Subthalamic deep brain stimulation in patients with a previous pallidotomy

Ondo, William G.; Silay, Yavuz Selim; Almaguer, Mike; Jankovic, Joseph

doi:10.1002/mds.20920

Cited by 20 publications

(25 citation statements)

References 12 publications

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“…The reduced motor improvement of STN DBS post pallidotomy found by Ondo et al . (2006) in conjunction with our results and those of Mogilner et al .…”

Section: Resultsmentioning

confidence: 83%

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Prior pallidotomy reduces and modifies neuronal activity in the subthalamic nucleus of Parkinson's disease patients

Zaidel

Moran

Marjan

et al. 2008

Eur J of Neuroscience

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Parkinson's disease (PD) patients with prior radio-frequency lesions in the internal segment of the globus pallidus (GPi, pallidotomy), whose symptoms have deteriorated, may be candidates for further invasive treatment such as subthalamic deep brain stimulation (STN DBS). Six patients with prior pallidotomy (five unilaterally; one bilaterally) underwent bilateral STN DBS. The microelectrode recordings (MERs, used intraoperatively for STN verification), ipsilateral and contralateral to pallidotomy, and MERs from 11 matched PD patients who underwent bilateral STN DBS without prior pallidotomy were compared. For each trajectory, average, variance and mean successive difference (MSD, a measure of irregularity) of the root mean square (RMS) of the STN MER were calculated. The RMS in trajectories ipsilateral to pallidotomy showed significant reduction of the mean average and MSD of STN activity when compared with trajectories from patients without prior pallidotomy. The RMS parameters contralateral to pallidotomy tend to lie between those ipsilateral to pallidotomy and those without prior pallidotomy. The average STN power spectral density of oscillatory activity was notably lower ipsilateral to pallidotomy than contralateral, or without prior pallidotomy. The finding that pallidotomy reduces STN activity and changes firing characteristics, in conjunction with the effectiveness of STN DBS despite prior pallidotomy, calls for reappraisal and modification of the current model of the basal ganglia (BG) cortical network. It highlights the critical role of direct projections from the BG to brain-stem structures and suggests a possible GPi-STN reciprocal positive-feedback mechanism.

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“…The reduced motor improvement of STN DBS post pallidotomy found by Ondo et al . (2006) in conjunction with our results and those of Mogilner et al .…”

Section: Resultsmentioning

confidence: 83%

“…Kleiner‐Fisman et al . (2004) found STN DBS post pallidotomy to be no less efficacious than STN DBS in patients without prior pallidotomy, whereas Ondo et al . (2006) found less motor improvement in patients with prior pallidotomy (dyskinesia scores, however, showed no less of an improvement).…”

Section: Introductionmentioning

confidence: 99%

Prior pallidotomy reduces and modifies neuronal activity in the subthalamic nucleus of Parkinson's disease patients

Zaidel

Moran

Marjan

et al. 2008

Eur J of Neuroscience

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“…In de novo patients, Peppe et al [11] did not find superiority of GPi plus STN DBS compared with STN DBS alone. In patients with previous pallidotomy, some authors have even observed a negative interaction, since STN DBS then resulted in more axial symptoms, particularly gait and balance problems [12][13][14]. Other authors, in contrast, did not find a negative influence of previous pallidotomies on subsequent STN DBS efficacy [15].…”

Section: Dear Sirsmentioning

confidence: 99%

Failure of long-term subthalamic nucleus stimulation corrected by additional pallidal stimulation in a patient with Parkinson’s disease

et al. 2011

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The subthalamic nucleus (STN) and the globus pallidus internus (GPi) are the main targets for deep brain stimulation (DBS) in advanced Parkinson's disease (PD) [1]. So far, randomized trials have failed to demonstrate clear superiority of either target [2,3]. Long-term efficacy, however, appears to be better in STN DBS, with reports on a decline of stimulation efficacy in GPi patients [4][5][6][7][8]. Moreover, STN DBS has been successful to reverse GPi DBS failure [6][7][8].Herein we present the first case of a PD patient with secondary STN DBS failure successfully corrected by additional GPi DBS.Akinetic-rigid PD started at age of 30 years. Family history did not suggest a hereditary form of PD, and genetic diagnostics were refused by the patient. Levodopa therapy was effective but complicated by dyskinesias and fluctuations. At the age of 50 years, the patient presented irregular motor fluctuations and spent 25% of the day in an off state. During the on state she had violating and severely disabling dyskinesias. Unified Parkinson's Disease Rating Scale (UPDRS) motor scores in the off and on state at this time were 83 (including 6 tremor points) and 14 points (no tremor points), respectively (see video and Fig. 1). Daily levodopa equivalent dose (LEDD) was 550 mg, body weight was 58 kg, and height was 169 cm [body mass index (BMI) 20 kg/m 2 ]. After 1 year of STN DBS, UPDRS motor scores in the off and on state were 31 points and 19 points, respectively (see video and Fig. 1). LEDD was reduced to 350 mg and body weight increased to 72 kg (BMI 25 kg/m 2 ). Symptom control remained stable during the next year but declined thereafter. Technical dysfunction or dislocation of the stimulation electrodes was excluded by impedance measurements, control of stimulation effects/side-effects, and stereotactic computed tomography (CT) scan. After 4 years of STN DBS and recurrence of significant motor fluctuations and dyskinesias, continuous intestinal levodopa infusion therapy was initiated concomitant to STN DBS. However, this therapy only transiently improved fluctuations and dyskinesias. At the age of 58 years, after 8 years of STN DBS and 4 years of additional levodopa infusion therapy, UPDRS motor scores in the medication off and on state with continued STN DBS were 78 points (including 1 tremor point) and 35 points (including 1 tremor point), respectively (see video and Fig. 1). The patient had lost body weight down to 48 kg (BMI 17 kg/m 2 ). GPi DBS was considered, particularly because of the severe choreatiform dyskinesias in the on state. STN DBS in the medication off state still had a small but significant effect on akinesia and rigidity, so that we Electronic supplementary material The online version of this article (

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“…22,33,38,39 Lentiform nucleus hypermetabolism on FDG-PET (positron emission tomography) scanning also correlates with the response to levodopa and pallidotomy and may correlate with the response to DBS. 40 Therefore, the levodopa test is an important part of the evaluation to determine the degree of benefit obtainable with surgery.…”

Section: Parkinson Diseasementioning

confidence: 99%