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Morbus Parkinson — Tiefe Hirnstimulation des Globus pallidus

  • T. J. Loher
  • J.-M. Burgunder
  • J. K. Krauss
Chapter

Zusammenfassung

Der Globus pallidus war eine der ersten Strukturen, welche zur Behandlung von Bewegungsstörungen angegangen wurde. Bereits in den 1940er Jahren führte Meyers Exstirpationen des Globus pallidus über einen offenen Zugang zur Behandlung von Parkinsonsymptomen durch [54]. Die erste stereotaktische Pallidotomie wurde von Spiegel und Wycis 1948 bei Patienten mit einer Huntingtonerkrankung vorgenommen [66]. In den 1950er Jahren wurden weltweit Tausende von Pallidotomien in erster Linie zur Behandlung der Parkinsonerkrankung durchgeführt [33]. Über den optimalen Zielpunkt im Pallidum bestand damals kein Konsens. Levy verglich die verschiedenen Zielpunkte im Rahmen einer ausführlichen Untersuchung (Abb. 1) [47]. Einige Untersucher wählten jedoch bereits ein ähnliches Target wie wir es heute verwenden, nämlich den sensomotorischen Anteil des Globus pallidus internus (GPi) im posteroventralen lateralen Aspekt dieser Struktur. Die damaligen pathophysiologischen Modelle der Parkinsonerkrankung trugen nur wenig zum Verständnis der Entstehung der Bradykinese und Akinese bei. Deshalb glaubten viele Untersucher, dass diese Symptome durch einen funktioneilen neurochirurgischen Eingriff entweder nicht beeinflusst werden könnten oder sie sich allenfalls noch verschlechtern würden. Als 1960 die bedeutende Studie von Svennilson und Kollegen publiziert wurde, wurde sie fast vollständig ignoriert [68]. Diese Studie berichtete über 81 Patienten, die zwischen 1951 und 1957 von Leksell mittels einer speziellen bipolaren Elektrode operiert wurden (Abb. 2). Es wurde nicht nur eine Besserung des Rigors und des Tremors beobachtet, sondern auch eine deutliche Besserung der Bradykinese. Als diese Studie veröffentlich wurde, hatten die meisten funktioneilen Neurochirurgen die Pallidotomie jedoch bereits verlassen. Hierfür gab es verschiedene Gründe, unter anderem die zunehmende Verbreitung der Thalamotomie, die Einführung von Levodopa und die damals unzureichenden pathophysiologischen Modelle. Das Pallidum als Zielpunkt zur Behandlung von Bewegungsstörungen wurde von Laitinen Mitte der 1980er Jahre wiederentdeckt [43]. Nach Veröffentlichung seiner Ergebnisse setzte eine Renaissance der funktioneilen Neurochirurgie bei Bewegungsstörungen ein. Zunächst in den Vereinigten Staaten und Skandinavien, später auch in anderen europäischen und asiatischen Ländern, wurden wiederum Tausende von Pallidotomien vorgenommen. Siegfried und Lippitz waren die ersten Untersucher, welche die Prinzipien der tiefen Hirnstimulation (THS) auf den Globus pallidus internus anwendeten [64]. Nachdem sich gezeigt hatte, dass der Nucleus subthalamicus (STN) ebenfalls ein geeigneter Zielpunkt zur Behandlung der Parkinsonerkrankung ist, wurde die STN- Stimulation in den Folgejahren bevorzugt. Dieser Beitrag gibt eine Übersicht über die bisherigen klinischen Ergebnisse der THS im GPi bei der Parkinsonerkrankung. Die Vor- und Nachteile im Hinblick auf die STN-Stimulation werden in einem gesonderten Kapitel behandelt.

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© Springer-Verlag Berlin Heidelberg 2004

Authors and Affiliations

  • T. J. Loher
  • J.-M. Burgunder
  • J. K. Krauss

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