Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea

Neurological diseases can be complicated by sialorrhea, an excessive flow of saliva. Patients suffering from moderate to severe sialorrhea have an ...

University of Torino, San Luigi Gonzaga Hospital

Subthalamic nucleus deep brain stimulation (STN DBS) is an effective therapeutic option for advanced Parkinson's disease (PD). Nevertheless, some patients develop gait disturbances despite a persistent improvement of PD segmental symptoms. Recent studies reported that stimulation of STN with low frequencies produced a positive effect on gait disorders and freezing episodes.

Transient effects of 80 Hz stimulation on gait in STN DBS treated PD patients: a 15 months follow-up study.

Deep brain stimulation of the subthalamic nucleus is an effective treatment for advanced Parkinson's disease. The benefits of bilateral subthalamic stimulation are well documented, and some studies reported outcomes with a follow-up of 5 to 6 years; nevertheless, few data are available beyond 5 years. We report a long-term prospective evaluation of 14 consecutive parkinsonian patients, treated by bilateral subthalamic stimulation for at least 9 years. Motor symptoms, activity of daily living, and motor complications were evaluated by means of the Unified Parkinson's Disease Rating Scale, while cognition and mood were assessed with a specific neuropsychological test battery; medication intake, stimulation parameters, comorbidity, and adverse events were also recorded. Patients were evaluated before surgery and at 1, 5, and ≥ 9 years after surgery. At last follow-up, deep brain stimulation significantly improved the motor score by 42% compared to baseline, whereas activities of daily living were no longer improved; there was a 39% reduction in the dosage of dopaminergic drugs and a 59% improvement of L-dopa-related motor complications. The neuropsychological assessment showed that 4 patients (29%) developed a significant cognitive decline over the follow-up period. These results indicate a persistent effect of deep brain stimulation of the subthalamic nucleus on the cardinal motor symptoms in advanced Parkinson's disease patients in the long-term; however, a worsening of patients' disability, mainly due to disease progression, was observed.

Beyond nine years of continuous subthalamic nucleus deep brain stimulation in Parkinson's disease.

Patients with young onset Parkinson's disease (YOPD) are often candidates for subthalamic nucleus-deep brain stimulation (STN-DBS). Nevertheless, few data have been reported on the long term STN-DBS clinical outcome of YOPD versus non-young onset Parkinson's disease (n-YOPD) patients.

Subthalamic nucleus deep brain stimulation outcome in young onset Parkinson's disease: a role for age at disease onset?

Duodenal infusion of levodopa/carbidopa gel (Duodopa) is an effective treatment option for advanced Parkinson's disease (PD). Long-term clinical experience up to 16 years suggests that the safety of this procedure is acceptable, while several observational studies showed that Duodopa reduces motor fluctuations and dyskinesias improving patients' quality of life (QoL). The aim of this study is to investigate the long-term motor and cognitive outcome of Duodopa treatment in advanced PD patients and its' impact on the QoL. Twenty-five consecutive PD patients were assessed using the Unified PD rating scale (UPDRS), a battery of neuropsychological tests, and the PD questionnaire (PDQ-39) at baseline and after a mean period of three years of Duodopa treatment. Seventeen out of 25 patients reached the follow-up evaluation; five patients discontinued Duodopa and three patients died of causes unrelated to drug infusion. Duodopa improved motor complications (UPDRS-IV) and quality of life (PDQ-39). A sub-group of subjects (41 %) developed a significant deterioration of cognitive functions over time. The most common adverse events were dislocation and the kinking of the intestinal tube. In conclusion, Duodopa therapy is effective in the long-term treatment of advanced PD patients. Continuous enteral levodopa infusion achieves a reduction of motor fluctuations and dyskinesias improving patients' QoL, despite the progression of PD motor symptoms and a significant decline in cognitive functions in a sub-group of patients.

Long-term duodenal levodopa infusion in Parkinson's disease: a 3-year motor and cognitive follow-up study.

Subthalamic Nucleus Deep Brain Stimulation (STN-DBS) represents a valid therapeutic option for advanced Parkinson's disease (PD), leading to a significant amelioration of motor fluctuations and levodopa-induced involuntary movements (IM). This study address the issue of whether stimulation frequency may influence the control of IM in STN-DBS treated patients, comparing the effects of 80 Hz and 130 Hz STN-DBS frequencies in 10 parkinsonian patients with residual IM (dyskinesia in 6 cases and dystonia in 4 cases).

80 Hz versus 130 Hz subthalamic nucleus deep brain stimulation: effects on involuntary movements.

Few clinical trials reported the comparative short-term efficacy of subthalamic nucleus deep brain stimulation (STN-DBS) versus medical therapy in advanced Parkinson's disease (PD). However, the comparative efficacy, safety and the potential disease-modifying effect of these treatments have not been investigated over a longer follow-up period.

Medical therapy and subthalamic deep brain stimulation in advanced Parkinson's disease: a different long-term outcome?

This observational study reports the long-term follow-up of 184 Parkinson's disease (PD) patients treated with subthalamic deep brain stimulation (STN-DBS), retrospectively analyzing the outcomes of subjects with pre-surgical mild cognitive impairment (MCI) compared to those of patients with normal cognition. Patients were divided into PD-MCI or normal cognition groups at baseline, and then compared after 1, 3, 5 and >5 years of follow-up. Subjects assessed by outpatient clinical follow-up evaluation, not performing a complete clinical and neuropsychological follow-up assessment, were separately considered and rated according to their functional autonomy in daily living activities. The MCI prevalence at baseline was 23 %, increasing to 34 % at 1 year and over 40 % after 3 years. Dementia progressively affected more than 30 % of subjects after a median time of 6 years in the PD-MCI group and 11 years in the normal cognition group (p: 0.028). The mortality risk was slightly higher in PD-MCI patients. Outpatient clinical evaluations showed a progressive increase of subjects completely dependent in the activities of daily living, which ranged from the 11 % at 3 years to 23 % at 5 years and 31 % at >5 years. MCI can be frequently observed in PD patients, possibly influencing the outcome of surgical therapy. Our findings confirm the sustained long-lasting efficacy of STN-DBS on motor functions in both PD-MCI and normal cognition subjects. PD-MCI patients showed a more precocious cognitive impairment, as expected by natural history studies, but no case of dementia was observed early after surgery.

Subthalamic deep brain stimulation: clinical and neuropsychological outcomes in mild cognitive impaired parkinsonian patients.

Subthalamic nucleus deep brain stimulation (STN-DBS) has been recently compared to a possible "second therapeutic honeymoon" for Parkinson's disease, as it might prevent the development of severe motor complications and lessen the social adjustment associated to disease progression. This study aims to evaluate whether an early surgical treatment could result in better long-term outcomes, comparing the follow-up evolution of 203 parkinsonian patients, treated at different stages of the disease course.

Earlier versus later subthalamic deep brain stimulation in Parkinson's disease.

Literature provides reports only of a limited follow-up single injection of botulinum toxin-A (BoNT-A) in patients with sialorrhea. The aim of our study is to evaluate the long-lasting efficacy and safety of ultrasound-guided BoNT-A injections for severe sialorrhea secondary to neurological dysphagia. We enrolled 38 severe adult sialorrhea patients referred consecutively to the neurology unit and performed bilateral parotid and submandibular gland BoNT-A injections under ultrasound guidance. The outcomes of the study were reduction of sialorrhea, duration of therapeutic effect, and subjective patient- and caregiver-reported satisfaction. A total of 113 BoNT-A administrations were given during the study period with a mean duration of follow-up of 20.2 ± 4.4 months. We observed a significant decrease from baseline in mean number of daily aspirations and a significant improvement in patient- and caregiver-reported outcomes following ultrasound-guided BoNT-A injections (p < 0.001 vs baseline for all comparisons) and the mean duration of the efficacy was 5.6 ± 1 months. No major treatment-related adverse events occurred and a low incidence of minor adverse events was reported. This study confirms the long-lasting efficacy and safety of ultrasound-guided BoNT-A injections for sialorrhea, regardless of the causative neurological disorder. These results should encourage the use of BoNT-A in the treatment of severe sialorrhea and highlight the role of ultrasound guidance to obtain optimal results in terms of safety and reproducible outcomes.

Carlo Alberto Artusi

Clinical and Biological Sciences Department,
Neurology Unit,
Clinical and Biological Sciences Department, Neurology Unit

University of Torino, San Luigi Gonzaga Hospital

Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea

Carlo Alberto Artusi

.css-o250i3{font-size:18px;font-family:Open Sans,sans-serif;line-height:21.6px;}Clinical and Biological Sciences Department,Neurology Unit,Clinical and Biological Sciences Department, Neurology Unit

University of Torino, San Luigi Gonzaga Hospital

Ultrasound-guided Botulinum Toxin-A Injections: A Method of Treating Sialorrhea

Clinical and Biological Sciences Department,
Neurology Unit,
Clinical and Biological Sciences Department, Neurology Unit