Deep brain stimulation response in pathologically confirmed cases of multiple system atrophy

Deep Brain Stimulation of the Globus Pallidus Internus and Externus in Multiple System Atrophy

BACKGROUND

Multiple system atrophy with parkinsonism (MSA-P) is a progressive condition with no effective treatment.

OBJECTIVE

The aim of this study was to describe the safety and efficacy of deep brain stimulation (DBS) of globus pallidus pars interna and externa in a cohort of patients with MSA-P.

METHODS

Six patients were included. Changes in Movement Disorders Society Unified Parkinson's Disease Rating Scale Part III (MDS-UPDRS III), Parkinson's Disease Questionnaire (PDQ-39) scores, and levodopa equivalent daily dose were compared before and after DBS. Electrode localization and volume tissue activation were calculated.

RESULTS

DBS surgery did not result in any major adverse events or intraoperative complications. Overall, no differences in MDS-UPDRS III scores were demonstrated (55.2 ± 17.6 preoperatively compared with 67.3 ± 19.2 at 1 year after surgery), although transient improvement in mobility and dyskinesia was reported in some subjects.

CONCLUSIONS

Globus pallidus pars interna and externa DBS for patients with MSA-P did not result in major complications, although it did not provide significant clinical benefit as measured by MDS-UPDRS III. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Case report: Combined therapy of bilateral subthalamic nucleus deep brain stimulation and spinal cord stimulation significantly improves motor function in a patient with multiple system atrophy with predominant parkinsonism

Multiple system atrophy with predominant parkinsonism (MSA-P) is a highly incapacitating disease with a short life expectancy and symptomatic therapy is still limited. In this report, we presented the case of a 65-year-old woman with a 3-year history of severe rigidity, bradykinesia, and gait dysfunction alongside severe freezing of gait diagnosed with MSA-P. She underwent combined therapy of bilateral subthalamic nucleus deep brain stimulation (DBS) and low-thoracic spinal cord stimulation (SCS). The double-blind evaluation of the Movement Disorder Society Sponsored Revision of the Unified Parkinson's Disease Rating Scale part III and 7-m Timed Up and Go at follow-ups showed her cardinal parkinsonian symptoms benefit significantly from DBS stimulation, while the improvement of SCS was mainly embodied in lower-limb symptoms. The combined stimulation achieved a better improvement of motor function than either DBS or SCS stimulation alone. Most notably, the improvement of lower-limb symptoms was significantly enhanced by the combined stimulation.

Deep brain stimulation for atypical parkinsonism: A systematic review on efficacy and safety

BACKGROUND

Atypical Parkinsonisms (APs) -including progressive supranuclear palsy (PSP), multiple system atrophy (MSA), and dementia with Lewy bodies (DLB)- are neurodegenerative diseases lacking satisfying symptomatic therapies. Deep Brain Stimulation (DBS) is an established neurosurgical option for advanced Parkinson disease (PD). Although DBS effectiveness in PD fed expectations for the treatment of APs, DBS is still not recommended for APs on the basis of expert consensus and lack of clinical trials.

OBJECTIVE

In this systematic review, we sought to analyze current evidence on the safety and efficacy of DBS in APs, discussing clinical indications, anatomical targets, and ethical issues.

METHODS

Following the PRISMA guidelines, we systematically searched PubMed for studies reporting the outcome of patients with APs treated with DBS.

RESULTS

We identified 25 eligible studies for a total of 66 patients with APs treated with DBS: 31 PSP, 22 MSA, 12 DLB, 1 unspecified parkinsonism with tongue tremor. Targeted nuclei were subthalamic nucleus (STN), globus pallidus pars-interna (GPi), pedunculopontine nucleus (PPN), and nucleus basalis of Meynert (nbM). Only 3/25 studies were randomized controlled trials, and most studies showed a high risk of bias.

CONCLUSION

Taking into account study biases and confounding factors, current evidence does not support the use of DBS in APs. However, some interesting insights arise from the literature, such as the high frequency of cognitive/neurobehavioral issues in MSA patients treated with STN-DBS, the low frequency of complications in trials of nbM-DBS for DLB, and the possible good response of dystonic symptoms in PSP with GPi DBS.

Parkinson's disease advanced therapies - A systematic review: More unanswered questions than guidance

In advanced Parkinson's disease (PD), therapeutic interventions include device-aided therapies such as continuous subcutaneous apomorphine infusion (CSAI), levodopa-carbidopa intestinal gel (LCIG) infusion, and deep brain stimulation (DBS). We reappraised the evidence guiding the decision of appropriate device-aided therapies in advanced PD, and systematically reviewed the literature (including ongoing clinical trials) comparing CSAI, LCIG, DBS in terms of efficacy and cost-effectiveness, with particular consideration to possible conflicts of interests. Of 14,980 documents screened, sixteen were included (4 and 13 studies examining efficacy and cost-effectiveness, respectively). LCIG and DBS showed higher efficacy compared to best medical therapy (BMT). DBS was more expensive than BMT and LCIG. Lifetime costs of CSAI were lower of those of DBS, and DBS lifetime costs were lower than those of LCIG. The majority of studies (11 out of 16) showed direct or indirect sponsorship from pharmaceutical or device companies. Only one ongoing clinical trial comparing LCIG with DBS was found. Device-aided therapies address unmet needs in advanced PD. LCIG and DBS are superior to BMT in head-to-head studies; however, initial and lifetime costs should be considered when choosing those therapies. Guidelines to assist clinicians and patients to choose device-aided therapies, free from conflict of interests, are required.

Patient Satisfaction in Surgery for Parkinson's Disease: A Systematic Review of the Literature

The objective of the study was to establish how patient satisfaction with surgical treatment of Parkinson's disease (PD) has been previously measured, determine whether an ideal patient satisfaction instrument exists, and to define the dimensions of care that determine patient satisfaction with the surgical treatment of PD.

A systematic search of four online databases, unpublished sources, and citations was undertaken to identify 15 studies reporting patient satisfaction with the surgical treatment of PD. Manuscripts were reviewed and instruments were categorized by content and method axes. One study was found to utilize two distinct patient satisfaction instruments, which brought the total number of satisfaction instruments assessed to 16. Major factors influencing patient satisfaction were identified and served as a structure to define the dimensions of patient satisfaction in the surgical treatment of PD.

Studies used predominantly multidimensional (10/16), rather than global (6/16) satisfaction instruments. Generic (12/16) rather than disease-specific (4/16) instruments were utilized more frequently. Every study reported on satisfaction with outcome and four studies reported on satisfaction with outcome and care. Six dimensions of patient status, outcome and care experience affecting patient satisfaction were identified: motor function, patient-specific health characteristics, programming/long-term care, surgical considerations, device/hardware, and functional independence. 

At present, no patient satisfaction instrument exists that is disease-specific and covers all dimensions of patient satisfaction in surgery for PD. For quality improvement, such a disease-specific, comprehensive patient satisfaction instrument should be designed, and, if demonstrated to be reliable and valid, widely implemented.

Postmortem studies of deep brain stimulation for Parkinson's disease: a systematic review of the literature

Deep brain stimulation (DBS), arguably the greatest therapeutic advancement in the treatment of Parkinson's disease since dopamine replacement therapy, is now routinely used. While the exact mechanisms by which DBS works still remain unknown, over the past three decades since it was first described, we have gained significant insight into several of the processes involved. Though often overlooked in this regard, increasing numbers of postmortem and autopsy studies are contributing significantly to our understanding. In this manuscript, we review the literature involving the pathological findings from autopsies in patients who have undergone deep brain stimulation surgeries for Parkinson's disease. The major results show that multiple stereotactic targeting methods can be accurate at placing leads in the desired nuclei that help with clinically effective results, that perioperative complications and inaccurate diagnosis as determined by autopsy can lead to suboptimal stimulation effect and that the normal long-term effects of chronic stimulation include fibrosis around the electrodes and a mild immune response. In addition, recent results suggest mechanisms by which DBS might be effective in Parkinson's disease i.e., through rescuing pathological changes in microvasculature and by promoting the proliferation of neural progenitor cells.

Current Concepts in the Treatment of Multiple System Atrophy

MSA is a progressive neurodegenerative disorder characterized by autonomic failure and a variable combination of poor levodopa-responsive parkinsonism and cerebellar ataxia (CA). Current therapeutic management is based on symptomatic treatment. Almost one third of MSA patients may benefit from l-dopa for the symptomatic treatment of parkinsonism, whereas physiotherapy remains the best therapeutic option for CA. Only midodrine and droxidopa were found to be efficient for neurogenic hypotension in double-blind, controlled studies, whereas other symptoms of autonomic failure may be managed with off-label treatments. To date, no curative treatment is available for MSA. Recent results of neuroprotective and -restorative trials have provided some hope for future advances. Considerations for future clinical trials are also discussed in this review.

Deep brain stimulation in multiple system atrophy mimicking idiopathic Parkinson's disease

Deep brain stimulation (DBS) is approved for idiopathic Parkinson's disease (IPD) but has a poor evidence base in Parkinson-plus syndromes such as multiple system atrophy (MSA). We describe the clinical and neuropathological findings in a man who was initially diagnosed with IPD, in whom DBS was unsuccessful, and in whom MSA was unexpectedly diagnosed at a subsequent autopsy. This case report highlights that DBS is often unsuccessful in MSA and also demonstrates that MSA can masquerade as IPD, which may explain treatment failure in a small group of patients apparently suffering from Parkinson's disease. Additionally, it also presents a case with an unusually long duration of disease prior to death, comparable only to a handful of other cases in the literature.

The natural history of multiple system atrophy: a prospective European cohort study

BACKGROUND

Multiple system atrophy (MSA) is a fatal and still poorly understood degenerative movement disorder that is characterised by autonomic failure, cerebellar ataxia, and parkinsonism in various combinations. Here we present the final analysis of a prospective multicentre study by the European MSA Study Group to investigate the natural history of MSA.

METHODS

Patients with a clinical diagnosis of MSA were recruited and followed up clinically for 2 years. Vital status was ascertained 2 years after study completion. Disease progression was assessed using the unified MSA rating scale (UMSARS), a disease-specific questionnaire that enables the semiquantitative rating of autonomic and motor impairment in patients with MSA. Additional rating methods were applied to grade global disease severity, autonomic symptoms, and quality of life. Survival was calculated using a Kaplan-Meier analysis and predictors were identified in a Cox regression model. Group differences were analysed by parametric tests and non-parametric tests as appropriate. Sample size estimates were calculated using a paired two-group t test.

FINDINGS

141 patients with moderately severe disease fulfilled the consensus criteria for MSA. Mean age at symptom onset was 56·2 (SD 8·4) years. Median survival from symptom onset as determined by Kaplan-Meier analysis was 9·8 years (95% CI 8·1-11·4). The parkinsonian variant of MSA (hazard ratio [HR] 2·08, 95% CI 1·09-3·97; p=0·026) and incomplete bladder emptying (HR 2·10, 1·02-4·30; p=0·044) predicted shorter survival. 24-month progression rates of UMSARS activities of daily living, motor examination, and total scores were 49% (9·4 [SD 5·9]), 74% (12·9 [8·5]), and 57% (21·9 [11·9]), respectively, relative to baseline scores. Autonomic symptom scores progressed throughout the follow-up. Shorter symptom duration at baseline (OR 0·68, 0·5-0·9; p=0·006) and absent levodopa response (OR 3·4, 1·1-10·2; p=0·03) predicted rapid UMSARS progression. Sample size estimation showed that an interventional trial with 258 patients (129 per group) would be able to detect a 30% effect size in 1-year UMSARS motor examination decline rates at 80% power.

INTERPRETATION

Our prospective dataset provides new insights into the evolution of MSA based on a follow-up period that exceeds that of previous studies. It also represents a useful resource for patient counselling and planning of multicentre trials.