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In a recent issue of the ARCHIVES, Kleiner-Fisman et al1 reported the use of motor cortical stimulation for multiple system atrophy (MSA)–related parkinsonism. A few comments are in order. We introduced extradural motor cortical stimulation for Parkinson disease (PD) in 1998 and have since reported 3 cases.2 - 4 We observed that low-frequency but not high-frequency extradural motor cortical stimulation relieved all signs of PD in a range comparable with deep brain stimulation (DBS). Our results have been confirmed by other European groups (unpublished observations). We also described a now deceased patient with MSA and parkinsonian symptoms.2
Motor cortical stimulation is normally performed extradurally, making this a minimally invasive technique with no reported mortality and no long-term disabling morbidity.5 One should not be put off by the seizure observed in 1 of the patients in the study by Kleiner-Fisman and colleagues; seizures can occur in the preliminary stages of parameters assessment and do not foreshadow the onset of a long-term epileptic syndrome. The subdural technique used by the authors can be safely skipped in favor of an extradural approach.
These authors make the interesting observation that high-frequency stimulation does not relieve MSA symptoms, although 3 of their patients reported subjective improvement. In PD, high-frequency stimulation in the range used in DBS does not achieve sustained benefit and may even worsen the clinical picture. Motor cortical stimulation for movement disorders should use low frequencies.2 Our patient with MSA also experienced partial and transitory improvement with low-frequency stimulation. We speculate that motor cortical stimulation entrains a particular oscillatory pattern in the motor cortex, in line with the theory of Kleiner-Fisman and colleagues.
The short pulse width used by the authors targets the cortex. Perhaps a longer one, such as the one used in our case, could achieve better results, albeit transitorily, by modulating both cortical and subcortical structures. These authors tried monopolar stimulation in 1 case. It appears that bipolar and not monopolar stimulation is indicated in the setting of extradural motor cortical stimulation.
Kleiner-Fisman et al1 should be commended for their excellent article. In a recent editorial, Lang6 highlighted the invasiveness of DBS, with its attendant mortality and morbidity, for which many patients are not good candidates; moreover, it is clear that DBS does not stop PD progression. If motor cortical stimulation is confirmed to achieve the same benefit as DBS for movement disorders, it will considerably increase the number of candidates, with no mortality or disabling morbidity.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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