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Estimulación cerebral profunda para la enfermedad de Parkinson: criterios de selección, abordaje quirúrgico, efectos secundarios y controversias.
Resumen
La enfermedad de Parkinson (EP) es la segunda enfermedad neurodegenerativa más frecuente. Afecta a 6 millones de personas en el mundo y esta cifra incrementará en los próximos años. El manejo consiste en la combinación de fármacos, fisioterapia y terapias avanzadas que incluyen dispositivos de uso parenteral (bombas de apomorfina y levodopa intestinal), cirugía ablativa y cirugía funcional. La estimulación cerebral profunda (ECP) consiste en la aplicación de estímulos eléctricos a través de electrodos implantados en núcleos profundos del cerebro que van conectados a un generador de impulsos (“marcapasos cerebral”); es una técnica aprobada mundialmente con más de 150 000 pacientes intervenidos. La cirugía puede controlar los síntomas motores (y algunos no motores) que han fallado al control por el tratamiento médico. En general, un candidato a ECP es aquel que tiene EP durante al menos 5 años, buena respuesta a la levodopa, complicaciones motoras por el tratamiento y perfil cognitivo-psiquiátrico adecuado. Durante el procedimiento el neurocirujano dirige por medio de estereotaxia los electrodos al núcleo seleccionado mientras el neurólogo monitorea la fisiología celular para que queden implantados en el sitio exacto. Existen complicaciones significativas, pero prevenibles y tratables, durante el procedimiento y en el postoperatorio. En el año 2016 nuestro equipo realizó con éxito la primera cirugía de ECP en Mérida, Yucatán. El objetivo de este trabajo es realizar una revisión descriptiva del proceso de selección, el procedimiento quirúrgico, los efectos secundarios y las controversias de esta técnica.
Palabras clave: enfermedad de Parkinson, estimulación cerebral profunda, núcleo subtalámico, globo pálido interno.
Abstract
Parkinson’s disease (PD) is the second most common neurodegenerative disease. It affects 6 million people worldwide and this amount will increase in the upcoming years. Management consists of a combination of drugs, physical therapy, and advanced therapies that include devices for parenteral use (apomorphine pumps and intestinal levodopa), ablative surgery, and functional surgery. Deep brain stimulation (DBS) is a modality in which electrical stimuli is delivered through electrodes implanted in deep nuclei of the brain that are connected to a pulse generator (“brain pacemaker”); it is a technique used worldwide with more than 150 000 operated patients. This procedure can control motor (and some non-motor) symptoms that have been failed to control by medical treatment. Briefly, a good candidate for DBS is one who has had PD for at least 5 years, a good response to levodopa, motor complications from treatment, and an adequate cognitive-psychiatric profile. During the procedure, the neurosurgeon uses stereotactic coordinates to direct the electrodes to the selected nucleus while the neurologist monitors cell physiology so they can be placed in the exact site. There are significant but preventable and treatable complications during the procedure and postoperatively. In 2016, our team performed the first surgery of this type in Mérida, Yucatán with successful results. The aim of this paper is to do a descriptive review of the selection process, the surgical intervention, complications, and the controversies on the use of DBS for PD.
Key words: Parkinson’s disease, deep brain stimulation, subthalamic nucleus, globus pallidus interna.
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