Ten-year outcome of subthalamic stimulation in Parkinson disease: a blinded evaluation.
ABSTRACT To assess the 10-year motor outcome of deep brain stimulation of the subthalamic nucleus (STN-DBS) in patients with Parkinson disease (PD).
Patients with PD with bilateral STN-DBS were assessed according to the Core Assessment Program for Surgical Interventional Therapies in Parkinson's Disease protocol and videotaped at baseline and 1, 5, and 10 years after surgery. An independent rater blinded to stimulation and medication condition scored the 10-year video assessments.
Movement Disorders Centre, Toronto Western Hospital, University Health Network, University of Toronto.
Eighteen patients with advanced PD and 10-year follow-up of STN-DBS.
Bilateral STN-DBS surgery.
The primary outcome was the change in blinded Unified Parkinson's Disease Rating Scale (UPDRS) motor scores/subscores between the no medication/stimulation condition vs the no medication/no stimulation condition at 10 years. Secondary outcomes were the changes in blinded UPDRS motor scores between the medication/no stimulation and medication/stimulation conditions, UPDRS II scores, UPDRS IV dyskinesia and motor fluctuations scores, and anti-PD medication dose (levodopa equivalent daily dose) at different points.
In the 18 patients available for follow-up at 10 years, STN-DBS still significantly improved the UPDRS total motor score (P = .007) and resting and action tremor (P < .01 and P = .02, respectively) and bradykinesia (P = .01) subscores. The UPDRS II scores in the medication and no medication conditions, UPDRS IV dyskinesia and motor fluctuations scores, and the levodopa equivalent daily dose were also significantly reduced compared with baseline. Axial signs showed the most progressive decline in stimulation and levodopa response over the years.
This class III study provides evidence that stimulation-induced motor improvement was sustained overall at 10 years, although part of the initial benefit wore off mainly because of progressive loss of benefit on axial signs over time.
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ABSTRACT: The last decade has seen major progress at all levels of neuroscience, from genes and molecules up to integrated systems-level models of brain function. In particular, there have been advances in the understanding of cell-type-specific contributions to function, together with a clearer account of how these contributions are coordinated from moment to moment to organise behavior. A major current endeavor is to leverage this knowledge to develop new therapeutic approaches. In Parkinson’s disease, there are a number of promising emerging treatments. Here, we will highlight three ambitious novel therapeutic approaches for this condition, each robustly driven by primary neuroscience. Pharmacogenetics genetically re-engineers neurons to produce neurotrophins that are neuroprotective to vulnerable dopaminergic cells or to directly replace dopamine through enzyme transduction. Deep brain stimulation (DBS) is undergoing a transformation, with adaptive DBS controlled by neural signals resulting in better motor outcomes and significant reductions in overall stimulation that could reduce side effects. Finally, optogenetics presents the opportunity to achieve cell-type-specific control with a high temporal specification on a large enough scale to effectively repair network-level dysfunction.Current Biology 09/2014; 24(18):R898–R909. · 9.92 Impact Factor
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ABSTRACT: Background Subthalamic nucleus (STN) deep brain stimulation (DBS) is a treatment option for patients with Parkinson's disease (PD) who have motor complications such as wearing off and dyskinesia. However, in some cases, the benefits of STN-DBS seem to diminish over time.AimWe investigated the reasons for hospitalization of PD patients who were previously implanted with DBS devices, and reviewed the management of problems related to DBS- and/or PD-related neurological symptoms. We also aimed to investigate the efficacy of our management of problems related to PD and/or DBS.MethodsA retrospective chart review was conducted on all hospitalized cases of patients who were previously implanted STN-DBS at our hospital or other institutions.ResultsA total of seventy-eight hospitalizations (47 STN-DBS patients) were identified. Thirty-four hospitalizations (24 STN-DBS patients) were due to worsening of PD-related or stimulation-related problems. The reasons for 34 hospitalizations included wearing-off/on-off (n=17), dyskinesia (n=12), gait disturbance (n=5), dysarthria (n=4), camptocormia (n=5), hallucination (n=6), and other psychiatric problems (n=10). Most of these problems were successfully managed by adjusting both medications and stimulation parameters (31 cases, 91.2%). No case was improved by only adjusting stimulation. The Unified Parkinoson's Disease Rating Scale part III score improved by 24.5% (pre 25.4±11.9 points, post 19.2±9.6, p=.02) by hospitalized management.Conclusion Appropriate management of medications and stimulation are the most important for patients who already underwent DBS in order to maximize the benefits of DBS.This article is protected by copyright. All rights reserved.Neurology and Clinical Neuroscience. 08/2014;
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ABSTRACT: We review the current application of deep brain stimulation (DBS) in Parkinson disease (PD) and consider the evidence that earlier use of DBS confers long-term symptomatic benefit for patients compared to best medical therapy. Electronic searches were performed of PubMed, Web of Knowledge, Embase, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials to identify all article types relating to the timing of DBS in PD. Current evidence suggests that DBS is typically performed in late stage PD, a mean of 14 to 15 years after diagnosis. Current guidelines recommend that PD patients who are resistant to medical therapies, have significant medication side effects and lengthening off periods, but are otherwise cognitively intact and medically fit for surgery be considered for DBS. If these criteria are rigidly interpreted, it may be that, by the time medical treatment options have been exhausted, the disease has progressed to the point that the patient may no longer be fit for neurosurgical intervention. From the evidence available, we conclude that surgical management of PD alone or in combination with medical therapy results in greater improvement of motor symptoms and quality of life than medical treatment alone. There is evidence to support the use of DBS in less advanced PD and that it may be appropriate for earlier stages of the disease than for which it is currently used. The improving short and long-term safety profile of DBS makes early application a realistic possibility. Ann Neurol 2013;73:565–575Annals of Neurology 05/2013; 73(5). · 11.91 Impact Factor