The Benefit of Subthalamic Deep Brain Stimulation for Pain in Parkinson Disease: A 2-Year Follow-up Study

Abstract BACKGROUND Pain is a well-recognized feature of Parkinson disease (PD), which is primarily a motor disorder. In a previous study, we showed that subthalamic deep brain stimulation (STN DBS) improves pain as well as motor symptoms 3 months after surgery in PD patients. OBJECTIVE To determine whether there is a long-term beneficial effect of STN DBS on pain in PD. METHODS We studied 21 patients with PD who underwent STN DBS. Motor symptoms were assessed using the Unified Parkinson's Disease Rating Scale and Hoehn and Yahr staging. Pain was evaluated by asking patients about the quality and severity of pain in each body part. Evaluations were performed at baseline and at 3 and 24 months after surgery. RESULTS At baseline, 18 of the 21 patients (86%) experienced pain. After surgery, most of the pain reported at baseline had improved or disappeared at 3 months and improved further at 24 months. The benefit of STN DBS for pain evaluated at 24 months was comparable to that with medication at baseline. At 24 months, 9 patients (43%) reported new pain that was not present at baseline. Most of the new pain was musculoskeletal in quality. Despite the development of new pain, the mean pain score at follow-up was lower than at baseline. CONCLUSION STN DBS improves pain in PD, and this beneficial effect persists, being observed after a prolonged follow-up of 24 months. In addition, in many of the PD patients new, mainly musculoskeletal pain developed on longer follow-up.

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Weight Change After Subthalamic Nucleus Deep Brain Stimulation in Patients With Isolated Dystonia

Frontiers in Neurology ◽

10.3389/fneur.2021.632913 ◽

2021 ◽

Vol 12 ◽

Author(s):

Weibin He ◽

Hongxia Li ◽

Yijie Lai ◽

Yunhao Wu ◽

Yiwen Wu ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Rating Scale ◽

The Body ◽

Motor Symptoms ◽

Motor Effects ◽

Stn Dbs ◽

Deep Brain

Purpose: Deep brain stimulation of the subthalamic nucleus (STN-DBS) is an effective treatment method for advanced Parkinson's disease (PD) and isolated dystonia and provides marked improvement of major motor symptoms. In addition, non-motor effects have been reported including weight gain (WG) in patients with PD after STN-DBS. However, it is still unclear whether patients with isolated dystonia also experience WG.Methods: Data from 47 patients with isolated dystonia who underwent bilateral STN-DBS surgery between October 2012 and June 2019 were retrospectively collected. The severity of dystonia was assessed via the Burke–Fahn–Marsden Dystonia Rating Scale (BFMDRS). Changes in the body mass index (BMI) and BFMDRS score were analyzed using paired Student's t-tests. Regression analysis was performed to identify factors that affected the BMI after surgery.Results: Postoperative WG was observed in 78.7% of patients. The percentage of overweight and obese patients increased from 25.5% (before STN-DBS) to 48.9% (at the last follow-up). The mean BMI and mean percentage change in BMI increased by 1.32 ± 1.83 kg/m2 (P < 0.001) and 6.28 ± 8.34%, respectively. BMI increased more in female than in male patients. At the last follow-up, BFMDRS movement and disability scores improved by 69.76 ± 33.23% and 65.66 ± 31.41%, respectively (both P < 0.001). The final regression model analysis revealed that sex and preoperative BMI alone were independently associated with BMI change (P < 0.05).Conclusions: STN-DBS is associated with postoperative WG with patients with isolated dystonia. WG is more prominent in female patients and is associated with preoperative weight but not with the efficacy of STN-DBS on motor symptoms.

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Rescuing Suboptimal Outcomes of Subthalamic Deep Brain Stimulation in Parkinson Disease by Surgical Lead Revision

Neurosurgery ◽

10.1093/neuros/nyz018 ◽

2019 ◽

Vol 85 (2) ◽

pp. E314-E321 ◽

Cited By ~ 4

Author(s):

Robert C Nickl ◽

Martin M Reich ◽

Nicoló Gabriele Pozzi ◽

Patrick Fricke ◽

Florian Lange ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Brain Stimulation ◽

Surgical Revision ◽

Motor Symptoms ◽

Optimal Position ◽

Number Of Patients ◽

Motor Improvement ◽

Stn Dbs ◽

Deep Brain

Abstract BACKGROUND Clinical trials have established subthalamic deep-brain-stimulation (STN-DBS) as a highly effective treatment for motor symptoms of Parkinson disease (PD), but in clinical practice outcomes are variable. Experienced centers are confronted with an increasing number of patients with partially “failed” STN-DBS, in whom motor benefit doesn’t meet expectations. These patients require a complex multidisciplinary and standardized workup to identify the likely cause. OBJECTIVE To describe outcomes in a series of PD patients undergoing lead revision for suboptimal motor benefit after STN-DBS surgery and characterize selection criteria for surgical revision. METHODS We investigated 9 PD patients with STN-DBS, who had unsatisfactory outcomes despite intensive neurological management. Surgical revision was considered if the ratio of DBS vs levodopa-induced improvement of UPDRS-III (DBS-rr) was below 75% and the electrodes were found outside the dorsolateral STN. RESULTS Fifteen electrodes were replaced via stereotactic revision surgery into the dorsolateral STN without any adverse effects. Median displacement distance was 4.1 mm (range 1.6-8.42 mm). Motor symptoms significantly improved (38.2 ± 6.6 to 15.5 ± 7.9 points, P < .001); DBS-rr increased from 64% to 190%. CONCLUSION Patients with persistent OFFmotor symptoms after STN-DBS should be screened for levodopa-responsiveness, which can serve as a benchmark for best achievable motor benefit. Even small horizontal deviations of the lead from the optimal position within the dorsolateral STN can cause stimulation responses, which are markedly inferior to the levodopa response. Patients with an image confirmed lead displacement and preserved levodopa response are candidates for lead revision and can expect significant motor improvement from appropriate lead replacement.

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Acoustic Voice Modifications in Individuals with Parkinson Disease Submitted to Deep Brain Stimulation

International Archives of Otorhinolaryngology ◽

10.1055/s-0038-1675392 ◽

2019 ◽

Vol 23 (02) ◽

pp. 203-208 ◽

Cited By ~ 2

Author(s):

Aline Juliane Romann ◽

Bárbara Costa Beber ◽

Carla Aparecida Cielo ◽

Carlos Roberto de Mello Rieder

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Brain Stimulation ◽

Statistical Difference ◽

Rating Scale ◽

Acoustic Measures ◽

Disease Rating ◽

The Voice ◽

Stn Dbs ◽

Deep Brain

Introduction Subthalamic nucleus deep brain stimulation (STN-DBS) improves motor function in individuals with Parkinson disease (PD). The evidence about the effects of STN-DBS on the voice is still inconclusive. Objective To verify the effect of STN-DBS on the voice of Brazilian individuals with PD. Methods Sixteen participants were evaluated on the Unified Parkinson Disease Rating Scale—Part III, and by the measurement of the acoustic modifications in on and off conditions of stimulation. Results The motor symptoms showed significant improvement with STN-DBS on. Regarding the acoustic measures of the voice, only the maximum fundamental frequency (fhi) showed a statistical difference between on- and off-conditions, with reduction in off-condition. Conclusion Changes in computerized acoustic measures are more valuable when interpreted in conjunction with changes in other measures. The single finding in fhi suggests that DBS-STN increases vocal instability. The interpretation of this result should be done carefully, since it may not be of great value if other measures that also indicate instability are not significantly different.

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Bilateral Subthalamic Nucleus Deep Brain Stimulation in Elderly Patients With Parkinson Disease: A Case-Control Study

Operative Neurosurgery ◽

10.1093/ons/opaa049 ◽

2020 ◽

Vol 19 (3) ◽

pp. 234-240

Author(s):

Kyle T Mitchell ◽

John R Younce ◽

Scott A Norris ◽

Samer D Tabbal ◽

Joshua L Dowling ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Rating Scale ◽

Intracerebral Hemorrhages ◽

Disease Rating ◽

Equivalent Reduction ◽

Stn Dbs ◽

Deep Brain

Abstract BACKGROUND Subthalamic nucleus deep brain stimulation (STN DBS) is an effective adjunctive therapy for Parkinson disease. Studies have shown improvement of motor function but often exclude patients older than 75 yr. OBJECTIVE To determine the safety and effectiveness of STN DBS in patients 75 yr and older. METHODS A total of 104 patients (52 patients >75 yr old, 52 patients <75 yr old) with STN DBS were paired and retrospectively analyzed. The primary outcome was change in Unified Parkinson Disease Rating Scale (UPDRS) subscale III at 1 yr postoperatively, OFF medication. Secondary outcomes were changes in UPDRS I, II, and IV subscales and levodopa equivalents. Complications and all-cause mortality were assessed at 30 d and 1 yr. RESULTS Both cohorts had significant improvements in UPDRS III at 6 mo and 1 yr with no difference between cohorts. Change in UPDRS III was noninferior to the younger cohort. The cohorts had similar worsening in UPDRS I at 1 yr, no change in UPDRS II, similar improvement in UPDRS IV, and similar levodopa equivalent reduction. There were similar numbers of postoperative intracerebral hemorrhages (2/52 in each cohort, more severe in the older cohort) and surgical complications (4/52 in each cohort), and mortality in the older cohort was similar to an additional matched cohort not receiving DBS. CONCLUSION STN DBS provides substantial motor benefit and reduction in levodopa equivalents with a low rate of complications in older patients, which is also noninferior to the benefit in younger patients. STN DBS remains an effective therapy for those over 75 yr.

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Spatial Topographies of Unilateral Subthalamic Nucleus Deep Brain Stimulation Efficacy for Ipsilateral, Contralateral, Midline, and Total Parkinson Disease Motor Symptoms

Operative Neurosurgery ◽

10.1227/neu.0000000000000613 ◽

2015 ◽

Vol 11 (1) ◽

pp. 80-88

Author(s):

Mahesh B Shenai ◽

Andrew Romeo ◽

Harrison C Walker ◽

Stephanie Guthrie ◽

Ray L Watts ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Subthalamic Nucleus ◽

Brain Stimulation ◽

Rating Scale ◽

Electrode Placement ◽

Kriging Interpolation ◽

Motor Symptoms ◽

Disease Rating ◽

Deep Brain

Abstract BACKGROUND Subthalamic nucleus (STN) deep brain stimulation is a successful intervention for medically refractory Parkinson disease, although its efficacy depends on optimal electrode placement. Even though the predominant effect is observed contralaterally, modest improvements in ipsilateral and midline symptoms are also observed. OBJECTIVE To elucidate the role of contact location of unilateral deep brain stimulation on contralateral, ipsilateral, and axial subscores of Parkinson disease motor symptoms. METHODS Eighty-six patients receiving first deep brain stimulation STN electrode placements were identified, yielding 73 patients with 3-month follow-up. Total preoperative and postoperative Unified Parkinson Disease Rating Scale Part III scores were obtained and divided into contralateral, ipsilateral, and midline subscores. Contact location was determined on immediate postoperative magnetic resonance imaging. A 3-dimensional ordinary “kriging” algorithm generated spatial interpolations for total, ipsilateral, contralateral, and midline symptom categories. Interpolative reconstructions were performed in the axial planes (z = −0.5, −1.0, −1.5, −3.5, −4.5, −6.0) and a sagittal plane (x = 12.0). Interpolation error and significance were quantified by use of a cross-validation technique and quantile-quantile analysis. RESULTS There was an overall reduction in Unified Parkinson Disease Rating Scale Part III symptoms: total = 37.0 ± 24.11% (P < .05), ipsilateral = 15.9 ± 51.8%, contralateral = 56.2 ± 26.8% (P < .05), and midline = 26.5 ± 34.7%. Kriging interpolation was performed and cross-validated with quantile-quantile analysis with high correlation (R2 > 0.92) and demonstrated regions of efficacy for each symptom category. Contralateral symptoms demonstrated broad regions of efficacy across the peri-STN area. The ipsilateral and midline regions of efficacy were constrained and located along the dorsal STN and caudal zona incerta. CONCLUSION We provide evidence for a unique functional topographic window in which contralateral, ipsilateral, and midline structures may achieve the best efficacy. Although there are overlapping regions, laterality demonstrates distinct topographies. Surgical optimization should target the intersection of optimal regions for these symptom categories.

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Bilateral Subthalamic Deep Brain Stimulation in Parkinson Disease Patients With Severe Tremor

Neurosurgery ◽

10.1227/01.neu.0000374850.98949.d4 ◽

2010 ◽

Vol 67 (3) ◽

pp. 626-632 ◽

Cited By ~ 18

Author(s):

Han-Joon Kim ◽

Beom S. Jeon ◽

Sun Ha Paek ◽

Jee-Young Lee ◽

Hee Jin Kim ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Brain Stimulation ◽

Action Tremor ◽

Dopaminergic Transmission ◽

Neurochemical Change ◽

Stn Dbs ◽

Deep Brain

Abstract BACKGROUND Previous studies have shown that subthalamic nucleus (STN) deep brain stimulation (DBS) improves tremor in Parkinson disease (PD). However, the patients included in those studies were unselected for tremor severity. OBJECTIVE We specifically assessed the effect of STN DBS on tremor in selected PD patients with severe tremor. METHODS Seventy-two PD patients who had received bilateral STN DBS were included. The effects of STN DBS on the off-medication tremor, the on-medication tremor, and the off-medication action tremor in patients selected as the worst one-third in each category at baseline were evaluated after a mean duration of > 2 years. RESULTS In patients with severe off-medication tremor, off-medication tremor score improved from 12.28 ± 2.80 at baseline to 1.93 ± 2.85 at the last follow-up (P < .001). The off-medication tremor in the off-stimulation state at the last follow-up was less severe than the preoperative off-medication tremor. In patients with severe on-medication tremor, on-medication tremor score improved from 6.17 ± 2.45 to 1.35 ± 2.58 (P < .001). In patients with severe off-medication action tremor, off-medication action tremor score improved from 5.08 ± 1.35 to 1.24 ± 1.42 (P < .001). CONCLUSION STN DBS is effective for severe off- and on-medication tremor and off-medication action tremor in PD. Our findings suggest that STN DBS reduces PD tremor through, at least in part, its effect on the tremor-generating mechanism independent of dopaminergic transmission and that long-term electrical stimulation of STN might induce a structural or neurochemical change leading to the improvement of tremor.

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Clinical profiles and outcomes of deep brain stimulation in G2019S LRRK2 Parkinson disease

Journal of Neurosurgery ◽

10.3171/2021.7.jns21190 ◽

2021 ◽

pp. 1-8

Author(s):

Katherine Leaver ◽

Aaron Viser ◽

Brian H. Kopell ◽

Roberto A. Ortega ◽

Joan Miravite ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Clinical Features ◽

Brain Stimulation ◽

Rating Scale ◽

Age Of Onset ◽

Disease Onset ◽

Hand Tremor ◽

Stn Dbs ◽

Deep Brain

OBJECTIVE The objective of this study was to evaluate clinical features and response to deep brain stimulation (DBS) in G2019S LRRK2-Parkinson disease (LRRK2-PD) and idiopathic PD (IPD). METHODS The authors conducted a clinic-based cohort study of PD patients recruited from the Mount Sinai Beth Israel Genetics database of PD studies. The cohort included 87 participants with LRRK2-PD (13 who underwent DBS) and 14 DBS participants with IPD enrolled between 2009 and 2017. The baseline clinical features, including motor ratings and levodopa-equivalent daily dose (LEDD), were compared among LRRK2-PD patients with and without DBS, between LRRK2-PD with DBS and IPD with DBS, and between LRRK2-PD with subthalamic nucleus (STN) and internal segment of the globus pallidus (GPi) DBS. Longitudinal motor scores (Unified Parkinson’s Disease Rating Scale–part III) and medication usage were also assessed pre- and postoperatively. RESULTS Compared to LRRK2-PD without DBS (n = 74), the LRRK2-PD with DBS cohort (n = 13) had a significantly younger age of onset, longer disease duration, were more likely to have dyskinesia, and were less likely to experience hand tremor at disease onset. LRRK2-PD participants were also more likely to be referred for surgery because of severe dyskinesia (11/13 [85%] vs 6/14 [43%], p = 0.04) and were less likely to be referred for medically refractory tremor (0/13 [0%] vs 6/14 [43%], p = 0.02) than were IPD patients. Among LRRK2-PD patients, both STN-DBS and GPi-DBS targets were effective, although the sample size was small for both groups. There were no revisions or adverse effects reported in the GPi-DBS group, while 2 of the LRRK2-PD participants who underwent STN-DBS required revisions and a third reported depression as a stimulation-related side effect. Medication reduction favored the STN group. CONCLUSIONS The LRRK2-PD cohort referred for DBS had a slightly different profile, including earlier age of onset and dyskinesia. Both the STN and GPi DBS targets were effective in symptom suppression. Patients with G2019S LRRK2 PD were well-suited for DBS therapy and had favorable motor outcomes regardless of the DBS target. LRRK2-DBS patients had longer disease durations and tended to have more dyskinesia. Dyskinesia commonly served as the trigger for DBS surgical candidacy. Medication-refractory tremor was not a common indication for surgery in the LRRK2 cohort.

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Thalamic deep brain stimulation for tremor in Parkinson disease, essential tremor, and dystonia

Neurology ◽

10.1212/wnl.0000000000004295 ◽

2017 ◽

Vol 89 (13) ◽

pp. 1416-1423 ◽

Cited By ~ 79

Author(s):

Rubens Gisbert Cury ◽

Valerie Fraix ◽

Anna Castrioto ◽

Maricely Ambar Pérez Fernández ◽

Paul Krack ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Essential Tremor ◽

Brain Stimulation ◽

Rating Scale ◽

Dystonic Tremor ◽

Over Time ◽

Deep Brain

Objective:To report on the long-term outcomes of deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (VIM) in Parkinson disease (PD), essential tremor (ET), and dystonic tremor.Methods:One hundred fifty-nine patients with PD, ET, and dystonia underwent VIM DBS due to refractory tremor at the Grenoble University Hospital. The primary outcome was a change in the tremor scores at 1 year after surgery and at the latest follow-up (21 years). Secondary outcomes included the relationship between tremor score reduction over time and the active contact position. Tremor scores (Unified Parkinson's Disease Rating Scale-III, items 20 and 21; Fahn, Tolosa, Marin Tremor Rating Scale) and the coordinates of the active contacts were recorded.Results:Ninety-eight patients were included. Patients with PD and ET had sustained improvement in tremor with VIM stimulation (mean improvement, 70% and 66% at 1 year; 63% and 48% beyond 10 years, respectively; p < 0.05). There was no significant loss of stimulation benefit over time (p > 0.05). Patients with dystonia exhibited a moderate response at 1-year follow-up (41% tremor improvement, p = 0.027), which was not sustained after 5 years (30% improvement, p = 0.109). The more dorsal active contacts' coordinates in the right lead were related to a better outcome 1 year after surgery (p = 0.029). During the whole follow-up, forty-eight patients (49%) experienced minor side effects, whereas 2 (2.0%) had serious events (brain hemorrhage and infection).Conclusions:VIM DBS is an effective long-term (beyond 10 years) treatment for tremor in PD and ET. Effects on dystonic tremor were modest and transient.Classification of evidence:This provides Class IV evidence. It is an observational study.

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Effect of unilateral subthalamic deep brain stimulation in highly asymmetrical Parkinson’s disease: 7-year follow-up

Journal of Neurosurgery ◽

10.3171/2018.5.jns172006 ◽

2019 ◽

Vol 131 (5) ◽

pp. 1508-1513

Author(s):

Gwanhee Ehm ◽

Han-Joon Kim ◽

Ji-Young Kim ◽

Jee-Young Lee ◽

Hee Jin Kim ◽

...

Keyword(s):

Parkinson’S Disease ◽

Parkinson's Disease ◽

Deep Brain Stimulation ◽

Brain Stimulation ◽

Rating Scale ◽

Initial Surgery ◽

Second Surgery ◽

Stn Dbs ◽

Deep Brain

OBJECTIVEFor patients with highly asymmetrical Parkinson’s disease (PD), unilateral subthalamic nucleus (STN) deep brain stimulation (DBS) has been suggested as a reasonable treatment. However, the results of a previous 2-year follow-up study involving patients with prominently asymmetrical PD who had unilateral STN DBS suggested that simultaneous bilateral surgery should be performed. In the present study, the authors analyze 7-year follow-up data from the same patient group to examine changes in motor benefit from unilateral STN DBS over time and the interval between initial unilateral surgery and a second (contralateral) STN DBS surgery.METHODSEight patients with highly asymmetrical parkinsonism who underwent unilateral STN DBS were evaluated. The factors measured were scores on the motor part of the Unified Parkinson’s Disease Rating Scale (UPDRS III), Hoehn and Yahr (HY) stage, and levodopa equivalent daily dose (LEDD). Evaluations occurred at 3, 6, and 12 months after the initial surgery and annually thereafter.RESULTSThe mean follow-up period was 91.5 months (range 36–105 months). Three years after the initial unilateral surgery, motor benefits on the contralateral side continued; however, an aggravation of the ipsilateral parkinsonism attenuated the improvement in total UPDRS III scores, which reverted to baseline. Axial motor score, LEDD, and HY stage did not differ from the baseline. Seven of 8 patients (87.5%) were considered candidates for a second surgery to offer additional motor benefits. Of the 7 candidates, 4 patients (50% of total patients) underwent the second surgery at 58.5 ± 11.6 (mean ± SD) months after the initial surgery. Three patients were not able to have the second surgery: one patient died of gastric cancer, one patient was severely immobilized by an accident, and one patient could not afford the second surgery. One patient remained content with the initial unilateral surgery throughout the follow-up period.CONCLUSIONSSeven of 8 patients with unilateral STN DBS became candidates for second surgery before battery replacement surgery of the first implanted device. Baseline asymmetry alone may not predict appropriate candidates for unilateral STN DBS. This study provides further evidence that, from a long-term perspective, initial simultaneous bilateral STN DBS should be considered for PD patients with prominently asymmetrical motor symptoms.

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Deep Brain Stimulation–Responsive Camptocormia in Parkinson Disease

Deep Brain Stimulation ◽

10.1093/med/9780190647209.003.0017 ◽

2020 ◽

pp. 89-92

Author(s):

Elena Call ◽

Helen Bronte-Stewart

Keyword(s):

Deep Brain Stimulation ◽

Parkinson Disease ◽

Brain Stimulation ◽

Rating Scale ◽

Freezing Of Gait ◽

Trunk Flexion ◽

Skeletal Deformity ◽

Dopaminergic Medication ◽

Stn Dbs ◽

Deep Brain

Camptocormia, involuntary flexion of the spine, is aggravated by action and improves when supine, if there is no skeletal deformity. Camptocormia in Parkinson disease (PD) is frequently refractory to dopaminergic medication. Deep brain stimulation (DBS) has been used to treat camptocormia with variable results. We present a PD patient with no camptocormia in the supine position but with progressive thoracic trunk flexion to about 90 degrees as he stood up. He had profound gait impairment and freezing of gait (FOG) off medication, but gait and FOG improved on medication. Camptocormia improved to about 30 degrees, but he had severe dyskinesias. Because he had no skeletal deformity, improved on medication, and had dyskinesias, he had bilateral 130 Hz subthalamic (STN) DBS. His Unified Parkinson’s Disease Rating Scale (UPDRS) Part III improved from 37 to 13 (off medication/on DBS), and after 14 months his camptocormia had resolved. Camptocormia that is responsive to dopaminergic medication, without a skeletal deformity, may respond to bilateral high-frequency STN DBS.

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