Deep Brain Stimulation Which Patients and When?

Deep Brain Stimulation Which Patients and When?

Erlick AC Pereira, Tipu Z Aziz
Published: US Neurological Disease 2007 - Issue I
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Deep brain stimulation (DBS) is neurosurgery that enables deep brain structures to be stimulated electrically by a pacemaker implanted under the skin. It has been popularized for those sufferers of Parkinson’s disease who have been unresponsive to drugs or have shown side effects from them. Its efficacy has been demonstrated robustly by clinical trials with multiple novel brain targets having been discovered recently. Many other indications for deep brain stimulation now exist, such as:

  • tremor and dystonia in movement disorders;
  • psychiatric disorders such as obsessive-compulsive disorder (OCD), depression, and Tourette’s syndrome;
  • cluster headache;
  • epilepsy; and
  • chronic pain including amputation, stroke, trigeminal neuralgia, and multiple sclerosis.

Novel indications of orthostatic hypotension and hypertension also show experimental promise. Here, we review the evidence for which patients are treated and when.

Parkinson’s Disease
Parkinson’s disease (PD) is a slowly progressive neurodegenerative disease characterized by tremor, rigidity, bradykinesia, and postural instability. It is common in middle or late life with prevalence rising to 1% in people over 60 years of age. Established basal ganglia brain structures currently targeted for PD DBS include the globus pallidus interna (GPi), ventralis intermedius nucleus of the thalamus (VIm), and subthalamic nucleus (STN). Over 30,000 patients have been implanted to date.1

The GPi has traditionally been targeted mainly for dyskinesia symptoms, STN for levodopa-refractory patients, and VIm for tremor. Despite its smaller size, the STN recently gained dominance over the GPi as the surgical target of choice for PD due to reports of favorable motor outcomes.2 A 156-patient, randomized, controlled, multicenter trial of STN DBS versus medical treatment alone showed a 25% benefit in motor function and 22% improvement in quality of life outcomes at six months after surgery.3 Sustained benefit with STN DBS has also been described after five years of follow-up.4,5 GPi and STN have been compared at four year follow-up;6 however, long-term, back-to-back, randomized, blinded, controlled trials of the two surgical targets are yet to be completed.7

The pedunculopontine nucleus (PPN) has been discovered in the last decade as a deep brain target, stimulation of which reduces gait abnormalities and postural instability.8 Like the STN, its clinical utility has been realized by nonhuman primate research.9,10 Initial results favor its use in PD patients blighted most by postural instability, in PD-plus syndromes of multiple system atrophy and progressive supranuclear palsy, and in those with symptoms not ameliorated by STN stimulation alone.11

Tremor
Tremor is the involuntary, rhythmic oscillation of a body part. Essential tremor prevalence varies greatly throughout the world and can be up to 2%. DBS can alleviate contralateral limb tremor in essential tremor, Holmes’ tremor, cerebellar tremor, tremulous multiple sclerosis, and tremor after head injury.12 For trunk, head, and voice tremors, bilateral DBS is considered.13 Brain targets considered in patients refractory to medication are the VIm and the zona incerta (ZI).

Sustained and consistent motor improvements with VIm DBS have been shown six years after surgery in 19 patients with essential tremor.14 Quality of life improvements have also been demonstrated in 40 patients one year after surgery.15 In multiple sclerosis, patient selection is paramount.16 Distal limb tremor responds best to VIm DBS and proximal limb tremor to ZI DBS.17 Post-operative benefits in motor function for 88% of patients and in daily functioning for 76% have been shown in a systematic review of 75 multiple sclerosis patients.18 Brain targets in DBS for head injury depend upon the prevailing movement disorder, with excellent results described in the small numbers of cases reported.19

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