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Mechanismen der tiefen Hirnstimulation

  • Chapter
Tiefe Hirnstimulation

Zusammenfassung

Die tiefe Hirnstimulation ist eine empirisch basierte Therapie, die auf die Erfahrungen der intraoperativen Teststimulation bei stereotaktischen Hirnoperationen in den 50er und 60er Jahren des letzten Jahrhunderts zurückgeht. Aufgrund der klinischen Effekte unterschied man damals eine niederfrequente „aktivierende“ Stimulation (1-5 Hz), die etwa bei thalamischen Eingriffen den Tremor antrieb, von einer hochfrequenten „blockierenden“ Stimulation (50-200 Hz), die den Effekt einer nachfolgenden Läsion imitierte. Wir wissen heute, dass die tiefe Hirnstimulation in den derzeit verwendeten Zielgebieten Nucleus ventrointermedius thalami (VIM), Globus pallidus internus (GPi) und Nucleus subthalamicus (STN) einen reversiblen „läsionsähnlichen“ Effekt hat. Diese funktioneile Inhibition der entsprechenden Kerngebiete ist frequenzabhängig. Für die Thalamusstimulation konnten Benabid und Kollegen [4] zeigen, dass die zur effektiven Unterdrückung des Tremors erforderliche Stromstärke steil bis zu einer Frequenz von etwa 100 Hz abfällt und dann ein Plateau erreicht, in dem die Schwelle für die Tremorsuppression bis über 1000 Hz weitgehend konstant bleibt. Die meist verwendete Frequenz von 130 Hz entstand aus dem praktischen Bedürfnis, einen mit hoher Sicherheit wirksamen Parameter für die Testung der übrigen Stimulationseinstellungen konstant zu halten und gleichzeitig den Energieverbrauch der Stimulation zu minimieren. Auch für die STN-Stimulation [44] und die Pallidumstimulation [16, 68] wurde belegt, dass erst Frequenzen über 100 Hz wirksam sind. Insgesamt wurden die heutigen Standardparameter der tiefen Hirnstimulation (monopolar kathodisch, Frequenz: 130 Hz, Impulsbreite: 60-90, selten bis 210 μs, Amplitude: 1-3,5 V) mehr oder minder durch „Versuch und Irrtum“ etabliert [67]. Diese Vorgehensweise war klinisch möglich, weil bei den ersten Anwendungen des Verfahrens im Bereich der Bewegungsstörungen die Symptome (Tremor, Rigor oder Bradykinese) mit nur kurzer Verzögerung ansprachen und daher eine schnelle Rückmeldung über den Therapieeffekt lieferten. Bei neuen Indikationen wie der Dystonie, aber auch psychiatrischen Erkrankungen oder der Epilepsie, treten die Effekte jedoch teilweise so verzögert ein, dass es schwierig oder unmöglich ist, die Stimulationsparameter anhand klinischer Kriterien zu optimieren. Zukünftige Entwicklungen in der tiefen Hirnstimulation werden daher in zunehmendem Maße davon abhängen, die physiologischen Wirkmechanismen der Hochfrequenzstimulation (HFS) besser zu verstehen.

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  1. J. Volkmann
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  2. A. Kupsch
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Editors and Affiliations

  1. Neurochirurgische Klinik, Universitätsklinikum Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany

    Joachim K. Krauss

  2. Neurologische Klinik, Universitätsklinikum Schleswig-Holstein - Campus Kiel, Schittenhelmstraße 10, 24105, Kiel, Germany

    Jens Volkmann

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Volkmann, J., Kupsch, A. (2004). Mechanismen der tiefen Hirnstimulation. In: Krauss, J.K., Volkmann, J. (eds) Tiefe Hirnstimulation. Steinkopff, Heidelberg. https://doi.org/10.1007/978-3-7985-1956-5_4

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  • DOI: https://doi.org/10.1007/978-3-7985-1956-5_4

  • Publisher Name: Steinkopff, Heidelberg

  • Print ISBN: 978-3-642-62359-2

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