The Role of Deep Brain Stimulation in Parkinson's Disease

1. The Role of Deep Brain
Stimulation in Parkinson’s
Disease
Ade Wijaya, MD – January 2019

2. Introduction
• Shaking palsy in 1817 by James Parkinson
• Debilitating neurologic complications related to the disease
• Limitations of PD pharmacotherapy
• Surgical therapies have consequently become attractive options for
some patients with advancing disease
Fang JY, Tolleson C. The role of deep brain stimulation in Parkinson’s disease: an overview and update on new developments. Neuropsychiatric disease and treatment. 2017;13:723.

3. Limitations of PD pharmacotherapy
• Frequent dosing
• The occurrence of dyskinesias
• Neuropsychiatric and autonomic side complications
Bjornestad A, Forsaa EB, Pedersen KF, Tysnes OB, Larsen JP, Alves G. Risk and course of motor complications in a population-based incident Parkinson’s disease cohort. Parkinsonism Relat Disord.2016;22:48–53.
Witjas T, Kaphan E, Azulay JP, et al. Nonmotor fluctuations in Parkinson’s disease: frequent and disabling. Neurology. 2002;59(3):408–413.
Zesiewicz TA, Sullivan KL, Arnulf I, et al. Practice parameter: treatment of nonmotor symptoms of Parkinson disease: report of the quality standards subcommittee of the American academy of neurology.Neurology. 2010;74(11):924–931.
Martinez-Fernandez R, Schmitt E, Martinez-Martin P, Krack P. The hidden sister of motor fluctuations in Parkinson’s disease: a review on nonmotor fluctuations. Mov Disord. 2016;31(8):1080–1094.

4. Deep Brain Stimulation History
Early
1900s PD
Surgery
1980s; Dr.
Benabid
DBS
2002 FDA
approved
Fang JY, Tolleson C. The role of deep brain stimulation in Parkinson’s disease: an overview and update on new developments. Neuropsychiatric disease and treatment. 2017;13:723.

5. Deep Brain Stimulation Mechanism of Action
• Controlling levodopa-responsive motor symptoms
• Approved for tremor and can have added benefit in treating
medication-refractory PD tremor
• Inhibitory effect
- Stimulation blocked depolarization of neurons within close proximity
to the electrode
- Neurotransmitter release
Fang JY, Tolleson C. The role of deep brain stimulation in Parkinson’s disease: an overview and update on new developments. Neuropsychiatric disease and treatment. 2017;13:723.

6. Deep Brain Stimulation Indication
• Parkinson’s Disease
• Essential Tremor
• Focal Dystonia
• Under investigation: Tourrete Syndrome and OCD
movementdisorders.ufhealth.org

7. Deep Brain Stimulation Candidates
• Idiopathic PD
• < 69 years old of age
• Responding well to medication
• Relatively good cognitive function
movementdisorders.ufhealth.org

8. Deep Brain Stimulation Procedure
• Relatively safe
• Low mortality
• Complications: intracranial bleeding, seizure, stroke, hardware
malfunction, infection, prolonged length of hospitalization, and
postoperative confusion
• Side effects: Paresthesias, diplopia, and muscle contraction; Effects
on cognition, speech, and mood have also been observed with
chronic stimulation
Fang JY, Tolleson C. The role of deep brain stimulation in Parkinson’s disease: an overview and update on new developments. Neuropsychiatric disease and treatment. 2017;13:723.

9. DBS Programming and Target Selection
• There is not one single best frequency for all patients.
• It is also possible that the optimal frequency for the same patient may
change over the course of DBS therapy.
• Targets: STN and the GPi, and additional VIM (thalamus) for tremor,
also PPNa (pedunculopontine nucleus area)
Fang JY, Tolleson C. The role of deep brain stimulation in Parkinson’s disease: an overview and update on new developments. Neuropsychiatric disease and treatment. 2017;13:723.

10. DBS New Technology
• Newer leads with the capability to “direct current” preferentially in a
nonconcentric pattern
• The capability to sense from the electrode and then alter the output
from the IPG - implantable pulse generator - based upon that input –
a so-called “closed-loop” system
Fang JY, Tolleson C. The role of deep brain stimulation in Parkinson’s disease: an overview and update on new developments. Neuropsychiatric disease and treatment. 2017;13:723.

11. Summary
• DBS has been shown to be a safe and effective therapy for PD
• The best PD patients for DBS are patients with clear, substantial
levodopa responsiveness, having relatively few comorbidities
(especially the absence of cognitive difficulties), and with clear
therapeutic goals for surgery that are already modified by their
medications (exception of medication-resistant tremor).