ganglia, a group of subcortical regions involved in motor control, is the hallmark of Parkinson's disease. The resulting molecular and cellular alterations mediate behavioral deficits and may modify neuronal responses to other neurotransmitters. In the present study, we sought to determine the effects of chronic dopamine (DA) depletion on responses mediated by stimulation of serotonergic 2C (5-HT(2C)) receptors, a serotonergic receptor subtype present in discrete regions of the basal ganglia. Specifically, the effects of unilateral lesions of nigrostriatal DA neurons on oral dyskinesia and Fos protein expression induced by the non-selective 5-HT(2C) agonist 1-(m-chlorophenyl)piperazine (m-CPP) were examined. Confirming previous findings, both peripheral and local injections of m-CPP into the subthalamic nucleus elicited oral dyskinesia. Nigrostriatal lesions markedly enhanced oral bouts induced by peripheral but not intrasubthalamic administration of m-CPP. In intact rats, Fos expression was increased by m-CPP (1 mg/kg, i.p.) in the striatum and the subthalamic nucleus. After nigrostriatal lesions, m-CPP-induced Fos expression remained unchanged in the subthalamic nucleus but was reduced in the medial quadrants of the striatum and was markedly enhanced in the entopeduncular nucleus. These data demonstrate regionally specific alterations in behavioral and cellular responses to a serotonergic agonist in an animal model of Parkinson's disease.

Animals↗

Neurosurgery at an earlier stage of Parkinson disease: a randomized, controlled trial.

BACKGROUND: Stimulation of the subthalamic nucleus is an effective treatment for advanced Parkinson disease (PD) and is currently performed after a mean disease duration of 14 years, when severe motor complications have resulted in marked loss of quality of life. We examined whether surgery at an early stage would maintain quality of life as well as improve motor function. METHODS: Twenty patients with PD of short duration (time elapsed since first symptom +/- SD: 6.8 +/- 1.0 years) with mild to moderate motor signs (Unified Parkinson's Disease Rating Scale III "off" medication: 29 +/- 12) who responded well to levodopa treatment were included in pairs, matched for age, duration and severity of disease, and impairment in socioprofessional functioning. Patients were prospectively randomized to undergo bilateral subthalamic nucleus stimulation (n = 10) or receive optimized medical treatment (n = 10). Parkinsonian motor scores, quality of life, cognition, and psychiatric morbidity were assessed at inclusion and at 6, 12, and 18 months after randomization. RESULTS: Quality of life was improved by 24% in surgical and 0% in nonsurgical patients (p < 0.05). After 18 months, the severity of parkinsonian motor signs "off" medication, levodopa-induced motor complications, and daily levodopa dose were reduced by 69%, 83%, and 57% in operated patients and increased by 29%, 15%, and 12% in the group with medical treatment only (p < 0.001). Adverse events were mild or transient, and overall psychiatric morbidity and anxiety improved in the surgical group. CONCLUSIONS: Subthalamic nucleus stimulation should be considered a therapeutic option early in the course of Parkinson disease.

Activities of Daily Living↗