Pub Date : 2020-06-01DOI: 10.1093/med/9780190647209.003.0008
Laura S. Surillo Dahdah, P. O'Suilleabhain, Hrishikesh Dadhich, Mazen T Elkurd, Shilpa Chitnis, R. Dewey
Patient selection is critical for optimizing clinical outcomes after deep brain stimulation (DBS) surgery. Patient expectations need to be addressed before DBS surgery to avoid disappointment. There are generally accepted criteria for DBS candidacy for treatment of Parkinson disease (PD), essential tremor (ET), and dystonia. For PD, selection criteria include a diagnosis of idiopathic PD and the presence of disabling or troubling motor symptoms such as motor fluctuations or dyskinesia (despite optimized pharmacologic treatment). Medication-resistant tremor is also an indication. The response of problematic motor symptoms to dopaminergic drugs is an important predictor of DBS response, favoring selection of patients for whom levodopa substantially improves tremor, bradykinesia, and rigidity. Rarely, gait is improved with DBS, and in some cases freezing can improve, although this is not a predictable post-DBS feature. Exclusion criteria include serious medical comorbidities, uncontrolled psychiatric illness (thought and mood disorders), and dementia. Preoperative magnetic resonance imaging with extensive white matter changes, vascular malformations, severe cerebral atrophy, or hydrocephalus can also be exclusions. The patient should clearly understand the risks and benefits of DBS, which should be assessed using a preoperative multidisciplinary evaluation (neurology, neurosurgery, neuropsychology, psychiatry, and rehabilitation). Use of a social worker and/or nutritionist can also be helpful in select cases.
{"title":"Patient Selection Criteria for Deep Brain Stimulation for Parkinson Disease","authors":"Laura S. Surillo Dahdah, P. O'Suilleabhain, Hrishikesh Dadhich, Mazen T Elkurd, Shilpa Chitnis, R. Dewey","doi":"10.1093/med/9780190647209.003.0008","DOIUrl":"https://doi.org/10.1093/med/9780190647209.003.0008","url":null,"abstract":"Patient selection is critical for optimizing clinical outcomes after deep brain stimulation (DBS) surgery. Patient expectations need to be addressed before DBS surgery to avoid disappointment. There are generally accepted criteria for DBS candidacy for treatment of Parkinson disease (PD), essential tremor (ET), and dystonia. For PD, selection criteria include a diagnosis of idiopathic PD and the presence of disabling or troubling motor symptoms such as motor fluctuations or dyskinesia (despite optimized pharmacologic treatment). Medication-resistant tremor is also an indication. The response of problematic motor symptoms to dopaminergic drugs is an important predictor of DBS response, favoring selection of patients for whom levodopa substantially improves tremor, bradykinesia, and rigidity. Rarely, gait is improved with DBS, and in some cases freezing can improve, although this is not a predictable post-DBS feature. Exclusion criteria include serious medical comorbidities, uncontrolled psychiatric illness (thought and mood disorders), and dementia. Preoperative magnetic resonance imaging with extensive white matter changes, vascular malformations, severe cerebral atrophy, or hydrocephalus can also be exclusions. The patient should clearly understand the risks and benefits of DBS, which should be assessed using a preoperative multidisciplinary evaluation (neurology, neurosurgery, neuropsychology, psychiatry, and rehabilitation). Use of a social worker and/or nutritionist can also be helpful in select cases.","PeriodicalId":100359,"journal":{"name":"Deep Brain Stimulation","volume":"20 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"81459196","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-06-01DOI: 10.1093/med/9780190647209.003.0011
J. T. Hinkle, A. Butala, V. Parfenov, Kelly A. Mills, Z. Mari
Parkinson disease (PD) is a neurodegenerative disorder characterized by rest tremor, rigidity, bradykinesia, and postural instability. While most cases of PD are sporadic in nature, cases secondary to genetic mutations have been identified. These are typically monogenic and often present as early-onset or juvenile-onset PD. While rare, individuals with PD may harbor multiple pathogenic variants in PD-linked genes, potentially leading to more severe presentations. This chapter reviews available data regarding deep brain stimulation (DBS) targets and DBS outcomes in cases that are genetically proved to be PD. We report a patient with juvenile-onset PD whose course featured severe peak-dose dyskinesias and generalized off dystonias. Genetic testing supported a rare diagnosis of digenic PD, with homogenous deletions in PRKN (Parkin) and a single transition in PARK6 (PINK1). Bilateral DBS electrodes were implanted into the globus pallidus pars interna (GPi), leading to significant amelioration of both off and on symptoms.
{"title":"Genetic Mutations and Deep Brain Stimulation","authors":"J. T. Hinkle, A. Butala, V. Parfenov, Kelly A. Mills, Z. Mari","doi":"10.1093/med/9780190647209.003.0011","DOIUrl":"https://doi.org/10.1093/med/9780190647209.003.0011","url":null,"abstract":"Parkinson disease (PD) is a neurodegenerative disorder characterized by rest tremor, rigidity, bradykinesia, and postural instability. While most cases of PD are sporadic in nature, cases secondary to genetic mutations have been identified. These are typically monogenic and often present as early-onset or juvenile-onset PD. While rare, individuals with PD may harbor multiple pathogenic variants in PD-linked genes, potentially leading to more severe presentations. This chapter reviews available data regarding deep brain stimulation (DBS) targets and DBS outcomes in cases that are genetically proved to be PD. We report a patient with juvenile-onset PD whose course featured severe peak-dose dyskinesias and generalized off dystonias. Genetic testing supported a rare diagnosis of digenic PD, with homogenous deletions in PRKN (Parkin) and a single transition in PARK6 (PINK1). Bilateral DBS electrodes were implanted into the globus pallidus pars interna (GPi), leading to significant amelioration of both off and on symptoms.","PeriodicalId":100359,"journal":{"name":"Deep Brain Stimulation","volume":"5 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77846791","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-06-01DOI: 10.1093/med/9780190647209.003.0033
Qiang Zhang, T. Thomsen
Deep brain stimulation (DBS) targeting the ventral intermediate (Vim) nucleus of thalamus has been established as an effective therapy for patients with debilitating essential tremor. However, some patients initially diagnosed with essential tremor (ET) later develop idiopathic Parkinson disease (PD), and Vim DBS is not as effective for other PD-related symptoms, including bradykinesia, rigidity, and dyskinesia. This chapter describes a patient with PD who initially presented with debilitating right-dominant tremor that was misdiagnosed as ET. He received bilateral Vim DBS with good tremor control. Two years later, he received bilateral globus pallidus internus (GPi) DBS for progression of his PD, and he has been reporting adequate relief of his PD symptoms. For patients with debilitating tremor, but relatively mild or no parkinsonian symptoms on presentation, after medical trials have been administered, a Vim DBS is a reasonable option for tremor relief. A second DBS placement targeting the GPi or subthalamic nucleus (STN) may be considered if more parkinsonian symptoms evolve and progress.
{"title":"Deep Brain Stimulation Targeting the Ventral Intermediate Nucleus of the Thalamus for Parkinsonian Tremor and Later Adding the Globus Pallidus Interna for Parkinson Disease Features","authors":"Qiang Zhang, T. Thomsen","doi":"10.1093/med/9780190647209.003.0033","DOIUrl":"https://doi.org/10.1093/med/9780190647209.003.0033","url":null,"abstract":"Deep brain stimulation (DBS) targeting the ventral intermediate (Vim) nucleus of thalamus has been established as an effective therapy for patients with debilitating essential tremor. However, some patients initially diagnosed with essential tremor (ET) later develop idiopathic Parkinson disease (PD), and Vim DBS is not as effective for other PD-related symptoms, including bradykinesia, rigidity, and dyskinesia. This chapter describes a patient with PD who initially presented with debilitating right-dominant tremor that was misdiagnosed as ET. He received bilateral Vim DBS with good tremor control. Two years later, he received bilateral globus pallidus internus (GPi) DBS for progression of his PD, and he has been reporting adequate relief of his PD symptoms. For patients with debilitating tremor, but relatively mild or no parkinsonian symptoms on presentation, after medical trials have been administered, a Vim DBS is a reasonable option for tremor relief. A second DBS placement targeting the GPi or subthalamic nucleus (STN) may be considered if more parkinsonian symptoms evolve and progress.","PeriodicalId":100359,"journal":{"name":"Deep Brain Stimulation","volume":"8 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"83682658","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-06-01DOI: 10.1093/med/9780190647209.003.0024
M. Kurtis, J. R. Pérez-Sánchez
Parkinson disease (PD) patients who have undergone surgery and develop festinating gait and postural instability are challenging to diagnose and treat. This chapter describes the case of an early-onset PD patient who underwent deep brain stimulation (DBS) 4 years after disease onset due to motor and nonmotor fluctuations and medication side effects (impulse control disorder). A year after surgery, the patient developed gait and balance problems in the on-medication/on-stimulation states that resolved after turning stimulation off or withdrawing medication for 12 hours. However, other symptoms, including as bradykinesia, rigidity, and tremor, reappeared. Troubleshooting involved magnetic resonance imaging to evaluate electrode placement and complete screening of all contacts with successful reprogramming and medication adjustments. The pathophysiology of balance problems is discussed, including the synergistic effects of subthalamic nucleus DBS and dopaminergic treatment, which may lead to increased postural sway and lower limb dystonia.
{"title":"Postural Instability and Gait Disorder After Subthalamic Nucleus Deep Brain Stimulation","authors":"M. Kurtis, J. R. Pérez-Sánchez","doi":"10.1093/med/9780190647209.003.0024","DOIUrl":"https://doi.org/10.1093/med/9780190647209.003.0024","url":null,"abstract":"Parkinson disease (PD) patients who have undergone surgery and develop festinating gait and postural instability are challenging to diagnose and treat. This chapter describes the case of an early-onset PD patient who underwent deep brain stimulation (DBS) 4 years after disease onset due to motor and nonmotor fluctuations and medication side effects (impulse control disorder). A year after surgery, the patient developed gait and balance problems in the on-medication/on-stimulation states that resolved after turning stimulation off or withdrawing medication for 12 hours. However, other symptoms, including as bradykinesia, rigidity, and tremor, reappeared. Troubleshooting involved magnetic resonance imaging to evaluate electrode placement and complete screening of all contacts with successful reprogramming and medication adjustments. The pathophysiology of balance problems is discussed, including the synergistic effects of subthalamic nucleus DBS and dopaminergic treatment, which may lead to increased postural sway and lower limb dystonia.","PeriodicalId":100359,"journal":{"name":"Deep Brain Stimulation","volume":"35 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79789082","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-06-01DOI: 10.1093/med/9780190647209.003.0021
M. Moscovich
Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is a safe and long-term effective treatment for medication-refractory dystonia. However, complications and side effects may occur. Freezing of gait (FOG) is a rare phenomenon in patients with dystonia, although very frequently this complication is observed in patients with Parkinson disease (PD). FOG can be disabling and may severely impair quality of life, even when episodic. This chapter reports on a case of a 49-year-old left-handed man presenting with FOG, impairment in balance, and walking difficulty. These issues emerged 3 years after successful bilateral GPi DBS for primary generalized dystonia.
{"title":"Freezing of Gait After Bilateral Globus Pallidus Interna Deep Brain Stimulation in Generalized Dystonia","authors":"M. Moscovich","doi":"10.1093/med/9780190647209.003.0021","DOIUrl":"https://doi.org/10.1093/med/9780190647209.003.0021","url":null,"abstract":"Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is a safe and long-term effective treatment for medication-refractory dystonia. However, complications and side effects may occur. Freezing of gait (FOG) is a rare phenomenon in patients with dystonia, although very frequently this complication is observed in patients with Parkinson disease (PD). FOG can be disabling and may severely impair quality of life, even when episodic. This chapter reports on a case of a 49-year-old left-handed man presenting with FOG, impairment in balance, and walking difficulty. These issues emerged 3 years after successful bilateral GPi DBS for primary generalized dystonia.","PeriodicalId":100359,"journal":{"name":"Deep Brain Stimulation","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73763241","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2020-06-01DOI: 10.1093/med/9780190647209.003.0031
A. Ramirez-Zamora
Neuropsychiatric symptoms, including impulse control disorders and mood changes, are common nonmotor features across all Parkinson disease (PD) stages. Subthalamic nucleus (STN) deep brain stimulation (DBS) is a safe and well-established treatment for the management of refractory motor fluctuations in PD; however, it has been associated with worsening neuropsychiatric symptoms in the short and long term. Recognizing the occurrence of stimulation-induced behavioral symptoms is critical to implement effective and timely treatment. Most reports indicate that stimulation of the ventral and medial region within the STN and surrounding structures, including the substantia nigra, might account for the occurrence of acute impulsive behaviors and hypomania, requiring adopting different programming strategies aimed at limiting behavioral side effects while reducing parkinsonism. Stimulation of the most dorsal and lateral contacts can mitigate behavioral side effects after STN DBS, but specific treatment needs to be applied based on the patient’s individual neuropsychiatric and motor presentations and specific imaging-based brain localization of DBS lead contacts.
{"title":"Acute Neuropsychiatric Symptoms and Impulse Control Disorders After Subthalamic Nucleus Deep Brain Stimulation","authors":"A. Ramirez-Zamora","doi":"10.1093/med/9780190647209.003.0031","DOIUrl":"https://doi.org/10.1093/med/9780190647209.003.0031","url":null,"abstract":"Neuropsychiatric symptoms, including impulse control disorders and mood changes, are common nonmotor features across all Parkinson disease (PD) stages. Subthalamic nucleus (STN) deep brain stimulation (DBS) is a safe and well-established treatment for the management of refractory motor fluctuations in PD; however, it has been associated with worsening neuropsychiatric symptoms in the short and long term. Recognizing the occurrence of stimulation-induced behavioral symptoms is critical to implement effective and timely treatment. Most reports indicate that stimulation of the ventral and medial region within the STN and surrounding structures, including the substantia nigra, might account for the occurrence of acute impulsive behaviors and hypomania, requiring adopting different programming strategies aimed at limiting behavioral side effects while reducing parkinsonism. Stimulation of the most dorsal and lateral contacts can mitigate behavioral side effects after STN DBS, but specific treatment needs to be applied based on the patient’s individual neuropsychiatric and motor presentations and specific imaging-based brain localization of DBS lead contacts.","PeriodicalId":100359,"journal":{"name":"Deep Brain Stimulation","volume":"68 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2020-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"87805416","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"17 Deep Brain Stimulation: Techniques and Practice for Pediatrics Indications","authors":"","doi":"10.1055/b-0039-168488","DOIUrl":"https://doi.org/10.1055/b-0039-168488","url":null,"abstract":"","PeriodicalId":100359,"journal":{"name":"Deep Brain Stimulation","volume":"97 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80654248","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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