Deep Brain Stimulation for Parkinson's Disease

Deep Brain Stimulation for Parkinson's Disease

Kelly E Lyons, Rajesh Pahwa
US Neurological Disease 2006 Issue II
Published: October 2008
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Parkinson's disease (PD) is a progressive neurodegenerative disease with the cardinal symptoms of bradykinesia, rigidity, and tremor. For the first several years, the symptoms of PD are generally well-controlled with medications such as dopamine agonists, monoamine oxidase type B (MAO-B) inhibitors, carbidopa/ levodopa, catechol-O-methyltransferase (COMT) inhibitors, and amantadine.1

However, as the disease progresses, disabling medication-related side effects, particularly motor fluctuations and dyskinesia, often occur and can become resistant to medication adjustments.

Due to the limitations of pharmacological treatments and advances in surgical and targeting techniques, deep brain stimulation (DBS) has been increasingly used as a treatment for advanced PD. Multiple studies have reported the safety and efficacy of DBS for the treatment of motor symptoms and medication-related motor complications in PD.2 There are currently three targets for DBS in PD: the subthalamic nucleus (STN), globus pallidus interna (GPi), and ventral intermediate (Vim) nucleus of the thalamus.

Patient Selection
Candidates for STN or GPi DBS should have idiopathic levodopa responsive PD with medication-resistant motor fluctuations or dyskinesia. Several studies have demonstrated that the strongest predictor of outcome after STN DBS is pre-operative levodopa responsiveness.3,4 PD patients older than 75 years are generally not considered candidates for DBS as they may have difficulty tolerating the procedure. Furthermore, younger age in addition to levodopa responsiveness has been reported to be a predictor of STN DBS outcome.5,6

Candidates should be seen by a neurologist specializing in movement disorders and should have been tried on multiple antiparkinsonian medications before being recommended for surgery. Neuropsychological assessment should be completed to rule out dementia and any significant cognitive, psychiatric, or behavioral abnormalities as these can worsen after surgery. There should be no significant abnormalities on neuroimaging and no other medical conditions that might increase surgical risk. Finally, the patient should have an adequate support network and be able to attend multiple follow-up visits to the surgical site.

DBS of the Vim nucleus of the thalamus is rarely used as a treatment for PD. Several studies demonstrated significant long-term tremor control with this procedure; however, there was minimal if any effect on bradykinesia, rigidity, and motor complications, which led to significant disability as the disease progressed.7,8 This procedure is therefore recommended only in patients with medication-resistant tremor dominant PD and minimal to no disability related to bradykinesia or rigidity.

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