Deep brain stimulation for Parkinson's disease dissociates mood and motor circuits: A functional MRI case study
Identifieur interne : 000964 ( PascalFrancis/Checkpoint ); précédent : 000963; suivant : 000965Deep brain stimulation for Parkinson's disease dissociates mood and motor circuits: A functional MRI case study
Auteurs : Taresa Stefurak [Canada] ; David Mikulis [Canada] ; Helen Mayberg [Canada] ; Anthony E. Lang [Canada] ; Stephanie Hevenor [Canada] ; Peter Pahapill [États-Unis] ; Jean Saint-Cyr [Canada] ; Andres Lozano [Canada]Source :
- Movement disorders [ 0885-3185 ] ; 2003.
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Abstract
Behavioral disturbances have been reported with subthalamic (STN) deep brain stimulation (DBS) treatment in Parkinson's disease (PD). We report correlative functional imaging (fMRI) of mood and motor responses induced by successive right and left DBS. A 36-year-old woman with medically refractory PD and a history of clinically remitted depression underwent uncomplicated implantation of bilateral STN DBS. High-frequency stimulation of the left electrode improved motor symptoms. Unexpectedly, right DBS alone elicited several reproducible episodes of acute depressive dysphoria. Structural and functional magnetic resonance imaging (fMRI) imaging was carried out with sequential individual electrode stimulation. The electrode on the left was within the inferior STN, whereas the right electrode was marginally superior and lateral to the intended STN target within the Fields of Forel/zona incerta. fMRI image analysis (Analysis of Functional Neurolmages, AFNI) contrasting OFF versus ON stimulation identified significant lateralized blood oxygen level-dependent (BOLD) signal changes with DBS (P < 0.001). Left DBS primarily showed changes in motor regions: increases in premotor and motor cortex, ventrolateral thalamus, putamen, and cerebellum as well as decreases in sensorimotor/supplementary motor cortex. Right DBS showed similar but less extensive change in motor regions. More prominent were the unique increases in superior prefrontal cortex, anterior cingulate (Brodmann's area [BA] 24), anterior thalamus, caudate, and brainstem, and marked widespread decreases in medial prefrontal cortex (BA 9/10). The mood disturbance resolved spontaneously in 4 weeks despite identical stimulation parameters. Transient depressive mood induced by subcortical DBS stimulation was correlated with changes in mesolimbic cortical structures. This case provides new evidence supporting cortical segregation of motor and nonmotor cortico-basal ganglionic systems that may converge in close proximity at the level of the STN and the adjacent white matter tracts (Fields of Forel/zona incerta).
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i1="02"><s1>University Health Network, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ><sZ>3 aut.</sZ><sZ>4 aut.</sZ><sZ>7 aut.</sZ><sZ>8 aut.</sZ></inist:fA14><country>Canada</country><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName><orgName type="university">Université de Toronto</orgName></affiliation></author><author><name sortKey="Mikulis, David" sort="Mikulis, David" uniqKey="Mikulis D" first="David" last="Mikulis">David Mikulis</name><affiliation wicri:level="4"><inist:fA14 i1="02"><s1>University Health Network, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ><sZ>3 aut.</sZ><sZ>4 aut.</sZ><sZ>7 aut.</sZ><sZ>8 aut.</sZ></inist:fA14><country>Canada</country><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName><orgName type="university">Université de Toronto</orgName></affiliation></author><author><name sortKey="Mayberg, Helen" sort="Mayberg, Helen" uniqKey="Mayberg H" first="Helen" last="Mayberg">Helen Mayberg</name><affiliation wicri:level="4"><inist:fA14 i1="01"><s1>Rotman Research Institute, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>1 aut.</sZ><sZ>3 aut.</sZ><sZ>5 aut.</sZ></inist:fA14><country>Canada</country><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName><orgName type="university">Université de Toronto</orgName></affiliation><affiliation wicri:level="4"><inist:fA14 i1="02"><s1>University Health Network, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ><sZ>3 aut.</sZ><sZ>4 aut.</sZ><sZ>7 aut.</sZ><sZ>8 aut.</sZ></inist:fA14><country>Canada</country><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName><orgName type="university">Université de Toronto</orgName></affiliation></author><author><name sortKey="Lang, Anthony E" sort="Lang, Anthony E" uniqKey="Lang A" first="Anthony E." last="Lang">Anthony E. Lang</name><affiliation wicri:level="4"><inist:fA14 i1="02"><s1>University Health Network, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ><sZ>3 aut.</sZ><sZ>4 aut.</sZ><sZ>7 aut.</sZ><sZ>8 aut.</sZ></inist:fA14><country>Canada</country><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName><orgName type="university">Université de Toronto</orgName></affiliation></author><author><name sortKey="Hevenor, Stephanie" sort="Hevenor, Stephanie" uniqKey="Hevenor S" first="Stephanie" last="Hevenor">Stephanie Hevenor</name><affiliation wicri:level="4"><inist:fA14 i1="01"><s1>Rotman Research Institute, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>1 aut.</sZ><sZ>3 aut.</sZ><sZ>5 aut.</sZ></inist:fA14><country>Canada</country><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName><orgName type="university">Université de Toronto</orgName></affiliation></author><author><name sortKey="Pahapill, Peter" sort="Pahapill, Peter" uniqKey="Pahapill P" first="Peter" last="Pahapill">Peter Pahapill</name><affiliation wicri:level="2"><inist:fA14 i1="03"><s1>Pennsylvania Neurosurgery and Neurosciences Institute</s1><s2>Harrisburg, Pennsylvania</s2><s3>USA</s3><sZ>6 aut.</sZ></inist:fA14><country>États-Unis</country><placeName><region type="state">Pennsylvanie</region></placeName></affiliation></author><author><name sortKey="Saint Cyr, Jean" sort="Saint Cyr, Jean" uniqKey="Saint Cyr J" first="Jean" last="Saint-Cyr">Jean Saint-Cyr</name><affiliation wicri:level="4"><inist:fA14 i1="02"><s1>University Health Network, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ><sZ>3 aut.</sZ><sZ>4 aut.</sZ><sZ>7 aut.</sZ><sZ>8 aut.</sZ></inist:fA14><country>Canada</country><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName><orgName type="university">Université de Toronto</orgName></affiliation></author><author><name sortKey="Lozano, Andres" sort="Lozano, Andres" uniqKey="Lozano A" first="Andres" last="Lozano">Andres Lozano</name><affiliation wicri:level="4"><inist:fA14 i1="02"><s1>University Health Network, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ><sZ>3 aut.</sZ><sZ>4 aut.</sZ><sZ>7 aut.</sZ><sZ>8 aut.</sZ></inist:fA14><country>Canada</country><placeName><settlement type="city">Toronto</settlement><region type="state">Ontario</region></placeName><orgName type="university">Université de Toronto</orgName></affiliation></author></analytic><series><title level="j" type="main">Movement disorders</title><title level="j" type="abbreviated">Mov. disord.</title><idno type="ISSN">0885-3185</idno><imprint><date when="2003">2003</date></imprint></series></biblStruct></sourceDesc><seriesStmt><title level="j" type="main">Movement disorders</title><title level="j" type="abbreviated">Mov. disord.</title><idno type="ISSN">0885-3185</idno></seriesStmt></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Adult</term><term>Case study</term><term>Complication</term><term>Depression</term><term>Electrical stimulus</term><term>Electrodes</term><term>Female</term><term>Instrumentation therapy</term><term>Localization</term><term>Nuclear magnetic resonance imaging</term><term>Parkinson disease</term><term>Subthalamic nucleus</term></keywords><keywords scheme="Pascal" xml:lang="fr"><term>Parkinson maladie</term><term>Imagerie RMN</term><term>Stimulus électrique</term><term>Noyau sousthalamique</term><term>Etat dépressif</term><term>Localisation</term><term>Electrode</term><term>Etude cas</term><term>Complication</term><term>Traitement instrumental</term><term>Adulte</term><term>Femelle</term><term>Dysphorie</term></keywords><keywords scheme="Wicri" type="topic" xml:lang="fr"><term>Adulte</term></keywords></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Behavioral disturbances have been reported with subthalamic (STN) deep brain stimulation (DBS) treatment in Parkinson's disease (PD). We report correlative functional imaging (fMRI) of mood and motor responses induced by successive right and left DBS. A 36-year-old woman with medically refractory PD and a history of clinically remitted depression underwent uncomplicated implantation of bilateral STN DBS. High-frequency stimulation of the left electrode improved motor symptoms. Unexpectedly, right DBS alone elicited several reproducible episodes of acute depressive dysphoria. Structural and functional magnetic resonance imaging (fMRI) imaging was carried out with sequential individual electrode stimulation. The electrode on the left was within the inferior STN, whereas the right electrode was marginally superior and lateral to the intended STN target within the Fields of Forel/zona incerta. fMRI image analysis (Analysis of Functional Neurolmages, AFNI) contrasting OFF versus ON stimulation identified significant lateralized blood oxygen level-dependent (BOLD) signal changes with DBS (P < 0.001). Left DBS primarily showed changes in motor regions: increases in premotor and motor cortex, ventrolateral thalamus, putamen, and cerebellum as well as decreases in sensorimotor/supplementary motor cortex. Right DBS showed similar but less extensive change in motor regions. More prominent were the unique increases in superior prefrontal cortex, anterior cingulate (Brodmann's area [BA] 24), anterior thalamus, caudate, and brainstem, and marked widespread decreases in medial prefrontal cortex (BA 9/10). The mood disturbance resolved spontaneously in 4 weeks despite identical stimulation parameters. Transient depressive mood induced by subcortical DBS stimulation was correlated with changes in mesolimbic cortical structures. This case provides new evidence supporting cortical segregation of motor and nonmotor cortico-basal ganglionic systems that may converge in close proximity at the level of the STN and the adjacent white matter tracts (Fields of Forel/zona incerta).</div></front></TEI><inist><standard h6="B"><pA><fA01 i1="01" i2="1"><s0>0885-3185</s0></fA01><fA03 i2="1"><s0>Mov. disord.</s0></fA03><fA05><s2>18</s2></fA05><fA06><s2>12</s2></fA06><fA08 i1="01" i2="1" l="ENG"><s1>Deep brain stimulation for Parkinson's disease dissociates mood and motor circuits: A functional MRI case study</s1></fA08><fA11 i1="01" i2="1"><s1>STEFURAK (Taresa)</s1></fA11><fA11 i1="02" i2="1"><s1>MIKULIS (David)</s1></fA11><fA11 i1="03" i2="1"><s1>MAYBERG (Helen)</s1></fA11><fA11 i1="04" i2="1"><s1>LANG (Anthony E.)</s1></fA11><fA11 i1="05" i2="1"><s1>HEVENOR (Stephanie)</s1></fA11><fA11 i1="06" i2="1"><s1>PAHAPILL (Peter)</s1></fA11><fA11 i1="07" i2="1"><s1>SAINT-CYR (Jean)</s1></fA11><fA11 i1="08" i2="1"><s1>LOZANO (Andres)</s1></fA11><fA14 i1="01"><s1>Rotman Research Institute, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>1 aut.</sZ><sZ>3 aut.</sZ><sZ>5 aut.</sZ></fA14><fA14 i1="02"><s1>University Health Network, University of Toronto</s1><s2>Toronto, Ontario</s2><s3>CAN</s3><sZ>1 aut.</sZ><sZ>2 aut.</sZ><sZ>3 aut.</sZ><sZ>4 aut.</sZ><sZ>7 aut.</sZ><sZ>8 aut.</sZ></fA14><fA14 i1="03"><s1>Pennsylvania Neurosurgery and Neurosciences Institute</s1><s2>Harrisburg, Pennsylvania</s2><s3>USA</s3><sZ>6 aut.</sZ></fA14><fA20><s1>1508-1516</s1></fA20><fA21><s1>2003</s1></fA21><fA23 i1="01"><s0>ENG</s0></fA23><fA43 i1="01"><s1>INIST</s1><s2>20953</s2><s5>354000119059740120</s5></fA43><fA44><s0>0000</s0><s1>© 2004 INIST-CNRS. All rights reserved.</s1></fA44><fA45><s0>93 ref.</s0></fA45><fA47 i1="01" i2="1"><s0>04-0130382</s0></fA47><fA60><s1>P</s1><s3>CC</s3></fA60><fA61><s0>A</s0></fA61><fA64 i1="01" i2="1"><s0>Movement disorders</s0></fA64><fA66 i1="01"><s0>USA</s0></fA66><fC01 i1="01" l="ENG"><s0>Behavioral disturbances have been reported with subthalamic (STN) deep brain stimulation (DBS) treatment in Parkinson's disease (PD). We report correlative functional imaging (fMRI) of mood and motor responses induced by successive right and left DBS. A 36-year-old woman with medically refractory PD and a history of clinically remitted depression underwent uncomplicated implantation of bilateral STN DBS. High-frequency stimulation of the left electrode improved motor symptoms. Unexpectedly, right DBS alone elicited several reproducible episodes of acute depressive dysphoria. Structural and functional magnetic resonance imaging (fMRI) imaging was carried out with sequential individual electrode stimulation. The electrode on the left was within the inferior STN, whereas the right electrode was marginally superior and lateral to the intended STN target within the Fields of Forel/zona incerta. fMRI image analysis (Analysis of Functional Neurolmages, AFNI) contrasting OFF versus ON stimulation identified significant lateralized blood oxygen level-dependent (BOLD) signal changes with DBS (P < 0.001). Left DBS primarily showed changes in motor regions: increases in premotor and motor cortex, ventrolateral thalamus, putamen, and cerebellum as well as decreases in sensorimotor/supplementary motor cortex. Right DBS showed similar but less extensive change in motor regions. More prominent were the unique increases in superior prefrontal cortex, anterior cingulate (Brodmann's area [BA] 24), anterior thalamus, caudate, and brainstem, and marked widespread decreases in medial prefrontal cortex (BA 9/10). The mood disturbance resolved spontaneously in 4 weeks despite identical stimulation parameters. Transient depressive mood induced by subcortical DBS stimulation was correlated with changes in mesolimbic cortical structures. This case provides new evidence supporting cortical segregation of motor and nonmotor cortico-basal ganglionic systems that may converge in close proximity at the level of the STN and the adjacent white matter tracts (Fields of Forel/zona incerta).</s0></fC01><fC02 i1="01" i2="X"><s0>002B26I</s0></fC02><fC03 i1="01" i2="X" l="FRE"><s0>Parkinson maladie</s0><s5>01</s5></fC03><fC03 i1="01" i2="X" l="ENG"><s0>Parkinson disease</s0><s5>01</s5></fC03><fC03 i1="01" i2="X" l="SPA"><s0>Parkinson enfermedad</s0><s5>01</s5></fC03><fC03 i1="02" i2="X" l="FRE"><s0>Imagerie RMN</s0><s5>04</s5></fC03><fC03 i1="02" i2="X" l="ENG"><s0>Nuclear magnetic resonance imaging</s0><s5>04</s5></fC03><fC03 i1="02" i2="X" l="SPA"><s0>Imaginería RMN</s0><s5>04</s5></fC03><fC03 i1="03" i2="X" l="FRE"><s0>Stimulus électrique</s0><s5>07</s5></fC03><fC03 i1="03" i2="X" l="ENG"><s0>Electrical stimulus</s0><s5>07</s5></fC03><fC03 i1="03" i2="X" l="SPA"><s0>Estímulo eléctrico</s0><s5>07</s5></fC03><fC03 i1="04" i2="X" l="FRE"><s0>Noyau sousthalamique</s0><s5>08</s5></fC03><fC03 i1="04" i2="X" l="ENG"><s0>Subthalamic nucleus</s0><s5>08</s5></fC03><fC03 i1="04" i2="X" l="SPA"><s0>Núcleo subtalámico</s0><s5>08</s5></fC03><fC03 i1="05" i2="X" l="FRE"><s0>Etat dépressif</s0><s5>10</s5></fC03><fC03 i1="05" i2="X" l="ENG"><s0>Depression</s0><s5>10</s5></fC03><fC03 i1="05" i2="X" l="SPA"><s0>Estado depresivo</s0><s5>10</s5></fC03><fC03 i1="06" i2="X" l="FRE"><s0>Localisation</s0><s5>13</s5></fC03><fC03 i1="06" i2="X" l="ENG"><s0>Localization</s0><s5>13</s5></fC03><fC03 i1="06" i2="X" l="SPA"><s0>Localización</s0><s5>13</s5></fC03><fC03 i1="07" i2="X" l="FRE"><s0>Electrode</s0><s5>14</s5></fC03><fC03 i1="07" i2="X" l="ENG"><s0>Electrodes</s0><s5>14</s5></fC03><fC03 i1="07" i2="X" l="SPA"><s0>Electrodo</s0><s5>14</s5></fC03><fC03 i1="08" i2="X" l="FRE"><s0>Etude cas</s0><s5>17</s5></fC03><fC03 i1="08" i2="X" l="ENG"><s0>Case study</s0><s5>17</s5></fC03><fC03 i1="08" i2="X" l="SPA"><s0>Estudio caso</s0><s5>17</s5></fC03><fC03 i1="09" i2="X" l="FRE"><s0>Complication</s0><s5>18</s5></fC03><fC03 i1="09" i2="X" l="ENG"><s0>Complication</s0><s5>18</s5></fC03><fC03 i1="09" i2="X" l="SPA"><s0>Complicación</s0><s5>18</s5></fC03><fC03 i1="10" i2="X" l="FRE"><s0>Traitement instrumental</s0><s5>19</s5></fC03><fC03 i1="10" i2="X" l="ENG"><s0>Instrumentation therapy</s0><s5>19</s5></fC03><fC03 i1="10" i2="X" l="SPA"><s0>Tratamiento instrumental</s0><s5>19</s5></fC03><fC03 i1="11" i2="X" l="FRE"><s0>Adulte</s0><s5>20</s5></fC03><fC03 i1="11" i2="X" l="ENG"><s0>Adult</s0><s5>20</s5></fC03><fC03 i1="11" i2="X" l="SPA"><s0>Adulto</s0><s5>20</s5></fC03><fC03 i1="12" i2="X" l="FRE"><s0>Femelle</s0><s5>21</s5></fC03><fC03 i1="12" i2="X" l="ENG"><s0>Female</s0><s5>21</s5></fC03><fC03 i1="12" i2="X" l="SPA"><s0>Hembra</s0><s5>21</s5></fC03><fC03 i1="13" i2="X" l="FRE"><s0>Dysphorie</s0><s4>INC</s4><s5>86</s5></fC03><fC07 i1="01" i2="X" l="FRE"><s0>Homme</s0></fC07><fC07 i1="01" i2="X" l="ENG"><s0>Human</s0></fC07><fC07 i1="01" i2="X" l="SPA"><s0>Hombre</s0></fC07><fC07 i1="02" i2="X" l="FRE"><s0>Système nerveux pathologie</s0><s5>37</s5></fC07><fC07 i1="02" i2="X" l="ENG"><s0>Nervous system diseases</s0><s5>37</s5></fC07><fC07 i1="02" i2="X" l="SPA"><s0>Sistema nervioso patología</s0><s5>37</s5></fC07><fC07 i1="03" i2="X" l="FRE"><s0>Système nerveux central pathologie</s0><s5>38</s5></fC07><fC07 i1="03" i2="X" l="ENG"><s0>Central nervous system disease</s0><s5>38</s5></fC07><fC07 i1="03" i2="X" l="SPA"><s0>Sistema nervosio central patología</s0><s5>38</s5></fC07><fC07 i1="04" i2="X" l="FRE"><s0>Encéphale pathologie</s0><s5>39</s5></fC07><fC07 i1="04" i2="X" l="ENG"><s0>Cerebral disorder</s0><s5>39</s5></fC07><fC07 i1="04" i2="X" l="SPA"><s0>Encéfalo patología</s0><s5>39</s5></fC07><fC07 i1="05" i2="X" l="FRE"><s0>Extrapyramidal syndrome</s0><s5>40</s5></fC07><fC07 i1="05" i2="X" l="ENG"><s0>Extrapyramidal syndrome</s0><s5>40</s5></fC07><fC07 i1="05" i2="X" l="SPA"><s0>Extrapiramidal síndrome</s0><s5>40</s5></fC07><fC07 i1="06" i2="X" l="FRE"><s0>Maladie dégénérative</s0><s5>41</s5></fC07><fC07 i1="06" i2="X" l="ENG"><s0>Degenerative disease</s0><s5>41</s5></fC07><fC07 i1="06" i2="X" l="SPA"><s0>Enfermedad degenerativa</s0><s5>41</s5></fC07><fC07 i1="07" i2="X" l="FRE"><s0>Imagerie médicale</s0><s5>45</s5></fC07><fC07 i1="07" i2="X" l="ENG"><s0>Medical imagery</s0><s5>45</s5></fC07><fC07 i1="07" i2="X" l="SPA"><s0>Imaginería médica</s0><s5>45</s5></fC07><fC07 i1="08" i2="X" l="FRE"><s0>Imagerie fonctionnelle</s0><s5>46</s5></fC07><fC07 i1="08" i2="X" l="ENG"><s0>Functional imaging</s0><s5>46</s5></fC07><fC07 i1="08" i2="X" l="SPA"><s0>Imaginería funcional</s0><s5>46</s5></fC07><fC07 i1="09" i2="X" l="FRE"><s0>Stimulation instrumentale</s0><s5>53</s5></fC07><fC07 i1="09" i2="X" l="ENG"><s0>Instrumental stimulation</s0><s5>53</s5></fC07><fC07 i1="09" i2="X" l="SPA"><s0>Estimulación instrumental</s0><s5>53</s5></fC07><fC07 i1="10" i2="X" l="FRE"><s0>Trouble humeur</s0><s5>61</s5></fC07><fC07 i1="10" i2="X" l="ENG"><s0>Mood disorder</s0><s5>61</s5></fC07><fC07 i1="10" i2="X" l="SPA"><s0>Trastorno humor</s0><s5>61</s5></fC07><fN21><s1>082</s1></fN21><fN82><s1>PSI</s1></fN82></pA></standard></inist><affiliations><list><country><li>Canada</li><li>États-Unis</li></country><region><li>Ontario</li><li>Pennsylvanie</li></region><settlement><li>Toronto</li></settlement><orgName><li>Université de Toronto</li></orgName></list><tree><country name="Canada"><region name="Ontario"><name sortKey="Stefurak, Taresa" sort="Stefurak, Taresa" uniqKey="Stefurak T" first="Taresa" last="Stefurak">Taresa Stefurak</name></region><name sortKey="Hevenor, Stephanie" sort="Hevenor, Stephanie" uniqKey="Hevenor S" first="Stephanie" last="Hevenor">Stephanie Hevenor</name><name sortKey="Lang, Anthony E" sort="Lang, Anthony E" uniqKey="Lang A" first="Anthony E." last="Lang">Anthony E. Lang</name><name sortKey="Lozano, Andres" sort="Lozano, Andres" uniqKey="Lozano A" first="Andres" last="Lozano">Andres Lozano</name><name sortKey="Mayberg, Helen" sort="Mayberg, Helen" uniqKey="Mayberg H" first="Helen" last="Mayberg">Helen Mayberg</name><name sortKey="Mayberg, Helen" sort="Mayberg, Helen" uniqKey="Mayberg H" first="Helen" last="Mayberg">Helen Mayberg</name><name sortKey="Mikulis, David" sort="Mikulis, David" uniqKey="Mikulis D" first="David" last="Mikulis">David Mikulis</name><name sortKey="Saint Cyr, Jean" sort="Saint Cyr, Jean" uniqKey="Saint Cyr J" first="Jean" last="Saint-Cyr">Jean Saint-Cyr</name><name sortKey="Stefurak, Taresa" sort="Stefurak, Taresa" uniqKey="Stefurak T" first="Taresa" last="Stefurak">Taresa Stefurak</name></country><country name="États-Unis"><region name="Pennsylvanie"><name sortKey="Pahapill, Peter" sort="Pahapill, Peter" uniqKey="Pahapill P" first="Peter" last="Pahapill">Peter Pahapill</name></region></country></tree></affiliations></record>Pour manipuler ce document sous Unix (Dilib)
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