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Troubles cognitifs - DBS du noyau de Meynert, du fornix ou autre

Les troubles cognitifs restent un des troubles majeurs de la maladie de Parkinson avancée, qui participe de façon importante à la détérioration de la qualité de vie. Comme dans la maladie d’Alzheimer, une défaillance du système cholinergique dans le nucleus basalis de Meynert contribue aux troubles cognitifs dans la maladie de Parkinson. Des études préliminaires dans la maladie d’Alzheimer (Laxton et al. 2010) et dans la maladie de Parkinson (Freund et al. 2009, Barnikol et al. 2010) montrent une possible amélioration des fonctions cognitives avec une stimulation cérébrale profonde du nucleus basalis de Meynert ou du fornix. D’autres cas n’ont pas montré d’amélioration clinique, bien que l’hypométabolisme temporo-pariétal typiquement observé dans la maladie d’Alzheimer soit clairement amélioré (Turnbull et al. 1985, Fontaine et al. 2013). D’autres cibles potentielles sont le noyau antérieur du thalamus, le cortex entorhinal, et le faisceau mamillo-thalamique (Laxton & Lozano 2013, Uitti et al. 2012, Suthana et al. 2012). Une étude sur le rat montre une augmentation de la neurogenèse dans l’hippocampe avec la stimulation cérébrale profonde à haute fréquence du nucléus antérieur du thalamus (Toda et al. 2008). On ne sait pas si cela est aussi le cas chez l’homme et à ce jour la DBS pour les troubles cognitifs reste expérimentale.

6 Conclusion

La stimulation cérébrale profonde du STN et, dans une moindre mesure, du GPi dans la maladie de Parkinson est très efficace au niveau moteur. Toutefois, elle peut avoir certains effets indésirables non-moteurs et la bonne sélection des patients est primordiale. Plus de 100'000 patients ont déjà bénéficié de cette intervention et l’avenir apportera une amélioration technique des cibles déjà utilisées et la confirmation de l’utilité d’autres cibles, surtout pour les troubles non-moteurs. Il est toutefois important de rester très prudent, d’utiliser uniquement des cibles pour lesquelles il existe de bonnes bases précliniques, de faire des études bien contrôlées et validées par des comités d’éthiques, afin de ne pas reproduire les erreurs de la psychochirurgie du 20ème siècle (Valenstein 1986).

7 Remerciements

Je tiens à remercier le Professeur Pierre Pollak pour son enseignement incomparable et son enthousiasme captivant et le Docteur Julien Bally pour la précieuse collaboration en écrivant la publication.

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