Feature GPi STN VIM Speech Less affects but also More problems Dysarthria is common does not help Dystonia GPi helps for both STN helps for medication-responsive dystonia (GPi and better for –nonresponsive “on-meds” dystonia) Dyskinesia GPi helps for both medication-on and –off dyskinesias / parkinsonism-plus syndromes parkinsonism unresponsiveness to levodopa moderate cognitive dysfunction ≥ Dementia usually starts 10 years* after PD diagnosis (protective factors tremor-predominant, no – axial symptoms, young-onset PD [dementia is delayed until age 70]) *if much earlier Lewy body dementia – Patient must be able to properly operate the neurostimulator. Dementia, as well as cognitive deficits, are not improved by DBS and might even be made worse by trauma of surgery. N.B. patients with cognitive decline or full-blown dementia may be at increased risk for DBS Limousin P, P, Pollak P et al. (1998). Electrical stimulation of the subthalamic nucleus in 339: 1105–1111. advanced Parkinson’s disease. N Engl J Med MI, Johansson F, Shamsgovara P (2000). Bilateral subthalamic nucleus stimulation in a Parkinsonian patient with preoperative deficits in speech and cognition: persisting improvement in 15: 136–139. mobility but increased dependency: a case study. Mov Disord difficulty postop DBS programming; anxiety – if anxiety is reactive to PD, then DBS helps; if anxiety is lifelong, then patient knows how to cope with it; worst if anxiety is due to PD affecting limbic circuits patients very difficult to program. – depression risk of postop suicide, so must be controlled and psychiatrist established preop. – (anticoagulants, terminal cancer, infectious disease, general surgical contraindications immunodeficiency, poorly controlled HTN, and so on); for diabetics, HbA1c has to be < 8.0% DBS achieve the best score as patient had on meds* preop and smoothen fluctuations! – *this applies only to early stages of PD; in advanced stages, PD patients are frozen no matter how much medication they get (becomes obvious if DBS battery dies)
Feature GPi STN VIM Speech Less affects but also does not help More problems Dysarthria is common Dystonia GPi helps for both medication-responsive and –nonresponsive STN helps for dystonia (GPi better for “on-meds” dystonia) Dyskinesia GPi helps for both medication-on and –off dyskinesias parkinsonism-plus syndromes / parkinsonism unresponsiveness to levodopa ≥ moderate cognitive dysfunction Dementia usually starts 10 years* after PD diagnosis (protective factors – tremor-predominant, no axial symptoms, young-onset PD [dementia is delayed until age 70]) *if much earlier – Lewy body dementia Patient must be able to properly operate the neurostimulator. Dementia, as well as cognitive deficits, are not improved by DBS and might even be made worse by trauma of surgery. N.B. patients with cognitive decline or full-blown dementia may be at increased risk for DBS Limousin P, P, Pollak P et al. (1998). Electrical stimulation of the subthalamic nucleus in advanced Parkinson’s disease. N Engl J Med 339: 1105–1111. MI, Johansson F, Shamsgovara P (2000). Bilateral subthalamic nucleus stimulation in a Parkinsonian patient with preoperative deficits in speech and cognition: persisting improvement in mobility but increased dependency: a case study. Mov Disord 15: 136–139. anxiety – difficulty postop DBS programming; if anxiety is reactive to PD, then DBS helps; if anxiety is lifelong, then patient knows how to cope with it; worst if anxiety is due to PD affecting limbic circuits – patients very difficult to program. depression – risk of postop suicide, so must be controlled and psychiatrist established preop. general surgical contraindications (anticoagulants, terminal cancer, infectious disease, immunodeficiency, poorly controlled HTN, and so on); for diabetics, HbA1c has to be < 8.0% DBS – achieve the best score as patient had on meds* preop and smoothen fluctuations! *this applies only to early stages of PD; in advanced stages, PD patients are frozen no matter how much medication they get (becomes obvious if DBS battery dies)
Op360.%20DBS.docx