Combined Unilateral Subthalamic Nucleus and Contralateral Globus Pallidus Interna Deep Brain Stimulation for Treatment of Parkinson Disease: A Pilot Study of Symptom-Tailored Stimulation

Abstract BACKGROUND Subthalamic nucleus (STN) and globus pallidus interna (GPi) are the most effective targets in deep brain stimulation (DBS) treatment for Parkinson disease (PD). However, the individualized selection of targets remains a clinical challenge. OBJECTIVE To combine unilateral STN and contralateral GPi stimulation (STN DBS in one brain hemisphere and GPi DBS in the other) to maximize the clinical advantages of each target while inducing fewer adverse side effects in selected patients with PD because each target has its own clinical effects and risk profiles. METHODS We reviewed the clinical outcomes of 8 patients with idiopathic PD treated with combined unilateral STN and contralateral GPi DBS. Clinical outcome assessments, focusing on motor and nonmotor symptoms, were performed at baseline and 6-mo and 12-mo follow-up. We performed the assessments under the following conditions: medication on and off (bilateral stimulation on and off and unilateral STN stimulation on). RESULTS Patients showed a significant improvement in motor symptoms, as assessed by the Unified Parkinson Disease Rating Scale III (UPDRS-III) and Timed Up-and-Go Test (TUG), in the off-medication/on-stimulation state at 6-mo and 12-mo follow-up. Also, patients reported a better quality of life, and their intake of levodopa was reduced at 12-mo follow-up. In the on-medication condition, bilateral stimulation was associated with an improvement in axial symptoms, with a 64% improvement in measures of gait and falls at 12-mo follow-up. No irreversible adverse side effects were observed. CONCLUSION Our findings suggest that combined unilateral STN and contralateral GPi DBS could offer an effective and well-tolerated DBS treatment for certain PD patients.

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Globus Pallidus Interna or Subthalamic Nucleus Deep Brain Stimulation for Parkinson Disease

JAMA Neurology ◽

10.1001/jamaneurol.2017.4321 ◽

2018 ◽

Vol 75 (3) ◽

pp. 367 ◽

Cited By ~ 44

Author(s):

Adolfo Ramirez-Zamora ◽

Jill L. Ostrem

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Globus Pallidus ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Deep Brain

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Comparison of Subthalamic Nucleus and Globus Pallidus Internus Deep Brain Stimulation Surgery on Parkinson Disease–Related Pain

World Neurosurgery ◽

10.1016/j.wneu.2019.11.026 ◽

2020 ◽

Vol 135 ◽

pp. e94-e99

Author(s):

Shun Gong ◽

Menting Xu ◽

Yingqun Tao ◽

Hai Jin ◽

Yang Liu ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Globus Pallidus ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Globus Pallidus Internus ◽

Deep Brain Stimulation Surgery ◽

Deep Brain

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Effects of deep brain stimulation in the subthalamic nucleus or globus pallidus internus on step initiation in Parkinson disease

Journal of Neurosurgery ◽

10.3171/2012.8.jns112006 ◽

2012 ◽

Vol 117 (6) ◽

pp. 1141-1149 ◽

Cited By ~ 49

Author(s):

Laura Rocchi ◽

Patricia Carlson-Kuhta ◽

Lorenzo Chiari ◽

Kim J. Burchiel ◽

Penelope Hogarth ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Globus Pallidus ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Step Length ◽

Globus Pallidus Internus ◽

Step Initiation ◽

Healthy Control ◽

Deep Brain

Object Difficulty with step initiation, called “start hesitation,” is related to gait bradykinesia and is an early hallmark of gait freezing in Parkinson disease (PD). Authors of this study investigated the effects of deep brain stimulation (DBS) and levodopa on step initiation before and 6 months after DBS surgery in 29 patients with PD who were randomized to either the bilateral subthalamic nucleus (STN) or globus pallidus internus (GPi) as the DBS site. Methods The authors measured the amplitude and duration of anticipatory postural adjustments (APAs), the feed-forward postural preparation that precedes the onset of voluntary step initiation, based on center-of-pressure displacements on a force plate. They also measured the length and velocity of the first step using a motion analysis system to study kinematics. Some of the patients (22) were from a large, multicenter, double-blind clinical trial, and all patients in the study (29, PD-DBS group) were randomized to DBS in either the bilateral STN (15 patients) or bilateral GPi (14 patients). Differences in step initiation were investigated in 2 conditions before surgery (off/on levodopa) and in 4 conditions after surgery (off/on levodopa combined with off/on DBS). Twenty-eight elderly healthy control volunteers (CTRL group) were also tested, and 9 control volunteers with PD who met the criteria for DBS (PD-C group) were tested at baseline and 6 months later. Results Patients in the PD-DBS group had smaller amplitudes and longer durations of APAs compared with those in the 28 healthy control volunteers in all conditions. Before surgery, APAs improved with levodopa. After surgery, the APAs were significantly worse than in the best-treatment state before surgery (DOPA condition), and responsiveness to levodopa decreased. No differences in APAs were detected between the STN and GPi groups. A comparison with PD control volunteers who did not undergo DBS surgery confirmed that a deterioration in step preparation was not related to disease progression. Step length and velocity were smaller in the PD-DBS group than in controls in all conditions. Before surgery, levodopa improved the length and velocity of the first step. Both step length and velocity were unchanged in the best-treatment state before surgery (DOPA condition) as compared with after surgery (DBS+DOPA), with only step velocity in the STN group getting worse after surgery. Conclusions Six months of DBS in the STN or GPi impaired anticipatory postural preparation for step initiation, the opposite effect as with levodopa. Deep brain stimulation disrupted postural preparation more than step execution, suggesting independent motor pathways for preparation and execution of gait. Although turning the stimulators on after surgery combined with levodopa benefited the postural preparation to step, a comparison of pre- and postsurgery conditions suggests that either the surgery itself or 6 months of continuous stimulation may lead to an alteration of circuits or plastic changes that impair step initiation.

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Deep Brain Stimulation Targeting the Ventral Intermediate Nucleus of the Thalamus for Parkinsonian Tremor and Later Adding the Globus Pallidus Interna for Parkinson Disease Features

Deep Brain Stimulation ◽

10.1093/med/9780190647209.003.0033 ◽

2020 ◽

pp. 161-168

Author(s):

Qiang Zhang ◽

Teri R. Thomsen

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Essential Tremor ◽

Globus Pallidus ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Parkinsonian Tremor ◽

Idiopathic Parkinson Disease ◽

Ventral Intermediate Nucleus ◽

Deep Brain

Deep brain stimulation (DBS) targeting the ventral intermediate (Vim) nucleus of thalamus has been established as an effective therapy for patients with debilitating essential tremor. However, some patients initially diagnosed with essential tremor (ET) later develop idiopathic Parkinson disease (PD), and Vim DBS is not as effective for other PD-related symptoms, including bradykinesia, rigidity, and dyskinesia. This chapter describes a patient with PD who initially presented with debilitating right-dominant tremor that was misdiagnosed as ET. He received bilateral Vim DBS with good tremor control. Two years later, he received bilateral globus pallidus internus (GPi) DBS for progression of his PD, and he has been reporting adequate relief of his PD symptoms. For patients with debilitating tremor, but relatively mild or no parkinsonian symptoms on presentation, after medical trials have been administered, a Vim DBS is a reasonable option for tremor relief. A second DBS placement targeting the GPi or subthalamic nucleus (STN) may be considered if more parkinsonian symptoms evolve and progress.

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Comparison of Globus Pallidus Interna and Subthalamic Nucleus in Deep Brain Stimulation for Parkinson Disease: An Institutional Experience and Review

Parkinson s Disease ◽

10.1155/2017/3410820 ◽

2017 ◽

Vol 2017 ◽

pp. 1-15 ◽

Cited By ~ 5

Author(s):

Shazia Mirza ◽

Umar Yazdani ◽

Richard Dewey III ◽

Neepa Patel ◽

Richard B. Dewey ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Globus Pallidus ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Medical Center ◽

Scientific Evidence ◽

Full Potential ◽

Ongoing Research ◽

Deep Brain

Deep Brain Stimulation (DBS) has revolutionized the lives of patients of Parkinson disease, offering therapeutic options to those not benefiting entirely from medications alone. With its proven track record of outperforming the best medical management, the goal is to unlock the full potential of this therapy. Currently, the Globus Pallidus Interna (GPi) and Subthalamic Nucleus (STN) are both viable targets for DBS, and the choice of site should focus on the constellation of symptoms, both motor and nonmotor, which are key determinants to quality of life. Our article sheds light on the specific advantages and drawbacks of the two sites, highlighting the need for matching the inherent properties of a target with specific desired effects in patients. UT Southwestern Medical Center has a robust and constantly evolving DBS program and the narrative from our center provides invaluable insight into the practical realities of DBS. The ultimate decision in selecting a DBS target is complex, ideally made by a multidisciplinary team, tailored towards each patient’s profile and their expectations, by drawing upon scientific evidence coupled with experience. Ongoing research is expanding our knowledge base, which should be dynamically incorporated into an institute’s DBS paradigm to ensure that patients receive the optimal therapy.

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Effect of deep brain stimulation of the subthalamic nucleus upon the contralateral subthalamic nucleus in Parkinson disease

Neuroscience Letters ◽

10.1016/j.neulet.2009.07.040 ◽

2009 ◽

Vol 463 (1) ◽

pp. 12-16 ◽

Cited By ~ 22

Author(s):

Peter Novak ◽

Joshua A. Klemp ◽

Larry W. Ridings ◽

Kelly E. Lyons ◽

Rajesh Pahwa ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Deep Brain ◽

Stimulation Of

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Bilateral stimulation of the subthalamic nucleus in patients with Parkinson disease: a study of efficacy and safety

Journal of Neurosurgery ◽

10.3171/jns.2002.96.4.0666 ◽

2002 ◽

Vol 96 (4) ◽

pp. 666-672 ◽

Cited By ~ 99

Author(s):

Tanya Simuni ◽

Jurg L. Jaggi ◽

Heather Mulholland ◽

Howard I. Hurtig ◽

Amy Colcher ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Bilateral Stimulation ◽

Content Type ◽

Preoperative Status ◽

Fine Print ◽

Deep Brain ◽

Stimulation Of

Object. Palliative neurosurgery has reemerged as a valid therapy for patients with advanced Parkinson disease (PD) that is complicated by severe motor fluctuations. Despite great enthusiasm for long-term deep brain stimulation (DBS) of the subthalamic nucleus (STN), existing reports on this treatment are limited. The present study was designed to investigate the safety and efficacy of bilateral stimulation of the STN for the treatment of PD. Methods. In 12 patients with severe PD, electrodes were stereotactically implanted into the STN with the assistance of electrophysiological conformation of the target location. All patients were evaluated preoperatively during both medication-off and -on conditions, as well as postoperatively at 3, 6, and 12 months during medication-on and -off states and stimulation-on and -off conditions. Tests included assessments based on the Unified Parkinson's Disease Rating Scale (UPDRS) and timed motor tests. The stimulation effect was significant in patients who were in the medication-off state, resulting in a 47% improvement in the UPDRS Part III (Motor Examination) score at 12 months, compared with preoperative status. The benefit was stable for the duration of the follow-up period. Stimulation produced no additional benefit during the medication-on state, however, when compared with patient preoperative status. Significant improvements were made in reducing dyskinesias, fluctuations, and duration of off periods. Conclusions. This study demonstrates that DBS of the STN is an effective treatment for patients with advanced, medication-refractory PD. Deep brain stimulation of the STN produced robust improvements in motor performance in these severely disabled patients while they were in the medication-off state. Serious adverse events were common in this cohort; however, only two patients suffered permanent sequelae.

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