Postoperative management of deep brain stimulation in Parkinson’s disease

Castrioto, Anna; Volkmann, Jens; Krack, Paul

doi:10.1016/b978-0-444-53497-2.00011-5

Cited by 35 publications

(42 citation statements)

References 146 publications

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“…One limitation of this study is the restriction of the assessment to wrist rigidity in acute settings. We made this choice because rigidity is the most reliable symptom to assess and a good predictor of improvement of other cardinal symptoms in PD . Axial symptoms need further studies focusing on long‐term outcomes.…”

Section: Discussionmentioning

confidence: 99%

Short pulse width in subthalamic stimulation in Parkinson's disease: a randomized, double‐blind study

Bouthour¹,

Wegrzyk

Momjian

et al. 2017

Movement Disorders

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width range, current steering, and other programmable features of the device. It is not possible to test all settings in a single programming visit, and more studies are needed to define the optimal parameter space for target signs.Another limitation was the lack of data on efficacy of chronic stimulation at a short pulse width. The participants were only exposed to each stimulation setting for a short time during a single programming visit; it is possible that long-term stimulation would have revealed differences between short and conventional pulse widths that were not apparent during the acute visit. However, the blinded assessment of motor signs (UPDRS III) during an acute stimulation challenge has previously been used as the primary efficacy endpoint in DBS studies [8][9][10] and reflected the chronic benefit of DBS.Despite these limitations, few controlled studies are aimed at achieving optimization of DBS programming, and this is the first double-blind assessment of the effect of a shorter pulse width and 1 of only a handful of DBS programming studies that have ever been conducted in a double-blind condition.In conclusion, stimulation using a shorter than currently recommended pulse width may be more efficient at achieving therapeutic efficacy and less likely to reach a side effect threshold. This may translate into a fundamentally new basic parameter setting for patients with DBS in PD. Supporting DataAdditional Supporting Information may be found in the online version of this article at the publisher's website. Short Pulse Width in AbstractBackground: We investigated the acute effect of short pulse widths on the therapeutic window in subthalamic nucleus deep brain stimulation in Parkinson's disease. Methods: We assessed 10 PD patients with STN-DBS at a 60-ms pulse width. We randomly and doubleblindedly applied 10-to 50-ms pulse widths. The principal outcome was the therapeutic window (difference --

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Section: Discussionmentioning

confidence: 99%

Short pulse width in subthalamic stimulation in Parkinson's disease: a randomized, double‐blind study

Bouthour¹,

Wegrzyk

Momjian

et al. 2017

Movement Disorders

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“…Following the surgery, the neurologist is faced with the challenge of balancing both the stimulation and medication therapies for the patient to maximize benefit and minimize side effects. This complex process is currently driven by clinical experience and typically incorporates guidelines developed from previous clinical studies (Bronstein et al ., 2011; Castrioto et al ., 2013). However, treatment optimization often requires multiple time-consuming follow-up visits because of the extremely large treatment parameter space.…”

Section: Introductionmentioning

confidence: 99%

Machine Learning Approach to Optimizing Combined Stimulation and Medication Therapies for Parkinson's Disease

et al. 2015

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Background Deep brain stimulation (DBS) of the subthalamic region is an established therapy for advanced Parkinson’s disease (PD). However, patients often require time-intensive postoperative management to balance their coupled stimulation and medication treatments. Given the large and complex parameter space associated with this task, we propose that clinical decision support systems (CDSS) based on machine learning algorithms could assist in treatment optimization. Objective Develop a proof-of-concept implementation of a CDSS that incorporates patient-specific details on both stimulation and medication. Methods Clinical data from 10 patients, and 89 post-DBS surgery visits, were used to create a prototype CDSS. The system was designed to provide three key functions: 1) information retrieval; 2) visualization of treatment, and; 3) recommendation on expected effective stimulation and drug dosages, based on three machine learning methods that included support vector machines, Naïve Bayes, and random forest. Results Measures of medication dosages, time factors, and symptom-specific preoperative response to levodopa were significantly correlated with postoperative outcomes (p<0.05) and their effect on outcomes was of similar magnitude to that of DBS. Using those results, the combined machine learning algorithms were able to accurately predict 86% (12/14) of the motor improvement scores at one year after surgery. Conclusions Using patient-specific details, an appropriately parameterized CDSS could help select theoretically optimal DBS parameter settings and medication dosages that have potential to improve the clinical management of PD patients.

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“…The increased incidence of apathy can be explained by a deviation from the recommended and usual postoperative management. 102 All patients were completely withdrawn from dopamine agonists immediately after surgery and levodopa was greatly reduced to the minimally required dose, with a parallel increase in stimulation parameters. 91 Half of the patients developed apathy in the course of the fi rst year of followup, and half of those also developed depression at the same time.…”

Section: Apathy After Deep Brain Stimulation In Parkinson's Diseasementioning

confidence: 99%

“…It is potentially reversible and both occurrence and improvement depend on patient management. 92,102 Panel 2 describes the clinical features of early reversible postoperative apathy. In a 2013 randomised study 103 comparing STN-DBS to best medical treatment in Parkinson's disease, the frequency of apathy did not diff er during the 2 years of follow-up, showing absence of early postoperative apathy when STN-DBS is accompanied by optimised medical treatment.…”

Section: Apathy After Deep Brain Stimulation In Parkinson's Diseasementioning

confidence: 99%

Apathy in Parkinson's disease: clinical features, neural substrates, diagnosis, and treatment

Pagonabarraga

Kulisevsky

Strafella

et al. 2015

The Lancet Neurology

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394

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Normal maintenance of human motivation depends on the integrity of subcortical structures that link the prefrontal cortex with the limbic system. Structural and functional disruption of diff erent networks within these circuits alters the maintenance of spontaneous mental activity and the capacity of aff ected individuals to associate emotions with complex stimuli. The clinical manifestations of these changes include a continuum of abnormalities in goal-oriented behaviours known as apathy. Apathy is highly prevalent in Parkinson's disease (and across many neurodegenerative disorders) and can severely aff ect the quality of life of both patients and caregivers. Diff erentiation of apathy from depression, and discrimination of its cognitive, emotional, and auto-activation components could guide an individualised approach to the treatment of symptoms. The opportunity to manipulate dopaminergic treatment in Parkinson's disease allows researchers to study a continuous range of motivational states, from apathy to impulse control disorders. Parkinson's disease can thus be viewed as a model that provides insight into the neural substrates of apathy.

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Postoperative management of deep brain stimulation in Parkinson’s disease

Cited by 35 publications

References 146 publications

Short pulse width in subthalamic stimulation in Parkinson's disease: a randomized, double‐blind study

Short pulse width in subthalamic stimulation in Parkinson's disease: a randomized, double‐blind study

Machine Learning Approach to Optimizing Combined Stimulation and Medication Therapies for Parkinson's Disease

Apathy in Parkinson's disease: clinical features, neural substrates, diagnosis, and treatment

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