Deep brain stimulation of the subthalamic nucleus in PD: an analysis of the exclusion causes
Introduction
The advanced phase of Parkinson's disease (PD) is mainly characterized by motor fluctuations (wearing offs, on–off phenomena) and drug-induced dyskinesias, related to the chronic dopaminergic treatment [1]. These complications often account for a significant worsening of the quality of life of PD patients [2]; for this reason, in the last years, surgical therapy was reconsidered as a good option for the treatment of advanced PD, when it is impossible to achieve a satisfactory clinical response by the pharmacological treatment [3], [4]. At present, Deep Brain Stimulation (DBS) of the Subthalamic Nucleus (STN) represents an effective therapy for PD, improving all cardinal symptoms of the disease (tremor, rigidity, akinesia) [5], [6], [7], [8] and allowing a significant reduction of the daily levodopa dose with a consequent improvement of drug-induced dyskinesias [9].
The selection of the PD patients candidates for STN DBS is a basic step to assure a satisfactory outcome of the surgical therapy; the aim of this study was to retrospectively analyze a large series of PD patients hospitalized for the protocol selection, in order to determine the percentage of subjects considered not suitable for the surgery and to identify the different exclusion motivations. All the patients hospitalized respected the following general inclusion criteria: a diagnosis of idiopathic PD, the presence of motor fluctuations and drug-induced dyskinesias, an age lower than 70 years and the absence of important medical diseases.
During the period of admission to hospital, the severity of motor fluctuations and dyskinesias was evaluated. We performed a supramaximal levodopa test, an MR of the brain and a neuropsychological assessment.
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Methods
We examined 98 patients, 40 women and 58 men; the mean age of the patients was 61 years (S.D. 5.9); the mean duration of the disease was 14 years (S.D. 5.2) with an average duration of levodopa therapy of 12.8 years (S.D. 5.2). The duration of the period with motor fluctuations and drug-induced dyskinesias was 6.1 years (S.D. 4.4).
The patients were hospitalized to undergo the following diagnostics.
(a) Hematochemistry and serology, chest X-ray and electrocardiogram to confirm the absence of any
Results
We identified 29 subjects (29.6%) not suitable for STN DBS; 19 patients (65.5%) showed a single exclusion condition, while 10 patients (34.5%) showed multiple conditions not compatible with the surgery (Table 1).
The mean age of the patients excluded (group A) was 62 years (S.D. 5.7), while the patients included (group B) showed a mean age of 60.7 years (S.D. 6); the mean duration of PD was 12.5 years (S.D. 5.5) for the group A and 14.7 years (S.D. 5) for the group B, with a mean duration of
Discussion
We report the data relative to the exclusion conditions for the surgical procedure of bilateral STN DBS in a large pool of PD patients. This surgical treatment is only effective in patients affected by idiopathic PD and the degree of the improvement of the motor symptoms seems to be proportional to the pre-operative response to levodopa [20] or apomorphine [21].
We found a single or multiple exclusion conditions in a relatively large percentage of patients (about 30%); the most frequent cause of
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2011, World NeurosurgeryCitation Excerpt :This is an important observation because the number of patients excluded from DBS on the basis of neuropsychiatric factors is not insignificant. The authors of one study reported that 29% of a potential 98 patients for DBS were deemed to be unsuitable candidates, with the most common reason of exclusion being that patients exhibited cognitive or psychiatric disorders (the reason for almost 50% of those excluded) (11). The challenge expressed by providers in our study concerned the exclusion of some patients who resided within a grey zone of cognitive or psychiatric function, even though the providers were somewhat uncertain about whether outcome would be detrimentally affected in these patients.
Management of motor complications in parkinson disease: Current and emerging therapies
2010, Neurologic ClinicsCitation Excerpt :DBS of the STN and GPi has replaced ablation procedures in the treatment of motor complications that cannot be adequately controlled with any of the medications mentioned earlier. The ideal candidate for STN DBS is relatively young with excellent response to levodopa but with substantial “off” time and dose-limiting dyskinesias, and has minimal or no cognitive or behavioral problems.42 In a randomized clinical trial involving 156 patients with PD with severe motor complications, best medical management was compared with STN DBS and medication.