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Mansouri A, Taslimi S, Badhiwala JH, Witiw CD, Nassiri F, Odekerken VJJ, De Bie RMA, Kalia SK, Hodaie M, Munhoz RP, Fasano A, Lozano AM. Deep brain stimulation for Parkinson’s disease: meta-analysis of results of randomized trials at varying lengths of follow-up. J Neurosurg 2018; 128:1199-1213. [DOI: 10.3171/2016.11.jns16715] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEDeep brain stimulation (DBS) is effective in the management of patients with advanced Parkinson’s disease (PD). While both the globus pallidus pars interna (GPi) and the subthalamic nucleus (STN) are accepted targets, their relative efficacy in randomized controlled trials (RCTs) has not been established beyond 12 months. The objective of this study was to conduct a meta-analysis of RCTs to compare outcomes among adults with PD undergoing DBS of GPi or STN at various time points, including 36 months of follow-up.METHODSThe MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL databases were searched. Registries for clinical trials, selected conference proceedings, and the table of contents for selected journals were also searched. Screens were conducted independently and in duplicate. Among the 623 studies initially identified (615 through database search, 7 through manual review of bibliographies, and 1 through a repeat screen of literature prior to submission), 19 underwent full-text review; 13 of these were included in the quantitative meta-analysis. Data were extracted independently and in duplicate. The Cochrane Collaboration tool was used to assess the risk of bias. The GRADE evidence profile tool was used to assess the quality of the evidence. Motor scores, medication dosage reduction, activities of daily living, depression, dyskinesias, and adverse events were compared. The influence of disease duration (a priori) and the proportion of male patients within a study (post hoc) were explored as potential subgroups.RESULTSThirteen studies (6 original cohorts) were identified. No difference in motor scores or activities of daily living was identified at 36 months. Medications were significantly reduced with STN stimulation (5 studies, weighted mean difference [WMD] −365.46, 95% CI −599.48 to −131.44, p = 0.002). Beck Depression Inventory scores were significantly better with GPi stimulation (3 studies; WMD 2.53, 95% CI 0.99–4.06 p = 0.001). The motor benefits of GPi and STN DBS for PD are similar.CONCLUSIONSThe motor benefits achieved with GPi and STN DBS for PD are similar. DBS of STN allows for a greater reduction of medication, but not as significant an advantage as DBS of GPi with respect to mood. This difference is sustained at 36 months. Further long-term studies are necessary.
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Affiliation(s)
- Alireza Mansouri
- 1Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto
- 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Canada; and
| | - Shervin Taslimi
- 1Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto
| | - Jetan H. Badhiwala
- 1Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto
| | - Christopher D. Witiw
- 1Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto
| | - Farshad Nassiri
- 1Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto
| | | | - Rob M. A. De Bie
- 3Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Suneil K. Kalia
- 1Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto
| | - Mojgan Hodaie
- 1Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto
| | - Renato P. Munhoz
- 4Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson’s Disease, Division of Neurology, Toronto Western Hospital, UHN, University of Toronto
| | - Alfonso Fasano
- 4Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson’s Disease, Division of Neurology, Toronto Western Hospital, UHN, University of Toronto
| | - Andres M. Lozano
- 1Division of Neurosurgery, Toronto Western Hospital, Department of Surgery, University of Toronto
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Li W, Abbas MM, Acharyya S, Ng HL, Tay KY, Au WL, Tan LCS. Suicide in Parkinson's Disease. Mov Disord Clin Pract 2018; 5:177-182. [PMID: 30363456 PMCID: PMC6174449 DOI: 10.1002/mdc3.12599] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 12/19/2017] [Accepted: 01/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Suicide is a potentially preventable event. Suicidal ideation is common in Parkinson's disease (PD), but literature on completed suicides is scarce. In this case-control study, we compared the clinical characteristics of PD subjects who completed suicide (case) with those who died from natural causes (control). METHODS PD patients from the National Neurosciences Institute's movement disorders database from 2002 till 2012 were identified. The database was linked to the Singapore National Registry of Disease Office for mortality information, and suicide deaths were confirmed with the coroner's office. The demographic and clinical variables were compared between the cases and controls and the significant factors were further analyzed using logistic regression analysis. RESULTS During the study period, 366 deaths were recorded and suicide accounted for 11 deaths. Ten subjects with suicide deaths with complete clinical information were compared with randomly selected 30 PD subjects who had died from natural causes. PD suicide patients were younger (65.9 vs. 74.48 years), had less comorbidities (CWI: 2.6 vs. 4.63), better cognition (MMSE: 25.75 vs. 21.36), lower 'ON' UPDRS motor scores (20.83 vs. 41.63), lower H &Y stage (2.16 vs. 3.86), and higher use of Entacapone than the PD non-suicide group. CONCLUSION Suicide is potentially preventable tragedy. PD patients with the identified clinical characteristics should be closely monitored for suicide ideations. Motor fluctuation is a treatable factor in such patients and should be aggressively managed.
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Affiliation(s)
- Wei Li
- Department of NeurologyNational Neuroscience InstituteSingapore
- Parkinson's Disease and Movement Disorders CenterNational Neuroscience InstituteSingapore
| | - Masoom M. Abbas
- Department of NeurologyNational Neuroscience InstituteSingapore
- Parkinson's Disease and Movement Disorders CenterNational Neuroscience InstituteSingapore
| | | | - Hwee Lan Ng
- Department of NeurologyNational Neuroscience InstituteSingapore
- Parkinson's Disease and Movement Disorders CenterNational Neuroscience InstituteSingapore
| | - Kay Yaw Tay
- Department of NeurologyNational Neuroscience InstituteSingapore
- Parkinson's Disease and Movement Disorders CenterNational Neuroscience InstituteSingapore
- Duke‐NUS Graduate Medical SchoolSingapore
| | - Wing Lok Au
- Department of NeurologyNational Neuroscience InstituteSingapore
- Parkinson's Disease and Movement Disorders CenterNational Neuroscience InstituteSingapore
- Duke‐NUS Graduate Medical SchoolSingapore
| | - Louis C. S. Tan
- Department of NeurologyNational Neuroscience InstituteSingapore
- Parkinson's Disease and Movement Disorders CenterNational Neuroscience InstituteSingapore
- Duke‐NUS Graduate Medical SchoolSingapore
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53
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Negida A, Elminawy M, El Ashal G, Essam A, Eysa A, Abd Elalem Aziz M. Subthalamic and Pallidal Deep Brain Stimulation for Parkinson's Disease. Cureus 2018; 10:e2232. [PMID: 29713577 PMCID: PMC5919761 DOI: 10.7759/cureus.2232] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 02/26/2018] [Indexed: 01/21/2023] Open
Abstract
Deep brain stimulation (DBS) is a surgical treatment in which stimulation electrodes are permanently implanted in basal ganglia to treat motor fluctuations and symptoms of Parkinson's disease (PD). Subthalamic nucleus (STN) and globus pallidus internus (GPi) are the commonly used targets for DBS in PD. Many studies have compared motor and non-motor outcomes of DBS in both targets. However, the selection of PD patients for DBS targets is still poorly studied. Therefore, we performed this narrative review to summarize published studies comparing STN DBS and GPi DBS. GPi DBS is better for patients with problems in speech, mood, or cognition while STN DBS is better from an economic point of view as it allows much reduction in antiparkinson medications and less battery consumption.
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Affiliation(s)
- Ahmed Negida
- Faculty of Medicine, Zagazig University, Egypt, Zagazig University, Egypt
| | - Mohamed Elminawy
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | - Athar Eysa
- Faculty of Medicine, Menoufia University
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54
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Willis AW, Thibault DP, Schmidt PN, Dorsey ER, Weintraub D. Hospital care for mental health and substance abuse conditions in Parkinson's disease. Mov Disord 2017; 31:1810-1819. [PMID: 27943472 DOI: 10.1002/mds.26832] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 07/19/2016] [Accepted: 08/24/2016] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE The objective of this study was to examine mental health conditions among hospitalized individuals with Parkinson's disease in the United States. METHODS This was a serial cross-sectional study of hospitalizations of individuals aged ≥60 identified in the Nationwide Inpatient Sample dataset from 2000 to 2010. We identified all hospitalizations with a diagnosis of PD, alcohol abuse, anxiety, bipolar disorder, depression, impulse control disorders, mania, psychosis, substance abuse, and attempted suicide/suicidal ideation. National estimates of each mental health condition were compared between hospitalized individuals with and without PD. Hierarchical logistic regression models determined which inpatient mental health diagnoses were associated with PD, adjusting for demographic, payer, geographic, and hospital characteristics. RESULTS We identified 3,918,703 mental health and substance abuse hospitalizations. Of these, 2.8% (n = 104, 437) involved a person also diagnosed with PD. The majority of mental health and substance abuse patients were white (86.9% of PD vs 83.3% of non-PD). Women were more common than men in both groups (male:female prevalence ratio, PD: 0.78, 0.78-0.79, non-PD: 0.58, 0.57-0.58). Depression (adjusted odds ratio 1.32, 1.31-1.34), psychosis (adjusted odds ratio 1.25, 1.15-1.33), bipolar disorder (adjusted odds ratio 2.74, 2.69-2.79), impulse control disorders (adjusted odds ratio 1.51, 1.31-1.75), and mania (adjusted odds ratio 1.43, 1.18-1.74) were more likely among PD patients, alcohol abuse was less likely (adjusted odds ratio 0.26, 0.25-0.27). We found no PD-associated difference in suicide-related care. CONCLUSIONS PD patients have unique patterns of acute care for mental health and substance abuse. Research is needed to guide PD treatment in individuals with pre-existing psychiatric illnesses, determine cross provider reliability of psychiatric diagnoses in PD patients, and inform efforts to improve psychiatric outcomes. © 2016 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Allison W Willis
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dylan P Thibault
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | | | - E Ray Dorsey
- Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
| | - Daniel Weintraub
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.,Parkinson's Disease and Mental Illness Research, Education and Clinical Centers, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, USA
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55
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Mole JA, Prangnell SJ. Role of clinical neuropsychology in deep brain stimulation: Review of the literature and considerations for clinicians. APPLIED NEUROPSYCHOLOGY-ADULT 2017; 26:283-296. [PMID: 29236528 DOI: 10.1080/23279095.2017.1407765] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Deep Brain Stimulation (DBS) is an effective surgical therapy for several neurological movement disorders. The clinical neuropsychologist has a well-established role in the neuropsychological evaluation and selection of surgical candidates. In this article, we argue that the clinical neuropsychologist's role is much broader, when considered in relation to applied psychologists' core competencies. We consider the role of the clinical neuropsychologist in DBS in relation to: assessment, formulation, evaluation and research, intervention or implementation, and communication. For each competence the relevant evidence-base was reviewed. Clinical neuropsychology has a vital role in presurgical assessment of cognitive functioning and psychological, and emotional and behavioral difficulties. Formulation is central to the selection of surgical candidates and crucial to intervention planning. Clinical neuropsychology has a well-established role in postsurgical assessment of cognitive functioning and psychological, emotional, and behavioral outcomes, which is fundamental to evaluation on an individual and service level. The unique contribution clinical neuropsychology makes to pre- and postsurgical interventions is also highlighted. Finally, we discuss how clinical neuropsychology can promote clear and effective communication with patients and between professionals.
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Affiliation(s)
- Joseph A Mole
- a Russell Cairns Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust , Oxford , UK
| | - Simon J Prangnell
- a Russell Cairns Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust , Oxford , UK
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56
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Kubu CS, Ford PJ. Clinical Ethics in the Context of Deep Brain Stimulation for Movement Disorders. Arch Clin Neuropsychol 2017; 32:829-839. [PMID: 29028865 PMCID: PMC5860076 DOI: 10.1093/arclin/acx088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/30/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Discuss common clinical ethical challenges encountered in working with patients who are candidates for deep brain stimulation (DBS) for the treatment of motor symptoms of Parkinson's disease (PD). METHOD The relevant literature is reviewed and supplemented by descriptive, ethically challenging cases stemming from decades of combined experience working on DBS teams. We outline ethical arguments and provide pragmatic recommendations to assist neuropsychologists working in movement disorder teams. RESULTS The goals of the pre-operative neuropsychological DBS assessment include: (1) identification of potential cognitive risk factors; (2) identification of relevant neuropsychiatric or neurobehavioral factors; (3) assessment of level of family support; and (4) systematic assessment of patient's and family member's goals or expectations for DBS. The information gleaned from the pre-operative neuropsychological assessment is highly relevant to the most commonly studied clinical ethics challenges encountered in DBS: (1) assessment of risk/benefit; (2) determinations regarding inclusion/exclusion; (3) autonomy; and (4) patient's perception of benefit and quality of life. CONCLUSIONS Neuropsychologists are particularly well poised to provide unique and important insights to assist with developing the most ethically sound practices that take into account patient's values as well as fiduciary responsibilities to the patient, the team, the profession, and the broader community.
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Affiliation(s)
- Cynthia S Kubu
- Center for Neurological Restoration, Cleveland Clinic, OH, USA
- Department of Bioethics, Cleveland Clinic, OH, USA
- Department of Psychiatry and Psychology, Cleveland Clinic, OH, USA
| | - Paul J Ford
- Center for Neurological Restoration, Cleveland Clinic, OH, USA
- Department of Bioethics, Cleveland Clinic, OH, USA
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57
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Dietrichs E, Odin P. Algorithms for the treatment of motor problems in Parkinson's disease. Acta Neurol Scand 2017; 136:378-385. [PMID: 28133726 PMCID: PMC5655734 DOI: 10.1111/ane.12733] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2017] [Indexed: 12/17/2022]
Abstract
Several different strategies are effective for medical treatment of motor problems in Parkinson's disease (PD). Many guidelines and evidence-based reviews are available, but there is no documentation or consensus in favor of just one treatment strategy. This review presents two algorithms that may be helpful when deciding how to treat a PD patient at various stages of the disease. The first algorithm suggests one way to treat PD from the first onset of motor symptoms. It is largely based on treatment recommendations from the Scandinavian countries and Germany. The other algorithm is meant as assistance for choosing among the different device-aided treatments for advanced PD. There is not sufficient comparative data to recommend one particular line of treatment, neither in early PD nor in advanced disease with motor complications. Individualized treatment is needed for each patient. The current algorithms only represent an alternative for aiding treatment decisions.
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Affiliation(s)
- E. Dietrichs
- Department of NeurologyOslo University Hospital and University of OsloOsloNorway
| | - P. Odin
- Department of NeurologySkåne University HospitalUniversity of LundLundSweden
- Department of NeurologyKlinikum‐BremerhavenBremerhavenGermany
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58
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Earlier Intervention with Deep Brain Stimulation for Parkinson's Disease. PARKINSONS DISEASE 2017; 2017:9358153. [PMID: 28951797 PMCID: PMC5603745 DOI: 10.1155/2017/9358153] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 05/29/2017] [Accepted: 07/13/2017] [Indexed: 12/22/2022]
Abstract
Neuromodulation of subcortical areas of the brain as therapy to reduce Parkinsonian motor symptoms was developed in the mid-twentieth century and went through many technical and scientific advances that established specific targets and stimulation parameters. Deep Brain Stimulation (DBS) was approved by the FDA in 2002 as neuromodulation therapy for advanced Parkinson's disease, prompting several randomized controlled trials that confirmed its safety and effectiveness. The implantation of tens of thousands of patients in North America and Europe ignited research into its potential role in early disease stages and the therapeutic benefit of DBS compared to best medical therapy. In 2013 the EARLY-STIM trial provided Class I evidence for the use of DBS earlier in Parkinson's disease. This finding led to the most recent FDA approval in patients with at least 4 years of disease duration and 4 months of motor complications as an adjunct therapy for patients not adequately controlled with medications. This following review highlights the historical development and advances made overtime in DBS implantation, the current application, and the challenges that come with it.
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59
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Abstract
Deep brain stimulation (DBS) is effective for Parkinson's disease (PD), dystonia, and essential tremor (ET). While motor benefits are well documented, cognitive and psychiatric side effects from the subthalamic nucleus (STN) and globus pallidus interna (GPi) DBS for PD are increasingly recognized. Underlying disease, medications, microlesions, and post-surgical stimulation likely all contribute to non-motor symptoms (NMS).
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60
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Timmer MHM, van Beek MHCT, Bloem BR, Esselink RAJ. What a neurologist should know about depression in Parkinson's disease. Pract Neurol 2017; 17:359-368. [PMID: 28739866 DOI: 10.1136/practneurol-2017-001650] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2017] [Indexed: 11/03/2022]
Abstract
Depression is a frequent non-motor symptom of Parkinson's disease. Its prevalence varies widely across studies (between 2.7% and 90%); around 35% have clinically significant depressive symptoms. Although depression can have an immense impact on the quality of life of affected patients and their caregivers, depressive symptoms in Parkinson's disease frequently remain unrecognised and, as a result, remain untreated. Here we overview the diagnostic challenges and pitfalls, including the factors contributing to the underdiagnosis of depression. We also discuss current ideas on the underlying pathophysiology. Finally, we offer a treatment approach based on currently available evidence.
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Affiliation(s)
- Monique H M Timmer
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Neurology and Parkinson Center, Radboud University Medical Center, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maria H C T van Beek
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bas R Bloem
- Department of Neurology and Parkinson Center, Radboud University Medical Center, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rianne A J Esselink
- Department of Neurology and Parkinson Center, Radboud University Medical Center, Nijmegen, The Netherlands.,Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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61
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Buhmann C, Huckhagel T, Engel K, Gulberti A, Hidding U, Poetter-Nerger M, Goerendt I, Ludewig P, Braass H, Choe CU, Krajewski K, Oehlwein C, Mittmann K, Engel AK, Gerloff C, Westphal M, Köppen JA, Moll CKE, Hamel W. Adverse events in deep brain stimulation: A retrospective long-term analysis of neurological, psychiatric and other occurrences. PLoS One 2017; 12:e0178984. [PMID: 28678830 PMCID: PMC5497949 DOI: 10.1371/journal.pone.0178984] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 05/22/2017] [Indexed: 11/18/2022] Open
Abstract
Background and objective The extent to which deep brain stimulation (DBS) can improve quality of life may be perceived as a permanent trade-off between neurological improvements and complications of therapy, comorbidities, and disease progression. Patients and methods We retrospectively investigated 123 consecutive and non-preselected patients. Indications for DBS surgery were Parkinson's disease (82), dystonia (18), tremor of different etiology (21), Huntington's disease (1) and Gilles de la Tourette syndrome (1). AEs were defined as any untoward clinical occurrence, sign or patient complaint or unintended disease if related or unrelated to the surgical procedures, implanted devices or ongoing DBS therapy. Results Over a mean/median follow-up period of 4.7 years (578 patient-years) 433 AEs were recorded in 106 of 123 patients (86.2%). There was no mortality or persistent morbidity from the surgical procedure. All serious adverse events (SAEs) that occurred within 4 weeks of surgery were reversible. Neurological AEs (193 in 85 patients) and psychiatric AEs (78 in 48 patients) were documented most frequently. AEs in 4 patients (suicide under GPI stimulation, weight gain >20 kg, impairment of gait and speech, cognitive decline >2 years following surgery) were severe or worse, at least possibly related to DBS and non reversible. In PD 23.1% of the STN-stimulated patients experienced non-reversible (or unknown reversibility) AEs that were at least possibly related to DBS in the form of impaired speech or gait, depression, weight gain, cognitive disturbances or urinary incontinence (severity was mild or moderate in 15 of 18 patients). Age and Hoehn&Yahr stage of STN-simulated PD patients, but not preoperative motor impairment or response to levodopa, showed a weak correlation (r = 0.24 and 0.22, respectively) with the number of AEs. Conclusions DBS-related AEs that were severe or worse and non-reversible were only observed in PD (4 of 82 patients; 4.9%), but not in other diseases. PD patients exhibited a significant risk for non-severe AEs most of which also represented preexisting and progressive axial and non-motor symptoms of PD. Mild gait and/or speech disturbances were rather frequent complaints under VIM stimulation. GPI stimulation for dystonia could be applied with negligible DBS-related side effects.
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Affiliation(s)
- Carsten Buhmann
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Torge Huckhagel
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Katja Engel
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandro Gulberti
- Institut für Neurophysiologie und Pathophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ute Hidding
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Ines Goerendt
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Ludewig
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Hanna Braass
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Chi-un Choe
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Kara Krajewski
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Andreas K. Engel
- Institut für Neurophysiologie und Pathophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes A. Köppen
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K. E. Moll
- Institut für Neurophysiologie und Pathophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
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Comparison of Globus Pallidus Interna and Subthalamic Nucleus in Deep Brain Stimulation for Parkinson Disease: An Institutional Experience and Review. PARKINSONS DISEASE 2017; 2017:3410820. [PMID: 28706748 PMCID: PMC5494569 DOI: 10.1155/2017/3410820] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/07/2017] [Indexed: 01/17/2023]
Abstract
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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63
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Cossu G, Sensi M. Deep Brain Stimulation Emergencies: How the New Technologies Could Modify the Current Scenario. Curr Neurol Neurosci Rep 2017; 17:51. [PMID: 28497305 DOI: 10.1007/s11910-017-0761-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
After 25 years of deep brain stimulation (DBS) for the treatment of Parkinson's disease, it has become increasingly recognized that a range of postoperative urgent situations and emergencies may occur. In this review we describe the possible scenarios of DBS-related emergencies: perioperative (intraoperative and early postoperative) and postoperative settings and issues from suboptimal control of motor and nonmotor symptoms in the early programming phase and during long-term follow-up. We also outline potential advantages in the management of these emergencies offered by the newest devices, emerging technologies, and new possibilities in programming.
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Affiliation(s)
- Giovanni Cossu
- Movement Disorders Unit, Department of Neurology, Brotzu General Hospital, Piazzale Ricchi 1, 09134, Cagliari, Italy.
| | - Mariachiara Sensi
- Department of Neurology, Azienda Ospedaliera Universitaria Arcispedale Sant'Anna, Ferrara, Italy
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64
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Patel AS. Deep Brain Stimulation Target Selection in an Advanced Parkinson's Disease Patient with Significant Tremor and Comorbid Depression. Tremor Other Hyperkinet Mov (N Y) 2017; 7:447. [PMID: 28428905 PMCID: PMC5395677 DOI: 10.7916/d8kd23nz] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 03/16/2017] [Indexed: 12/01/2022] Open
Abstract
CLINICAL VIGNETTE A 67-year-old female with advanced Parkinson's disease (PD), medically refractory tremor, and a history of significant depression presented for evaluation of deep brain stimulation (DBS) candidacy. CLINICAL DILEMMA Traditionally, the subthalamic nucleus (STN) has been preferred over the globus pallidus interna (GPi) as a DBS target for PD patients with levodopa-responsive fluctuations in rigidity and akinesia, for whom tremor is also a significant source of impairment. However, STN stimulation is avoided in patients with a significant pre-surgical history of mood disorder. CLINICAL SOLUTION Bilateral DBS of the GPi led to significant short-term improvement in PD motor symptoms, including significant tremor reduction. GAP IN KNOWLEDGE There is insufficient evidence to support or refute clinicians' traditional preference for STN stimulation in treating refractory PD tremor. Similarly, the available evidence for risk of worsening depression and/or suicidality after STN DBS is mixed. Both questions require further clarification to guide patient and clinician decision-making.
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Affiliation(s)
- Amar S. Patel
- Department of Neurology, Yale School of Medicine, Yale University, New Haven, CT, USA,*To whom correspondence should be addressed. E-mail:
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Faggiani E, Benazzouz A. Deep brain stimulation of the subthalamic nucleus in Parkinson’s disease: From history to the interaction with the monoaminergic systems. Prog Neurobiol 2017; 151:139-156. [DOI: 10.1016/j.pneurobio.2016.07.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 07/08/2016] [Indexed: 11/16/2022]
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Medical Management of Parkinson's Disease after Initiation of Deep Brain Stimulation. Can J Neurol Sci 2017; 43:626-34. [PMID: 27670207 DOI: 10.1017/cjn.2016.274] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In this review, we have gathered all the available evidence to guide medication management after deep brain stimulation (DBS) in Parkinson's disease (PD). Surprisingly, we found that almost no study addressed drug-based management in the postoperative period. Dopaminergic medications are usually reduced, but whether the levodopa or dopamine agonist is to be reduced is left to the personal preference of the treating physician. We have summarized the pros and cons of both approaches. No study on the management of cognitive problems after DBS has been done, and only a few studies have explored the pharmacological management of such DBS-resistant symptoms as voice (amantadine), balance (donepezil) or gait disorders (amantadine, methylphenidate). As for the psychiatric problems so frequently reported in PD patients, researchers have directed their attention to the complex interplay between stimulation and reduction of dopaminergic drugs only recently. In conclusion, studies addressing medical management following DBS are still needed and will certainly contribute to the ultimate success of DBS procedures.
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Williams NR, Sahlem G, Pannu J, Takacs I, Short B, Revuelta G, George MS. Neuroversion: using electroconvulsive therapy as a bridge to deep brain stimulation implantation. Neurocase 2017; 23:26-30. [PMID: 28376692 DOI: 10.1080/13554794.2016.1276605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Parkinson's disease (PD) is a movement disorder with significant neuropsychiatric comorbidities. Electroconvulsive therapy (ECT) is effective in treating these neuropsychiatric symptoms; however, clinicians are reluctant to use ECT in patients with deep brain stimulation (DBS) implantations for fear of damaging the device, as well as potential cognitive side effects. Right unilateral ultra-brief pulse (RUL UBP) ECT has a more favorable cognitive side-effect profile yet has never been reported in PD patients with DBS implants. We present a case series of three patients with a history of PD that all presented with psychiatric decompensation immediately prior to planned DBS surgery. All three patients had DBS electrode(s) in place at the time and an acute course of ECT was utilized in a novel method to "bridge" these individuals to neurosurgery. The patients all experienced symptom resolution (psychosis and/or depression and/or anxiety) without apparent cognitive side effects. This case series not only illustrates that right unilateral ultra-brief pulse can be utilized in patients with DBS electrodes but also illustrates that this intervention can be utilized as a neuromodulatory "bridge", where nonoperative surgical candidates with unstable psychiatric symptoms can be converted to operative candidates in a manner similar to electrical cardioversion.
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Affiliation(s)
- Nolan R Williams
- a Department of Psychiatry , Stanford University , Stanford , CA , USA
| | - Greg Sahlem
- b Department of Psychiatry , Medical University of South Carolina , Charleston , SC , USA
| | - Jaspreet Pannu
- a Department of Psychiatry , Stanford University , Stanford , CA , USA
| | - Istvan Takacs
- d Department of Neurosurgery , Medical University of South Carolina , Charleston , SC , USA
| | - Baron Short
- b Department of Psychiatry , Medical University of South Carolina , Charleston , SC , USA
| | - Gonzalo Revuelta
- c Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
| | - Mark S George
- b Department of Psychiatry , Medical University of South Carolina , Charleston , SC , USA.,c Department of Neurology , Medical University of South Carolina , Charleston , SC , USA
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Kurtis MM, Rajah T, Delgado LF, Dafsari HS. The effect of deep brain stimulation on the non-motor symptoms of Parkinson's disease: a critical review of the current evidence. NPJ Parkinsons Dis 2017; 3:16024. [PMID: 28725706 PMCID: PMC5516616 DOI: 10.1038/npjparkd.2016.24] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 09/15/2016] [Accepted: 09/26/2016] [Indexed: 12/31/2022] Open
Abstract
The benefit of deep brain stimulation (DBS) in controlling the motor symptoms of Parkinson's disease is well established, however, the impact on the non-motor symptoms (NMS) remains to be elucidated, although the growing investigative efforts are promising. This article reviews the reported data and considers the level of evidence available with regard to the effect of DBS on NMS total burden and on the cognitive, neuropsychiatric, sleep, pain, dysautonomic, and weight domains. Multiple case series suggest that DBS improves the burden of NMS by reducing prevalence, intensity, and non-motor fluctuations. There is level I evidence on the effect of DBS on cognition and mood. Slight cognitive decline has been reported in most class I studies, although the functional effect is probably minimal. Two randomized prospective studies reported no change in depression while improvement of anxiety has been reported by a class I trial. Prospective cohort studies point to improvement of hyperdopaminergic behaviors, such as impulse control disorders, while others report that hypodopaminergic states, like apathy, can appear after DBS. There is only class III evidence supporting the benefit of DBS on other NMS such as nocturnal sleep, pain, dysautonomia (urinary, gastrointestinal, cardiovascular, and sweating), and weight loss. Although preliminary results are promising, randomized prospectively controlled trials with NMS as primary end points are necessary to further explore the effect of DBS on these often invalidating symptoms and offer conclusions about efficacy.
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Affiliation(s)
- Mónica M Kurtis
- Movement Disorders Unit, Neurology Department, Hospital Ruber Internacional, Madrid, Spain
| | - Thadshani Rajah
- Kings Parkinson's Centre of Excellence, Kings College and Kings College Hospital, London, UK
| | - Luisa F Delgado
- Fundación Universitaria de Ciencias de la Salud, Hospital San José—Hospital Infantil Universitario de San José, Bogotá, Colombia
| | - Haidar S Dafsari
- Department of Neurology, University Hospital Cologne, Cologne, Germany
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Oldani L, Altamura AC, Abdelghani M, Young AH. Brain stimulation treatments in bipolar disorder: A review of the current literature. World J Biol Psychiatry 2016; 17:482-94. [PMID: 25471324 DOI: 10.3109/15622975.2014.984630] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Brain stimulation techniques are non-pharmacologic strategies which offer additional therapeutic options for treatment-resistant depression (TRD). The purpose of this paper is to review the current literature regarding the use of brain stimulation in resistant bipolar disorder (BD), with particular reference to hypomanic/manic symptoms. METHODS Keywords pertaining to the brain simulation techniques used in the treatment of depression (either unipolar or bipolar) along with their role in regard to hypomanic/manic symptoms were used to conduct an electronic search of the literature. Pertinent findings were identified by the authors and reviewed. RESULTS Brain stimulation techniques represent a valid therapeutic option in TRD. They have been extensively studied in unipolar depression and, to a minor extent, in the depressive phase of BD, showing encouraging but often limited results. With exception of electroconvulsive therapy, the efficacy of brain stimulation in the treatment of manic symptoms of bipolar patients is still uncertain and needs to be fully evaluated. CONCLUSIONS Brain stimulation in BD is derived from its use in unipolar depression. However, there are many important differences between these two disorders and more studies with a systematic approach need to be conducted on larger samples of bipolar patients with treatment-resistant characteristics.
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Affiliation(s)
- Lucio Oldani
- a Department of Psychiatry , University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico , Milan , Italy
| | - A Carlo Altamura
- a Department of Psychiatry , University of Milan, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico , Milan , Italy
| | - Mohamed Abdelghani
- b Complex Depression, Anxiety and Trauma Service (CDAT) and Neurodevelopmental Service (Adult ADHD and Adult ASD), Camden and Islington NHS Foundation Trust, St Pancras Hospital , London , UK
| | - Allan H Young
- c Centre for Affective Disorders, Institute of Psychiatry, King's College London , Denmark Hill, London , UK
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Tendler A, Barnea Ygael N, Roth Y, Zangen A. Deep transcranial magnetic stimulation (dTMS) - beyond depression. Expert Rev Med Devices 2016; 13:987-1000. [PMID: 27601183 DOI: 10.1080/17434440.2016.1233812] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Deep transcranial magnetic stimulation (dTMS) utilizes different H-coils to study and treat a variety of psychiatric and neurological conditions with identifiable brain targets. The availability of this technology is dramatically changing the practice of psychiatry and neurology as it provides a safe and effective way to treat even drug-resistant patients. However, up until now, no effort was made to summarize the different types of H-coils that are available, and the conditions for which they were tested. Areas covered: Here we assembled all peer reviewed publication that used one of the H-coils, together with illustrations of the effective field they generate within the brain. Currently, the technology has FDA clearance for depression and European clearance for additional disorders, and multi-center trials are exploring its safety and effectiveness for OCD, PTSD, bipolar depression and nicotine addiction. Expert commentary: Taken together with positive results in smaller scale experiments, dTMS coils represent a non-invasive way to manipulate pathological activity in different brain structures and circuits. Advances in stimulation and imaging methods can now lead to efficacious and logical treatments. This should reduce the stigma associated with mental disorders, and improve access to psychiatric treatment.
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Affiliation(s)
- Aron Tendler
- a Advanced Mental Health Care Inc ., Royal Palm Beach , FL , USA.,c Brainsway Ltd ., Jerusalem , Israel
| | - Noam Barnea Ygael
- b Department of Life Sciences, Zlotowski Centre for Neuroscience , Ben-Gurion University of the Negev , Beer-Sheva , Israel
| | - Yiftach Roth
- b Department of Life Sciences, Zlotowski Centre for Neuroscience , Ben-Gurion University of the Negev , Beer-Sheva , Israel.,c Brainsway Ltd ., Jerusalem , Israel
| | - Abraham Zangen
- b Department of Life Sciences, Zlotowski Centre for Neuroscience , Ben-Gurion University of the Negev , Beer-Sheva , Israel.,c Brainsway Ltd ., Jerusalem , Israel
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Wagle Shukla A, Okun MS. State of the Art for Deep Brain Stimulation Therapy in Movement Disorders: A Clinical and Technological Perspective. IEEE Rev Biomed Eng 2016; 9:219-33. [PMID: 27411228 DOI: 10.1109/rbme.2016.2588399] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Deep brain stimulation (DBS) therapy is a widely used brain surgery that can be applied for many neurological and psychiatric disorders. DBS is American Food and Drug Administration approved for medication refractory Parkinson's disease, essential tremor and dystonia. Although DBS has shown consistent success in many clinical trials, the therapy has limitations and there are well-recognized complications. Thus, only carefully selected patients are ideal candidates for this surgery. Over the last two decades, there have been significant advances in clinical knowledge on DBS. In addition, the surgical techniques and technology related to DBS has been rapidly evolving. The goal of this review is to describe the current status of DBS in the context of movement disorders, outline the mechanisms of action for DBS in brief, discuss the standard surgical and imaging techniques, discuss the patient selection and clinical outcomes in each of the movement disorders, and finally, introduce the recent advancements from a clinical and technological perspective.
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Cyron D. Mental Side Effects of Deep Brain Stimulation (DBS) for Movement Disorders: The Futility of Denial. Front Integr Neurosci 2016; 10:17. [PMID: 27147988 PMCID: PMC4837159 DOI: 10.3389/fnint.2016.00017] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 03/29/2016] [Indexed: 01/08/2023] Open
Affiliation(s)
- Donatus Cyron
- Neurosurgery, Städtisches Klinikum Karlsruhe Karlsruhe, Germany
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73
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Boel JA, Odekerken VJJ, Geurtsen GJ, Schmand BA, Cath DC, Figee M, van den Munckhof P, de Haan RJ, Schuurman PR, de Bie RMA. Psychiatric and social outcome after deep brain stimulation for advanced Parkinson's disease. Mov Disord 2015; 31:409-13. [PMID: 26660279 DOI: 10.1002/mds.26468] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 09/21/2015] [Accepted: 10/05/2015] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The aim of this study was to assess psychiatric and social outcome 12 months after bilateral deep brain stimulation (DBS) of the globus pallidus pars interna (GPi) and subthalamic nucleus (STN) for advanced Parkinson's disease (PD). METHODS We randomly assigned patients to receive GPi DBS (n = 65) or STN DBS (n = 63). Standardized psychiatric and social questionnaires were assessed at baseline and after 12 months. RESULTS No differences were found between GPi DBS and STN DBS on psychiatric evaluation. Within-group comparisons showed small but statistically significant changes on several measures in both groups. Descriptive statistics indicated slight changes in social functioning. Marital satisfaction of patients and partners remained relatively stable after GPi and STN DBS. CONCLUSIONS We found neither differences in psychiatric and social outcome between GPi DBS and STN DBS nor any relevant within-group differences. The decision for GPi DBS or STN DBS cannot be based on expected psychiatric or social effects.
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Affiliation(s)
- Judith A Boel
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Psychology, University of Amsterdam, The Netherlands
| | | | - Gert J Geurtsen
- Department of Medical Psychology, Academic Medical Center, Amsterdam, The Netherlands
| | - Ben A Schmand
- Department of Psychology, University of Amsterdam, The Netherlands.,Department of Medical Psychology, Academic Medical Center, Amsterdam, The Netherlands
| | - Danielle C Cath
- Altrecht Academic Anxiety Center, Utrecht, The Netherlands; Department of Clinical and Health Psychology, Utrecht University, The Netherlands
| | - Martijn Figee
- Department of Psychiatry, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Rob J de Haan
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - P Richard Schuurman
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Rob M A de Bie
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
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Sako W, Murakami N, Miyazaki Y, Izumi Y, Kaji R. On-period unified Parkinson's disease rating scale before surgery correlates with differences in outcomes between pallidal and subthalamic stimulation: a meta-analysis. Neurol Sci 2015; 37:135-137. [PMID: 26335017 DOI: 10.1007/s10072-015-2376-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 08/26/2015] [Indexed: 11/24/2022]
Affiliation(s)
- Wataru Sako
- Department of Clinical Neuroscience, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan.
| | - Nagahisa Murakami
- Department of Clinical Neuroscience, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Yoshimichi Miyazaki
- Department of Clinical Neuroscience, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Yuishin Izumi
- Department of Clinical Neuroscience, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
| | - Ryuji Kaji
- Department of Clinical Neuroscience, Institute of Biomedical Sciences, Tokushima University Graduate School, 3-18-15 Kuramoto-cho, Tokushima, 770-8503, Japan
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Fernandez HH, Standaert DG, Chatamra K, Benesh JA. Reply to letter: Suicide in Parkinson's disease patients treated with levodopa-carbidopa Intestinal Gel. Mov Disord 2015; 30:1435-6. [PMID: 26179940 PMCID: PMC5034823 DOI: 10.1002/mds.26316] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 05/22/2015] [Indexed: 11/18/2022] Open
Affiliation(s)
- Hubert H Fernandez
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
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Kim HJ, Jeon BS, Paek SH. Nonmotor Symptoms and Subthalamic Deep Brain Stimulation in Parkinson's Disease. J Mov Disord 2015; 8:83-91. [PMID: 26090080 PMCID: PMC4460544 DOI: 10.14802/jmd.15010] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 04/18/2015] [Accepted: 04/20/2015] [Indexed: 12/24/2022] Open
Abstract
Subthalamic deep brain stimulation (STN DBS) is an established treatment for the motor symptoms in patients with advanced Parkinson’s disease (PD). In addition to improvements in motor symptoms, many studies have reported changes in various nonmotor symptoms (NMSs) after STN DBS in patients with PD. Psychiatric symptoms, including depression, apathy, anxiety, and impulsivity, can worsen or improve depending on the electrical stimulation parameters, the locations of the stimulating contacts within the STN, and changes in medications after surgery. Global cognitive function is not affected by STN DBS, and there is no increase in the incidence of dementia after STN DBS compared to that after medical treatment, although clinically insignificant declines in verbal fluency have been consistently reported. Pain, especially PD-related pain, improves with STN DBS. Evidence regarding the effects of STN DBS on autonomic symptoms and sleep-related problems is limited and remains conflicting. Many symptoms of nonmotor fluctuations, which are occasionally more troublesome than motor fluctuations, improve with STN DBS. Although it is clear that NMSs are not target symptoms for STN DBS, NMSs have a strong influence on the quality of life of patients with PD, and clinicians should thus be aware of these NMSs when deciding whether to perform surgery and should pay attention to changes in these symptoms after STN DBS to ensure the optimal care for patients.
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Affiliation(s)
- Han-Joon Kim
- Department of Neurology, Movement Disorder Center, Neuroscience Research Institute, College of Medicine, Seoul National University, Seoul, Korea
| | - Beom S Jeon
- Department of Neurology, Movement Disorder Center, Neuroscience Research Institute, College of Medicine, Seoul National University, Seoul, Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Movement Disorder Center, Neuroscience Research Institute, College of Medicine, Seoul National University, Seoul, Korea
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Abstract
Despite the application of deep brain stimulation (DBS) as an efficient treatment modality for psychiatric disorders, such as obsessive-compulsive disorder (OCD), Gilles de la Tourette Syndrome (GTS), and treatment refractory major depression (TRD), few patients are operated or included in clinical trials, often for fear of the potential risks of an approach deemed too dangerous. To assess the surgical risks, we conducted an analysis of publications on DBS for psychiatric disorders. A PubMed search was conducted on reports on DBS for OCD, GTS, and TRD. Forty-nine articles were included. Only reports on complications related to DBS were selected and analyzed. Two hundred seventy-two patients with a mean follow-up of 22 months were included in our analysis. Surgical mortality was nil. The overall mortality was 1.1 %: two suicides were unrelated to DBS and one death was reported to be unlikely due to DBS. The majority of complications were transient and related to stimulation. Long-term morbidity occurred in 16.5 % of cases. Three patients had permanent neurological complications due to intracerebral hemorrhage (2.2 %). Complications reported in DBS for psychiatric diseases appear to be similar to those reported for DBS in movement disorders. But class I evidence is lacking. Our analysis was based mainly on small non-randomized studies. A significant number of patients (approximately 150 patients) who were treated with DBS for psychiatric diseases had to be excluded from our analysis as no data on complications was available. The exact prevalence of complications of DBS in psychiatric diseases could not be established. DBS for psychiatric diseases is promising, but remains an experimental technique in need of further evaluation. A close surveillance of patients undergoing DBS for psychiatric diseases is mandatory.
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Alkemade A, Schnitzler A, Forstmann BU. Topographic organization of the human and non-human primate subthalamic nucleus. Brain Struct Funct 2015; 220:3075-86. [PMID: 25921975 PMCID: PMC4575692 DOI: 10.1007/s00429-015-1047-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 04/15/2015] [Indexed: 12/22/2022]
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is used to relieve motor symptoms of Parkinson's disease. A tripartite system of STN subdivisions serving motoric, associative, and limbic functions was proposed, mainly based on tracing studies, which are limited by low numbers of observations. The evidence is compelling and raises the question as to what extent these functional zones are anatomically segregated. The majority of studies indicate that there is anatomical overlap between STN functional zones. Using ultrahigh-resolution magnetic resonance imaging techniques it is now possible to visualize the STN with high spatial resolution, and it is feasible that in the near future stereotactic guided placement of electrical stimulators aided by high-resolution imaging will allow for more specific stimulation of the STN. The neuroanatomical and functional makeup of these subdivisions and their level of overlap would benefit from clarification before serving as surgical targets. We discuss histological and imaging studies, as well as clinical observations and electrophysiological recordings in DBS patients. These studies provide evidence for a topographical organization within the STN, although it remains unclear to what extent functionally and anatomically distinct subdivisions overlap.
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Affiliation(s)
- Anneke Alkemade
- Cognitive Science Center Amsterdam, University of Amsterdam, Nieuwe Achtergracht 129, 1018 WS, Amsterdam, The Netherlands.
| | - Alfons Schnitzler
- Department of Neurology, Medical Faculty, Center for Movement Disorders and Neuromodulation, Heinrich-Heine University, Düsseldorf, Germany.,Medical Faculty, Institute of Clinical Neuroscience and Medical Psychology, Heinrich-Heine University, Düsseldorf, Germany
| | - Birte U Forstmann
- Cognitive Science Center Amsterdam, University of Amsterdam, Nieuwe Achtergracht 129, 1018 WS, Amsterdam, The Netherlands
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Abdel-Salam OME. Prevalence, clinical features and treatment of depression in Parkinson’s disease: An update. World J Neurol 2015; 5:17-38. [DOI: 10.5316/wjn.v5.i1.17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 01/10/2015] [Accepted: 02/09/2015] [Indexed: 02/06/2023] Open
Abstract
Parkinson’s disease (PD) is one of the most prevalent neurodegenerative diseases which typically affects individuals over 65 years. Although the symptomatology is predominantly motor, neuropsychiatric manifestations, e.g., depression, apathy, anxiety, and cognitive impairment occur in the course of the illness and can have a great impact on the quality of life in these patients. Parkinson’s disease is commonly comorbid with depression with prevalence rates of depression, generally higher than those reported in general population. Depression in PD is frequently underestimated and consequently undertreated, which have significant effects on the quality of life in these patients. The neurobiology of depression in PD is complex and involves alterations in dopaminergic, serotonergic, noradrenergic and possibly other neurotransmitter systems which are affected in the course of the disease. The tricyclic antidepressants and the selective serotonin reuptake inhibitors are the two classes of antidepressant drugs used for depressive symptoms in PD. Several published studies suggested that both classes are of comparable efficacy. Other serotonergic antidepressants, e.g., nefazodone and trazodone have also been of benefit. Meanwhile, there are limited data available on other drugs but these suggest a benefit from the serotonin and noradrenaline reuptake inhibitors such as mirtazapine, venlafaxine, atomoxetine and duloxetine. Some of the drugs used in symptomatic treatment of PD, e.g., the irreversible selective inhibitors of the enzyme monoamine oxidase-B, rasagiline and selegiline as well as the dopamine receptor agonist pramipexole are likely to have direct antidepressant activity independent of their motor improving action. This would make these drugs an attractive option in depressed subjects with PD. The aim of this review is to provide an updated data on the prevalence, clinical features of depression in subjects with PD. The effects of antiparkinsonian and antidepressant drugs on depressive symptoms in these patients are also discussed.
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Alamri A, Ughratdar I, Samuel M, Ashkan K. Deep brain stimulation of the subthalamic nucleus in Parkinson's disease 2003–2013: Where are we another 10 years on? Br J Neurosurg 2015; 29:319-28. [DOI: 10.3109/02688697.2014.997669] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Kocabicak E, Temel Y, Höllig A, Falkenburger B, Tan SK. Current perspectives on deep brain stimulation for severe neurological and psychiatric disorders. Neuropsychiatr Dis Treat 2015; 11:1051-66. [PMID: 25914538 PMCID: PMC4399519 DOI: 10.2147/ndt.s46583] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Deep brain stimulation (DBS) has become a well-accepted therapy to treat movement disorders, including Parkinson's disease, essential tremor, and dystonia. Long-term follow-up studies have demonstrated sustained improvement in motor symptoms and quality of life. DBS offers the opportunity to selectively modulate the targeted brain regions and related networks. Moreover, stimulation can be adjusted according to individual patients' demands, and stimulation is reversible. This has led to the introduction of DBS as a treatment for further neurological and psychiatric disorders and many clinical studies investigating the efficacy of stimulating various brain regions in order to alleviate severe neurological or psychiatric disorders including epilepsy, major depression, and obsessive-compulsive disorder. In this review, we provide an overview of accepted and experimental indications for DBS therapy and the corresponding anatomical targets.
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Affiliation(s)
- Ersoy Kocabicak
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, the Netherlands ; Department of Neuroscience, Maastricht University, Maastricht, the Netherlands ; Department of Neurosurgery, Ondokuz Mayıs University, Samsun, Turkey
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, the Netherlands ; Department of Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Anke Höllig
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | | | - Sonny Kh Tan
- Department of Neuroscience, Maastricht University, Maastricht, the Netherlands ; Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
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Okun MS, Wu SS, Fayad S, Ward H, Bowers D, Rosado C, Bowen L, Jacobson C, Butson C, Foote KD. Acute and Chronic Mood and Apathy Outcomes from a randomized study of unilateral STN and GPi DBS. PLoS One 2014; 9:e114140. [PMID: 25469706 PMCID: PMC4254912 DOI: 10.1371/journal.pone.0114140] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 11/03/2014] [Indexed: 12/13/2022] Open
Abstract
Objective To study mood and behavioral effects of unilateral and staged bilateral subthalamic nucleus (STN) and globus pallidus internus (GPi) deep brain stimulation (DBS) for Parkinson's disease (PD). Background There are numerous reports of mood changes following DBS, however, most have focused on bilateral simultaneous STN implants with rapid and aggressive post-operative medication reduction. Methods A standardized evaluation was applied to a subset of patients undergoing STN and GPi DBS and who were also enrolled in the NIH COMPARE study. The Unified Parkinson Disease Rating Scale (UPDRS III), the Hamilton depression (HAM-D) and anxiety rating scales (HAM-A), the Yale-Brown obsessive-compulsive rating scale (YBOCS), the Apathy Scale (AS), and the Young mania rating scale (YMRS) were used. The scales were repeated at acute and chronic intervals. A post-operative strategy of non-aggressive medication reduction was employed. Results Thirty patients were randomized and underwent unilateral DBS (16 STN, 14 GPi). There were no baseline differences. The GPi group had a higher mean dopaminergic dosage at 1-year, however the between group difference in changes from baseline to 1-year was not significant. There were no differences between groups in mood and motor outcomes. When combining STN and GPi groups, the HAM-A scores worsened at 2-months, 4-months, 6-months and 1-year when compared with baseline; the HAM-D and YMRS scores worsened at 4-months, 6-months and 1-year; and the UPDRS Motor scores improved at 4-months and 1-year. Psychiatric diagnoses (DSM-IV) did not change. No between group differences were observed in the cohort of bilateral cases. Conclusions There were few changes in mood and behavior with STN or GPi DBS. The approach of staging STN or GPi DBS without aggressive medication reduction could be a viable option for managing PD surgical candidates. A study of bilateral DBS and of medication reduction will be required to better understand risks and benefits of a bilateral approach.
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Affiliation(s)
- Michael S. Okun
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
- Department of Neurosurgery, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
- * E-mail:
| | - Samuel S. Wu
- Department of Biostatistics, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
| | - Sarah Fayad
- Department of Psychiatry, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
| | - Herbert Ward
- Department of Psychiatry, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
| | - Dawn Bowers
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
- Department of Clinical and Health Psychology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
| | - Christian Rosado
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
| | - Lauren Bowen
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
| | - Charles Jacobson
- Department of Neurology, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
| | - Christopher Butson
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Kelly D. Foote
- Department of Neurosurgery, Center for Movement Disorders and Neurorestoration, University of Florida, Gainesville, Gainesville, FL, United States of America
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84
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Castelli L, Tonello D, Rizzi L, Zibetti M, Lanotte M, Lopiano L. Alexithymia in patients with Parkinson's disease treated with DBS of the subthalamic nucleus: a case-control study. Front Psychol 2014; 5:1168. [PMID: 25352821 PMCID: PMC4195283 DOI: 10.3389/fpsyg.2014.01168] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 09/26/2014] [Indexed: 01/04/2023] Open
Abstract
Objectives: To evaluate the effect of deep brain stimulation of the subthalamic nucleus (STN-DBS) on alexithymia, a deficit in affective regulation, comparing patients with Parkinson’s disease (PD) submitted to STN-DBS (DBS group) to PD patients not yet treated with STN-DBS (pre-DBS group) and to healthy participants (C group). Methods: We recruited 27 consecutive STN-DBS PD patients, 38 consecutive pre-DBS patients and 27 healthy participants. Patients were assessed for alexithymia (Toronto Alexithymia Scale), depression, [beck depression inventory (BDI)], and cognitive functions (reasoning, memory, attentional, and executive tests). Results: The DBS patients performed worse than the pre-DBS patients in the corsi’s block-tapping test, in the phonemic fluency task and in the Frontal Assessment Battery. Around 30% of DBS (29.6%) and pre-DBS (31.6%) patients resulted alexithymic, compared with 14.8% in the C group. The results pointed out significantly higher alexithymia scores in both the DBS and pre-DBS groups compared with the C group, while no difference emerged between the DBS and pre-DBS groups. Pre-DBS group showed a significantly higher BDI score than the C group, while DBS group did not. Conclusion: Although the results suggest that STN-DBS does not affect alexithymia, both the DBS and pre-DBS patients reported higher prevalence (about 30%) of alexithymia than did healthy subjects (14.8%).
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Affiliation(s)
- Lorys Castelli
- Department of Psychology, University of Turin Turin, Italy
| | - Debora Tonello
- Department of Psychology, University of Turin Turin, Italy
| | - Laura Rizzi
- Department of Neuroscience, University of Turin Turin, Italy
| | | | - Michele Lanotte
- Department of Neuroscience, University of Turin Turin, Italy
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Heumann R, Moratalla R, Herrero MT, Chakrabarty K, Drucker-Colín R, Garcia-Montes JR, Simola N, Morelli M. Dyskinesia in Parkinson's disease: mechanisms and current non-pharmacological interventions. J Neurochem 2014; 130:472-89. [DOI: 10.1111/jnc.12751] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 04/23/2014] [Accepted: 04/27/2014] [Indexed: 01/24/2023]
Affiliation(s)
- Rolf Heumann
- Molecular Neurobiochemistry; Ruhr-University Bochum; Bochum Germany
| | | | - Maria Trinidad Herrero
- Clinical & Experimental Neuroscience (NiCE-CIBERNED); School of Health Sciences; University Jaume I; Castelló, and School of Medicine; University of Murcia; Murcia Spain
| | | | - René Drucker-Colín
- Instituto de Fisiología Celular; Universidad Nacional Autónoma de México; Mexico City México
| | | | - Nicola Simola
- Department of Biomedical Sciences; Section of Neuropsychopharmacology; University of Cagliari; Cagliari Italy
| | - Micaela Morelli
- Department of Biomedical Sciences; Section of Neuropsychopharmacology; University of Cagliari; Cagliari Italy
- National Institute of Neuroscience (INN); University of Cagliari; Cagliari Italy
- National Research Council (CNR); Neuroscience Institute; Cagliari Italy
- Center of Excellence on Neurobiology of Dependence; University of Cagliari; Cagliari Italy
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86
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Børretzen MN, Bjerknes S, Sæhle T, Skjelland M, Skogseid IM, Toft M, Dietrichs E. Long-term follow-up of thalamic deep brain stimulation for essential tremor - patient satisfaction and mortality. BMC Neurol 2014; 14:120. [PMID: 24903550 PMCID: PMC4052337 DOI: 10.1186/1471-2377-14-120] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Accepted: 05/29/2014] [Indexed: 11/11/2022] Open
Abstract
Background Ventral intermediate thalamic nucleus (VIM) deep brain stimulation (DBS) is an effective treatment for tremor, but there is limited data on long-term efficacy and mortality after VIM-DBS. Here we report the analysis of patient satisfaction and mortality in all patients treated in our center 1996–2010 with VIM-DBS for essential tremor (ET). Methods Forty-six consecutive patients were included in this study. Medical records were reviewed, and a follow-up questionnaire was sent to all surviving patients. Results Seventy percent of all possible participants (26 patients) answered the questionnaire. Follow-up time for the responding patients was median 6.0 years (2–16). Median self-reported score on visual analogue scale of the initial postoperative effect on tremor was 8.5 (0.1–10), with a significant reduction to 7.4 (0–10) at follow-up (p = 0.001). Patients reported a median score of 10 (0–10) for overall patient satisfaction with VIM-DBS treatment. Eight patients (17%) died after median 8.9 years (0.6–15) after surgery, at median age 77.4 years (70–89). One patient (2%) committed suicide seven months after the operation. Calculated standard mortality ratio among ET patients was 1.3 (CI 0.6–2.6), similar to the general population. Conclusion We found no significant increase in mortality in this cohort of VIM-DBS operated ET patients compared to the general population in Norway. The patients reported high long-term satisfaction and continuing effect of VIM-DBS on tremor even after many years. VIM-DBS therefore seems to be an effective symptomatic long-term treatment of ET. However, one patient committed suicide. Only one other suicide has previously been reported after VIM-DBS. It is therefore still unclear whether VIM-DBS increases suicide risk.
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Affiliation(s)
| | | | | | | | | | | | - Espen Dietrichs
- Department of Neurology, Oslo University Hospital, PO Box 4950, Nydalen N-0424 Oslo, Norway.
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87
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Abstract
Depressive disturbances are common in patients with Parkinson's disease (PD) and influence many other clinical aspects of the disease. In addition to causing inherent emotional distress, depressive disorders negatively impact quality of life, motor and cognitive deficits, functional disability, and other psychiatric comorbidities in patients with PD. Knowledge of the pathophysiology of PD depression remains limited. However, clinical studies demonstrate the efficacy of medications and psychotherapies for PD depression, underscoring the importance of their timely detection and concerted management.
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88
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Williams NR, Foote KD, Okun MS. STN vs. GPi Deep Brain Stimulation: Translating the Rematch into Clinical Practice. Mov Disord Clin Pract 2014; 1:24-35. [PMID: 24779023 DOI: 10.1002/mdc3.12004] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
When formulating a deep brain stimulation (DBS) treatment plan for a patient with Parkinson's disease (PD), two critical questions should be addressed: 1- Which brain target should be chosen to optimize this patient's outcome? and 2- Should this patient's DBS operation be unilateral or bilateral? Over the past two decades, two targets have emerged as leading contenders for PD DBS; the subthalamic nucleus (STN) and the globus pallidus internus (GPi). While the GPi target does have a following, most centers have uniformly employed bilateral STN DBS for all Parkinson's disease cases (Figure 1). This bilateral STN "one-size-fits-all" approach was challenged by an editorial entitled "STN vs. GPi: The Rematch," which appeared in the Archives of Neurology in 2005. Since 2005, a series of well designed clinical trials and follow-up studies have addressed the question as to whether a more tailored approach to DBS therapy might improve overall outcomes. Such a tailored approach would include the options of targeting the GPi, or choosing a unilateral operation. The results of the STN vs. GPi 'rematch' studies support the conclusion that bilateral STN DBS may not be the best option for every Parkinson's disease surgical patient. Off period motor symptoms and tremor improve in both targets, and with either unilateral or bilateral stimulation. Advantages of the STN target include more medication reduction, less frequent battery changes, and a more favorable economic profile. Advantages of GPi include more robust dyskinesia suppression, easier programming, and greater flexibility in adjusting medications. In cases where unilateral stimulation is anticipated, the data favor GPi DBS. This review summarizes the accumulated evidence regarding the use of bilateral vs. unilateral DBS and the selection of STN vs. GPi DBS, including definite and possible advantages of different targets and approaches. Based on this evidence, a more patient-tailored, symptom specific approach will be proposed to optimize outcomes of PD DBS therapy. Finally, the importance of an interdisciplinary care team for screening and effective management of DBS patients will be reaffirmed. Interdisciplinary teams can facilitate the proposed patient-specific DBS treatment planning and provide a more thorough analysis of the risk-benefit ratio for each patient.
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Affiliation(s)
- Nolan R Williams
- Department of Psychiatry, Medical University of South Carolina, Charleston SC ; Department of Neurosciences, Medical University of South Carolina, Charleston SC
| | - Kelly D Foote
- Departments of Neurology and Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration and the McKnight Brain Institute, UF Health College of Medicine, Gainesville FL
| | - Michael S Okun
- Departments of Neurology and Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration and the McKnight Brain Institute, UF Health College of Medicine, Gainesville FL
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89
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Castrioto A, Lhommée E, Moro E, Krack P. Mood and behavioural effects of subthalamic stimulation in Parkinson's disease. Lancet Neurol 2014; 13:287-305. [PMID: 24556007 DOI: 10.1016/s1474-4422(13)70294-1] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Deep-brain stimulation (DBS) of the subthalamic nucleus (STN) is an established treatment for motor complications in Parkinson's disease. 20 years of experience with this procedure have contributed to improved understanding of the role of the STN in motor, cognitive, and emotional control. In Parkinson's disease, the pathological STN neuronal activity leads to motor, cognitive, and emotional inhibition. Deafferentation of the STN by DBS can reverse such behavioural inhibition. The release of this brake allows both motor and non-motor improvement, but can also be associated with excessive motor, cognitive, and emotional behavioural disinhibition. Conversely, the notable reduction in anti-parkinsonian drug dose allowed by motor improvement can unveil mesolimbic hypodopaminergic behaviours such as apathy, anxiety, or depression. Fine-tuning of stimulation parameters with dopaminergic drugs is necessary to prevent or improve pathological behaviours.
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Affiliation(s)
- Anna Castrioto
- Movement Disorder Unit, Department of Psychiatry and Neurology, Centre Hospitalier Universitaire de Grenoble, Joseph Fourier University, Grenoble, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Unit 836, Grenoble Institut des Neurosciences, Grenoble, France; Clinica Neurologica, Università di Perugia, Ospedale Santa Maria della Misericordia, Perugia, Italy
| | - Eugénie Lhommée
- Movement Disorder Unit, Department of Psychiatry and Neurology, Centre Hospitalier Universitaire de Grenoble, Joseph Fourier University, Grenoble, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Unit 836, Grenoble Institut des Neurosciences, Grenoble, France
| | - Elena Moro
- Movement Disorder Unit, Department of Psychiatry and Neurology, Centre Hospitalier Universitaire de Grenoble, Joseph Fourier University, Grenoble, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Unit 836, Grenoble Institut des Neurosciences, Grenoble, France
| | - Paul Krack
- Movement Disorder Unit, Department of Psychiatry and Neurology, Centre Hospitalier Universitaire de Grenoble, Joseph Fourier University, Grenoble, France; Institut National de la Santé et de la Recherche Médicale (INSERM), Unit 836, Grenoble Institut des Neurosciences, Grenoble, France.
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90
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Quinn DK, Deligtisch A, Rees C, Brodsky A, Evans D, Khafaja M, Abbott CC. Differential diagnosis of psychiatric symptoms after deep brain stimulation for movement disorders. Neuromodulation 2014; 17:629-36; discussion 636. [PMID: 24512146 DOI: 10.1111/ner.12153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 11/28/2013] [Accepted: 12/12/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The presence of a deep brain stimulator (DBS) in a patient with a movement disorder who develops psychiatric symptoms poses unique diagnostic and therapeutic challenges for the treating clinician. Few sources discuss approaches to diagnosing and treating these symptoms. MATERIALS AND METHODS The authors review the literature on psychiatric complications in DBS for movement disorders and propose a heuristic for categorizing symptoms according to their temporal relationship with the DBS implantation process. RESULTS Psychiatric symptoms after DBS can be categorized as preimplantation, intra-operative/perioperative, stimulation related, device malfunction, medication related, and chronic stimulation related/long term. Once determined, the specific etiology of a symptom guides the practitioner in treatment. CONCLUSIONS A structured approach to psychiatric symptoms in DBS patients allows practitioners to effectively diagnose and treat them when they arise.
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Affiliation(s)
- Davin K Quinn
- Department of Psychiatry, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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91
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Perestelo-Pérez L, Rivero-Santana A, Pérez-Ramos J, Serrano-Pérez P, Panetta J, Hilarion P. Deep brain stimulation in Parkinson’s disease: meta-analysis of randomized controlled trials. J Neurol 2014; 261:2051-60. [DOI: 10.1007/s00415-014-7254-6] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 01/14/2014] [Accepted: 01/16/2014] [Indexed: 12/21/2022]
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Wagle Shukla A, Okun MS. Surgical treatment of Parkinson's disease: patients, targets, devices, and approaches. Neurotherapeutics 2014; 11:47-59. [PMID: 24198187 PMCID: PMC3899492 DOI: 10.1007/s13311-013-0235-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Surgical treatment for Parkinson's disease (PD) has evolved from ablative procedures, within a variety of brain regions, to implantation of electrodes into specific targets of the basal ganglia. Electrode implantation surgery, referred to as deep brain stimulation (DBS), is preferred to ablative procedures by many experts owing to its reversibility, programmability, and the ability to be safely performed bilaterally. Several randomized clinical studies have demonstrated the effectiveness of DBS surgery for control of PD symptoms. Many brain targets, including the subthalamic nucleus and the globus pallidus internus, have emerged as potentially effective, with each target being closely associated with important pros and cons. Selection of appropriate PD candidates through a methodical interdisciplinary screening is considered a prerequisite for a successful surgical outcome. Despite recent growth in DBS knowledge, there is currently no consensus on the ideal surgical technique, the best surgical approach, and the most appropriate surgical target. DBS is now targeted towards treating specific PD-related symptoms in a given individual, and not simply addressing the disease with one pre-defined approach. In this review we will discuss the historical aspects of surgical treatments, the selection of an appropriate DBS candidate, the current surgical techniques, and recently introduced DBS-related technologies. We will address important pre- and postoperative issues related to DBS. We will also discuss the lessons learned from the randomized clinical studies for DBS and the shifting paradigm to tailor to a more patient-centered and symptom-specific approach.
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Affiliation(s)
- Aparna Wagle Shukla
- Center for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, 3450 Hull Road, Gainesville, FL, 32607, USA,
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93
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Jahanshahi M. Effects of deep brain stimulation of the subthalamic nucleus on inhibitory and executive control over prepotent responses in Parkinson's disease. Front Syst Neurosci 2013; 7:118. [PMID: 24399941 PMCID: PMC3872293 DOI: 10.3389/fnsys.2013.00118] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 12/06/2013] [Indexed: 12/19/2022] Open
Abstract
Inhibition of inappropriate, habitual or prepotent responses is an essential component of executive control and a cornerstone of self-control. Via the hyperdirect pathway, the subthalamic nucleus (STN) receives inputs from frontal areas involved in inhibition and executive control. Evidence is reviewed from our own work and the literature suggesting that in Parkinson's disease (PD), deep brain stimulation (DBS) of the STN has an impact on executive control during attention-demanding tasks or in situations of conflict when habitual or prepotent responses have to be inhibited. These results support a role for the STN in an inter-related set of processes: switching from automatic to controlled processing, inhibitory and executive control, adjusting response thresholds and influencing speed-accuracy trade-offs. Such STN DBS-induced deficits in inhibitory and executive control may contribute to some of the psychiatric problems experienced by a proportion of operated cases after STN DBS surgery in PD. However, as no direct evidence for such a link is currently available, there is a need to provide direct evidence for such a link between STN DBS-induced deficits in inhibitory and executive control and post-surgical psychiatric complications experienced by operated patients.
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Affiliation(s)
- Marjan Jahanshahi
- Cognitive Motor Neuroscience Group and Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, The National Hospital for Neurology and Neurosurgery London, UK
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94
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Subthalamic neurostimulation for Parkinson's disease with early fluctuations: balancing the risks and benefits. Lancet Neurol 2013; 12:1025-34. [PMID: 24050735 DOI: 10.1016/s1474-4422(13)70151-0] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Electrical stimulation of the subthalamic nucleus is an established treatment for patients with advanced Parkinson's disease with pharmacologically unresponsive fluctuations. Compared with pharmacological treatment, subthalamic neurostimulation significantly improves motor symptoms, particularly during the phases of poor response to drug treatment, and reduces the severity of dyskinesias. Importantly, it also significantly improves quality of life and other integral measures of disease severity. The treatment response can last for more than 10 years, although there is no evidence that levodopa-resistant symptoms are delayed by subthalamic neurostimulation. At present, the mean disease duration for patients at the time of implantation is 12 years. In a recent study (EARLYSTIM) in patients with a disease duration of 7·5 years and fluctuations for 1·5 years, similar improvements in clinical outcomes were reported. These findings suggest that neurostimulation of the subthalamic nucleus could be used earlier in the disease course for carefully selected patients if the benefits of the treatment are weighed against the surgical risks and the lifelong need for specialised care by an experienced team. As mobility is consistently improved during the times with poor mobility by reducing fluctuations and delaying levodopa-sensitive complications, we propose that this treatment changes the disease course.
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95
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Eggington S, Valldeoriola F, Chaudhuri KR, Ashkan K, Annoni E, Deuschl G. The cost-effectiveness of deep brain stimulation in combination with best medical therapy, versus best medical therapy alone, in advanced Parkinson's disease. J Neurol 2013; 261:106-16. [PMID: 24158271 PMCID: PMC3895185 DOI: 10.1007/s00415-013-7148-z] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 10/04/2013] [Accepted: 10/04/2013] [Indexed: 11/11/2022]
Abstract
Parkinson’s disease (PD) is a complex progressive movement disorder leading to motor and non-motor symptoms that become increasingly debilitating as the disease advances, considerably reducing quality of life. Advanced treatment options include deep brain stimulation (DBS). While clinical effectiveness of DBS has been demonstrated in a number of randomised controlled trials (RCT), evidence on cost-effectiveness is limited. The cost-effectiveness of DBS combined with BMT, versus BMT alone, was evaluated from a UK payer perspective. Individual patient-level data on the effect of DBS on PD symptom progression from a large 6-month RCT were used to develop a Markov model representing clinical progression and capture treatment effect and costs. A 5-year time horizon was used, and an incremental cost-effectiveness ratio (ICER) was calculated in terms of cost per quality-adjusted life-years (QALY) and uncertainty assessed in deterministic sensitivity analyses. Total discounted costs in the DBS and BMT groups over 5 years were £68,970 and £48,243, respectively, with QALYs of 2.21 and 1.21, giving an incremental cost-effectiveness ratio of £20,678 per QALY gained. Utility weights in each health state and costs of on-going medication appear to be the key drivers of uncertainty in the model. The results suggest that DBS is a cost-effective intervention in patients with advanced PD who are eligible for surgery, providing good value for money to health care payers.
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Affiliation(s)
- Simon Eggington
- Medtronic International Trading Sàrl, Route du Molliau 31, 1131, Tolochenaz, Switzerland,
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96
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Voon V, Howell NA, Krack P. Psychiatric considerations in deep brain stimulation for Parkinson’s disease. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:147-54. [DOI: 10.1016/b978-0-444-53497-2.00012-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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