Direction and Predictive Factors for the Shift of Brain Structure During Deep Brain Stimulation Electrode Implantation for Advanced Parkinson's Disease

Objectives. The aims of this study were to clarify the direction and degree of brain shift, and to determine the predictive factors for a brain shift during deep brain stimulation (DBS) of the subthalamic nucleus (STN). Materials and Methods. To evaluate the brain shift during bilateral STN‐DBS, the position of the anterior commissure (AC), posterior commissure (PC), midcommissure point (MC), and tip of the frontal lobe and anterior horn of the lateral ventricle were calculated pre‐ and poststereotactic operations in the three‐dimensional direction employing special software (Leksell SurgiPlan). To determine the predictive factors for a brain shift, patient's age, operation hours, width of the third ventricle, bicaudate index (BCI), and cella media index (CMI) were compared with the shift of MC. Results. In 50 patients, the MC shifted mainly in the posterior direction (y‐axis: 1.27 ± 0.7 mm), and the shifts in the inferior direction (z‐axis: 0.11 ± 0.43 mm) and lateral direction (x‐axis: 0.02 ± 0.39 mm) were small. The shift of the MC in the posterior direction correlated well with the shift of the tip of the anterior lobe and anterior horn. Among the predictive factors examined, namely, the patient's age, operation hours, width of the third ventricle, BCI, and CMI, only the CMI showed a correlation with the shift of the MC (r = 0.42, p < 0.01, Pearson's correlation coefficient; and p < 0.05, logistic regression analysis). Conclusions. In bilateral STN‐DBS, brain shift occurred mainly in the posterior direction, and the CMI is useful for the prediction of a brain shift. Enlargement of the body part of the lateral ventricle is the most reliable factor for predicting a brain shift.     

Cognitive Effects of Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease with GBA1 Pathogenic Variants

Genetic subtyping of patients with Parkinson's disease (PD) may assist in predicting the cognitive and motor outcomes of subthalamic deep brain stimulation (STN-DBS). Practical questions were recently raised with the emergence of new data regarding suboptimal cognitive outcomes after STN-DBS in individuals with PD associated with pathogenic variants in glucocerebrosidase gene (GBA1-PD). However, a variety of gaps and controversies remain. (1) Does STN-DBS truly accelerate cognitive deterioration in GBA1-PD? If so, what is the clinical significance of this acceleration? (2) How should the overall risk-to-benefit ratio of STN-DBS in GBA1-PD be established? (3) If STN-DBS has a negative effect on cognition in GBA1-PD, how can this effect be minimized? (4) Should PD patients be genetically tested before STN-DBS? (5) How should GBA1-PD patients considering STN-DBS be counseled? We aim to summarize the currently available relevant data and detail the gaps and controversies that exist pertaining to these questions. In the absence of evidence-based data, all authors strongly agree that clinicians should not categorically deny DBS to PD patients based solely on genotype (GBA1 status). We suggest that PD patients considering DBS may be offered genetic testing for GBA1, where available and feasible, so the potential risks and benefits of STN-DBS can be properly weighed by both the patient and clinician. © 2023 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.     

Cost‐effectiveness of deep brain stimulation in patients with Parkinson's disease

In addition to medical treatment, deep brain stimulation has become an alternative therapeutic option in advanced Parkinson's disease. High initial costs of surgery have to be weighted against long‐term gains in health‐related quality of life. The objective of this study was to assess the cost‐effectiveness of deep brain stimulation compared with long‐term medical treatment. We performed a cost‐utility analysis using a lifetime Markov model for Parkinson's disease. Health utilities were evaluated using the EQ‐5D generic health status measure. Data on effectiveness and adverse events were obtained from clinical studies, published reports, or meta‐analyses. Costs were assessed from the German health care provider perspective. Both were discounted at 3% per year. Key assumptions affecting costs and health status were investigated using one‐way and two‐way sensitivity analyses. The lifetime incremental cost‐utility ratio for deep brain stimulation was €6700 per quality‐adjusted life year (QALY) and €9800 and €2500 per United Parkinson's Disease Rating Scale part II (motor experiences of daily living) and part III (motor examination) score point gained, respectively. Deep brain stimulation costs were mainly driven by the cost of surgery and of battery exchange. Health status was improved and motor complications were reduced by DBS. Sensitivity analysis revealed that battery life time was the most influential parameter, with the incremental cost‐utility ratio ranging from €20,000 per QALY to deep brain stimulation dominating medical treatment. Deep brain stimulation can be considered cost‐effective, offering a value‐for‐money profile comparable to other well accepted health care technologies. Our data support adopting and reimbursing deep brain stimulation within the German health care system. © 2013 Movement Disorder Society     

Deep Brain Stimulation of the Subthalamic and Pedunculopontine Nucleus in a Patient with Parkinson's Disease

Deep brain stimulation (DBS) of the pedunculopontine nucleus (PPN) is a novel therapy developed to treat Parkinson''s disease. We report a patient who underwent bilateral DBS of the PPN and subthalamic nucleus (STN). He suffered from freezing of gait (FOG), bradykinesia, rigidity and mild tremors. The patient underwent bilateral DBS of the PPN and STN. We compared the benefits of PPN-DBS and STN-DBS using motor and gait subscores. The PPN-DBS provided modest improvements in the gait disorder and freezing episodes, while the STN-DBS failed to improve the dominant problems. This special case suggests that PPN-DBS may have a unique role in ameliorating the locomotor symptoms and has the potential to provide improvement in FOG.     

Dyskinesia in Parkinson's Disease Treated by Deep Brain Stimulation Once Electrode Position Was Revised: Case Report

Repositioning of a subthalamic nucleus deep brain stimulation lead alleviated a parkinsonian patient's dyskinesias without the need for parkinsonian medication reduction. After the initial placement and programming, the patient was doing well. During repair of a skin erosion, the lead moved ventral and the patient developed severe dyskinesias and, when the deep brain stimulation system was on, diplopia. Multiple reprogramming attempts did not alleviate these problems. The electrode was moved dorsally by about 6 mm. Intraoperatively the patient's dyskinesias stopped with no diplopia with the stimulator on. Two years after the revision the patient is doing very well.     

Lesser-Known Aspects of Deep Brain Stimulation for Parkinson's Disease: Programming Sessions,Hardware Surgeries,Residential Care Admissions,and Deaths

ObjectiveThe long-term treatment burden, duration of community living, and survival of patients with Parkinson's disease (PD) after deep brain stimulation (DBS) implantation are unclear. This study aims to determine the frequency of programming, repeat hardware surgeries (of the intracranial electrode, implantable pulse generator [IPG], and extension-cable), and the timings of residential care and death in patients with PD treated with DBS.Materials and MethodsIn this cross-sectional, population-based study, individual-level data were collected from the Australian government covering a 15-year period (2002–2016) on 1849 patients with PD followed from DBS implantation.ResultsThe mean DBS implantation age was 62.6 years and mean follow-up 5.0 years. Mean annual programming rates were 6.9 in the first year and 2.8 in subsequent years. 51.4% of patients required repeat hardware surgery. 11.3% of patients had repeat intracranial electrode surgery (including an overall 1.1% of patients who were completely explanted). 47.6% of patients had repeat IPG/extension-cable surgery including for presumed battery depletion. 6.2% of patients had early repeat IPG/extension-cable surgery (within one year of any previous such surgery). Thirty-day postoperative mortality was 0.3% after initial DBS implantation and 0.6% after any repeat hardware surgery. 25.3% of patients were admitted into residential care and 17.4% died. The median interval to residential care and death was 10.2 years and 11.4 years, respectively. Age more than 65 years was associated with fewer repeat hardware surgeries for presumed complications (any repeat surgery of electrodes, extension-cables, and early IPG surgery) and greater rates of residential care admission and death.ConclusionsData from a large cohort of patients with PD treated with DBS found that the median life span after surgery is ten years. Repeat hardware surgery, including of the intracranial electrodes, is common. These findings support development of technologies to reduce therapy burden such as enhanced surgical navigation, hardware miniaturization, and improved battery efficiency.