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Neurosurgery
Systematic review
Directional deep brain stimulation electrodes in Parkinson’s disease: meta-analysis and systematic review of the literature
  1. Victor Hvingelby1,2,
  2. Fareha Khalil3,4,
  3. Flavia Massey5,
  4. Alexander Hoyningen6,7,
  5. San San Xu3,8,
  6. Joseph Candelario-McKeown9,
  7. Harith Akram3,10,
  8. Thomas Foltynie10,
  9. Patricia Limousin3,
  10. Ludvic Zrinzo3,
  11. Marie T Krüger3,11
  1. 1Department of Clinical Medicine, Aarhus Universitet, Aarhus, Denmark
  2. 2Aarhus Universitetshospital, Aarhus, Denmark
  3. 3UCL Functional Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
  4. 4Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
  5. 5University College London Medical School, London, UK
  6. 6Department of Neurosurgery, Kantonsspital St Gallen, Sankt Gallen, Switzerland
  7. 7Department of Basic Neuroscience, University of Geneva, Geneve, Switzerland
  8. 8Department of Clinical and Movement Neurosciences, University College London, London, UK
  9. 9Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
  10. 10Movement Disorders, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
  11. 11Department of Functional Neurosurgery, Albert-Ludwigs-Universitat Freiburg, Freiburg im Breisgau, Germany
  1. Correspondence to Dr Marie T Krüger; marie.krueger{at}nhs.net

Abstract

Background Since their introduction in 2015, directional leads have practically replaced conventional leads for deep brain stimulation (DBS) in Parkinson’s disease (PD). Yet, the benefits of directional DBS (dDBS) over omnidirectional DBS (oDBS) remain unclear. This meta-analysis and systematic review compares the literature on dDBS and oDBS for PD.

Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Database searches included Pubmed, Cochrane (CENTRAL) and EmBase, using relevant keywords such as ‘directional’, ‘segmented’, ‘brain stimulation’ and ‘neuromodulation’. The screening was based on the title and abstract.

Results 23 papers reporting on 1273 participants (1542 leads) were included. The therapeutic window was 0.70 mA wider when using dDBS (95% CI 0.13 to 1.26 mA, p=0.02), with a lower therapeutic current (0.41 mA, 95% CI 0.27 to 0.54 mA, p=0.01) and a higher side-effect threshold (0.56 mA, 95% CI 0.38 to 0.73 mA, p<0.01). However, there was no relevant difference in mean Unified Parkinson’s Disease Rating Scale III change after dDBS (45.8%, 95% CI 30.7% to 60.9%) compared with oDBS (39.0%, 95% CI 36.9% to 41.2%, p=0.39), in the medication-OFF state. Median follow-up time for dDBS and oDBS studies was 6 months and 3 months, respectively (range 3–12 for both). The use of directionality often improves dyskinesia, dysarthria, dysesthesia and pyramidal side effects. Directionality was used in 55% of directional leads at 3–6 months, remaining stable over time (56% at a mean of 14.1 months).

Conclusions These findings suggest that stimulation parameters favour dDBS. However, these do not appear to have a significant impact on motor scores, and the availability of long-term data is limited. dDBS is widely accepted, but clinical data justifying its increased complexity and cost are currently sparse.

PROSPERO registration number CRD42023438056.

Data availability statement

Data are available upon reasonable request. Not Applicable.

https://doi.org/10.1136/jnnp-2024-333947

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    Data availability statement

    Data are available upon reasonable request. Not Applicable.

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    Footnotes

    • Contributors (1) Research project: A. Conception, B. Organisation, C. Execution; (2) Statistical analysis: A. Design, B. Execution, C. Review and Critique; (3) Manuscript: A. Writing of the first draft, B. Review and Critique. VH: 1BC, 2ABC, 3AB. FK: 1C, 2BC, 3B. FVM-M: 1C, 2BC, 3B. AH: 1C, 2C, 3B. SSX: 2C, 3B. JC-M: 2C, 3B. HA: 2C, 3B. TF: 2C, 3B. PL: 2C, 3B. LZ: 1C, 2BC, 3B. MK: 1ABC, 2C, 3AB. MK serves as guarantor.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests MK is a consultant for Boston Scientific, Brainlab and Elekta and has received travel and research funding from Medtronic. LZ is a consultant for Boston Scientific, Medtronic and Brainlab.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.