Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Subthalamic Nucleus and Globus Pallidus Internus Deep Brain Stimulation for the Treatment of Patients With Parkinson's Disease: Executive Summary

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Subthalamic... Abstract QUESTION 1 Is bilateral subthalamic nucleus deep brain stimulation (STN DBS) more, less, or as effective as bilateral globus pallidus internus deep brain stimulation (GPi DBS) in treating motor symptoms of Parkinson's disease, as measured by improvements in Unified Parkinson's Disease Rating Scale, part III (UPDRS-III) scores? RECOMMENDATION Given that bilateral STN DBS is at least as effective as bilateral GPi DBS in treating motor symptoms of Parkinson's disease (as measured by improvements in UPDRS-III scores), consideration can be given to the selection of either target in patients undergoing surgery to treat motor symptoms. (Level I) QUESTION 2 Is bilateral STN DBS more, less, or as effective as bilateral GPi DBS in allowing reduction of dopaminergic medication in Parkinson's disease? RECOMMENDATION When the main goal of surgery is reduction of dopaminergic medications in a patient with Parkinson's disease, then bilateral STN DBS should be performed instead of GPi DBS. (Level I) QUESTION 3 Is bilateral STN DBS more, less, or as effective as bilateral GPi DBS in treating dyskinesias associated with Parkinson's disease? RECOMMENDATION There is insufficient evidence to make a generalizable recommendation regarding the target selection for reduction of dyskinesias. However, when the reduction of medication is not anticipated and there is a goal to reduce the severity of “on” medication dyskinesias, the GPi should be targeted. (Level I) QUESTION 4 Is bilateral STN DBS more, less, or as effective as bilateral GPi DBS in improving quality of life measures in Parkinson's disease? RECOMMENDATION When considering improvements in quality of life in a patient undergoing DBS for Parkinson's disease, there is no basis to recommend bilateral DBS in 1 target over the other. (Level I) QUESTION 5 Is bilateral STN DBS associated with greater, lesser, or a similar impact on neurocognitive function than bilateral GPi DBS in Parkinson disease? RECOMMENDATION If there is significant concern about cognitive decline, particularly in regards to processing speed and working memory in a patient undergoing DBS, then the clinician should consider using GPi DBS rather than STN DBS, while taking into consideration other goals of surgery. (Level I) QUESTION 6 Is bilateral STN DBS associated with a higher, lower, or similar risk of mood disturbance than GPi DBS in Parkinson's disease? RECOMMENDATION If there is significant concern about the risk of depression in a patient undergoing DBS, then the clinician should consider using pallidal rather than STN stimulation, while taking into consideration other goals of surgery. (Level I) QUESTION 7 Is bilateral STN DBS associated with a higher, lower, or similar risk of adverse events compared to GPi DBS in Parkinson's disease? RECOMMENDATION There is insufficient evidence to recommend bilateral DBS in 1 target over the other in order to minimize the risk of surgical adverse events.  The full guideline can be found at: https://www.cns.org/guidelines/deep-brain-stimulation-parkinsons-disease. Deep brain stimulation, Globus pallidus internus, Guidelines, Neuromodulation, Parkinson's disease, Subthalamic nucleus ABBREVIATIONS ABBREVIATIONS BDI Beck Depression Inventory DBS deep brain stimulation GPi DBS globus pallidus internus deep brain stimulation PD Parkinson's disease PDQ Parkinson's Disease Questionnaire STN DBS subthalamic nucleus deep brain stimulation UPDRS-III Unified Parkinson's Disease Rating Scale, Part III VA veterans affairs The efficacy of bilateral deep brain stimulation (DBS) for the treatment of motor symptoms and levodopa-induced dyskinesias in Parkinson's Disease (PD) patients is well established.1-7 However, the effectiveness of selecting different stimulation targets is less clear. To date, 2 different targets have been proposed for the treatment of motor symptoms of PD, the subthalamic nucleus (STN) and globus pallidus internus (GPi). While there is evidence to suggest that both are effective when combined with best medical treatment vs best medical treatment alone,6 the circumstances in which 1 target should be selected over the other are still disputed. It is also unknown whether STN and GPi DBS induce similar benefits. METHODS Details of the systematic literature review are provided in the full text of this guideline (https://www.cns.org/guidelines/deep-brain-stimulation-parkinsons-disease). A PubMed search was conducted for articles published between 1966 and February, 2017. Two different search strategies were used and the results were combined, yielding 151 unique abstracts. The selected studies were classified according to criteria for evidence on therapeutic effectiveness as detailed in the Joint Guidelines Committee Guideline Development Methodology. RESULTS The combined search queries yielded a total of 151 unique abstracts, which were screened for eligibility. A total of 18 articles were included in the final analysis. For Question 1, 2 Class I,8,9 2 Class II,10,11 and 6 Class III12-17 studies found no differences between the 2 targets in motor score improvements at various time points, up to 5 yr postoperatively, in various medication and stimulation conditions. In contrast, 2 articles,18,19 including 1 Class I study,18 found that STN stimulation is associated with greater improvement in motor scores assessed in the “off” medication/“on” stimulation condition. The advantage seen in the STN cohort in this study persisted at 3-yr follow-up.11 No study to date has demonstrated a difference in the motor response to STN or GPi DBS in the “on” medication/”on” stimulation state. With respect to Question 2, compelling evidence was derived from 3 Class I studies,8,9,18 2 Class II studies,11,20 and 6 Class III studies10,12-15,17showing greater reduction in dopaminergic medications following STN than GPi DBS. For the third question, a single study provides Class I evidence18 that the severity of “on” medication dyskinesias, but not the amount of time with dyskinesias, is reduced to a greater extent following pallidal stimulation than subthalamic stimulation. The remaining 2 Class I studies showed no significant differences in the reduction of dyskinesias between these surgical targets.8,9 For Question 4, no study demonstrated a significant difference between the 2 targets regarding improvement in quality of life. Class I evidence from 3 studies have shown comparable improvements in quality of life as measured by the Unified Parkinson's Disease Rating Scale, Part II (UPDRS-II) at 1 yr,8 the composite Parkinson's Disease Questionnaire (PDQ-39) at 2 yr,9 or a quality of life questionnaire at 1 yr.18 Three-year follow-up in the veterans affairs (VA) study utilized the PDQ-39 and did not reveal a difference between the 2 surgical targets, as shown by a single Class II study.20 Six Class III studies10,12,14,15,21,22 showed improvements in quality of life following DBS without differences between the 2 targets. With respect to Question 5, neurocognitive function was formally assessed using various batteries in 5 studies.9,18,20,23,24 Class I evidence was provided by 3 of these studies, in which patients and assessors were blinded to the stimulation site.9,18,23 In 1 of these studies,9 STN DBS was associated with a significantly greater decline in processing speed and working memory compared to GPi DBS. For Question 6, Class I evidence from the VA Cooperative Study demonstrated a slight improvement in the GPi group (5.8%) compared to a slight worsening in the STN group (–11.6%) on the Beck Depression Inventory (BDI; P = .02).9 There were no differences between groups when this cohort was assessed for suicidal ideation and suicidal behaviors at 6, 12, and 24 mo postoperatively using the UPDRS-I.25 The NSTAPS 3-yr follow-up study found that there were no differences between targets when measuring with a composite of mood, cognitive, and behavioral effects (Class II).11 Class III evidence comes from 2 trials. A retrospective study of 27 patients demonstrated that both GPi and STN DBS groups were associated with a trend towards reduced Hamilton Depression Scale scores up to 12 mo postoperatively.17 Another retrospective series demonstrated decreases on the BDI score 12 mo postoperatively in both the STN DBS group (21.1%) and the GPi group (27.0%).24 Thus, there is Class I evidence from a single study suggesting that, compared to STN DBS, GPi stimulation is associated with better outcomes in terms of depression. For Question 7, no study showed a significantly higher risk of adverse events related to 1 surgical target over another. DISCUSSION AND CONCLUSION PD is characterized by many symptoms, which may vary in severity and response to medications and DBS. This clinical heterogeneity can make selection of the appropriate target for DBS somewhat complex. Based on the current literature, there are areas of agreement and disagreement over the question of target superiority in DBS for the treatment of PD. Ultimately, the selection of a specific brain target for stimulation should be tailored to the needs of the individual patient. Disclosures These evidence-based clinical practice guidelines were funded exclusively by the Congress of Neurological Surgeons (CNS) and the American Society for Stereotactic and Functional Neurosurgery, which received no funding from outside commercial sources to support the development of this document. Conflict of Interest The DBS for Parkinson's Disease Task Force members were required to report all possible COIs prior to beginning work on the guideline, using the COI disclosure form of the American Association of Neurological Surgeons (AANS)/CNS Joint Guidelines Review Committee, including potential COIs that are unrelated to the topic of the guideline. The CNS Guidelines Committee and Guideline Task Force Chair reviewed the disclosures and either approved or disapproved the nomination. The CNS Guidelines Committee and Guideline Task Force Chair are given latitude to approve nominations of Task Force members with possible conflicts and address this by restricting the writing and reviewing privileges of that person to topics unrelated to the possible COIs. The conflict of interest findings are provided in detail in the full-text introduction and methods manuscript (https://www.cns.org/guidelines/deep-brain-stimulation-parkinsons-disease). Disclaimer of Liability This clinical systematic review and evidence-based guideline was developed by a multidisciplinary physician volunteer task force and serves as an educational tool designed to provide an accurate review of the subject matter covered. These guidelines are disseminated with the understanding that the recommendations by the authors and consultants who have collaborated in their development are not meant to replace the individualized care and treatment advice from a patient's physician(s). If medical advice or assistance is required, the services of a competent physician should be sought. The proposals contained in these guidelines may not be suitable for use in all circumstances. The choice to implement any particular recommendation contained in these guidelines must be made by a managing physician in light of the situation in each particular patient and on the basis of existing resources. Notes Sponsored by: Congress of Neurological Surgeons (CNS) and the American Society for Stereotactic and Functional Neurosurgery (ASSFN) Endorsed by: Joint Guidelines Committee of the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) No part of this manuscript has been published or submitted for publication elsewhere. REFERENCES 1. Pahwa R, Factor SA, Lyons KE et al.   Practice parameter: treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology . 2006; 66( 7): 983- 995. Google Scholar CrossRef Search ADS PubMed  2. Perestelo-Perez L, Rivero-Santana A, Perez-Ramos J, Serrano-Perez P, Panetta J, Hilarion P. Deep brain stimulation in Parkinson's disease: meta-analysis of randomized controlled trials. J Neurol . 2014; 261( 11): 2051- 2060. Google Scholar CrossRef Search ADS PubMed  3. Okun MS, Gallo BV, Mandybur G et al.   Subthalamic deep brain stimulation with a constant-current device in Parkinson's disease: an open-label randomised controlled trial. Lancet Neurol . 2012; 11( 2): 140- 149. Google Scholar CrossRef Search ADS PubMed  4. Rodriguez-Oroz MC, Moro E, Krack P. Long-term outcomes of surgical therapies for Parkinson's disease. Mov Disord . 2012; 27( 14): 1718- 1728. Google Scholar CrossRef Search ADS PubMed  5. Deuschl G, Schade-Brittinger C, Krack P et al.   A randomized trial of deep-brain stimulation for Parkinson's disease. N Engl J Med . 2006; 355( 9): 896- 908. Google Scholar CrossRef Search ADS PubMed  6. Weaver FM, Follett K, Stern M et al.   Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA . 2009; 301( 1): 63- 73. Google Scholar CrossRef Search ADS PubMed  7. Schuepbach WM, Rau J, Knudsen K et al.   Neurostimulation for Parkinson's disease with early motor complications. N Engl J Med . 2013; 368( 7): 610- 622. Google Scholar CrossRef Search ADS PubMed  8. Anderson VC, Burchiel KJ, Hogarth P, Favre J, Hammerstad JP. Pallidal vs subthalamic nucleus deep brain stimulation in Parkinson disease. Arch Neurol . 2005; 62( 4): 554- 560. Google Scholar CrossRef Search ADS PubMed  9. Follett KA, Weaver FM, Stern M et al.   Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. N Engl J Med . 2010; 362( 22): 2077- 2091. Google Scholar CrossRef Search ADS PubMed  10. Moro E, Lozano AM, Pollak P et al.   Long-term results of a multicenter study on subthalamic and pallidal stimulation in Parkinson's disease. Mov Disord.  2010; 25( 5): 578- 586. Google Scholar CrossRef Search ADS PubMed  11. Odekerken VJ, Boel JA, Schmand BA et al.   GPi vs STN deep brain stimulation for Parkinson disease. Neurology . 2016; 86( 8): 755- 761. Google Scholar CrossRef Search ADS PubMed  12. Deep-Brain Stimulation for Parkinson's Disease Study G Obeso JA, Olanow CW et al.   Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson's disease. N Engl J Med . 2001; 345( 13): 956- 963. Google Scholar CrossRef Search ADS PubMed  13. Evidente VG, Premkumar AP, Adler CH, Caviness JN, Driver-Dunckley E, Lyons MK. Medication dose reductions after pallidal versus subthalamic stimulation in patients with Parkinson's disease. Acta Neurol Scand . 2011; 124( 3): 211- 214. Google Scholar CrossRef Search ADS PubMed  14. Minguez-Castellanos A, Escamilla-Sevilla F, Katati MJ et al.   Different patterns of medication change after subthalamic or pallidal stimulation for Parkinson's disease: target related effect or selection bias? J Neurol Neurosurg Psychiatry . 2005; 76( 1): 34- 39. Google Scholar CrossRef Search ADS PubMed  15. Rodriguez-Oroz MC, Obeso JA, Lang AE et al.   Bilateral deep brain stimulation in Parkinson's disease: a multicentre study with 4 years follow-up. Brain . 2005; 128( 10): 2240- 2249. Google Scholar CrossRef Search ADS PubMed  16. Scotto di Luzio AE, Ammannati F, Marini P, Sorbi S, Mennonna P. Which target for DBS in Parkinson's disease? Subthalamic nucleus versus globus pallidus internus. Neurol Sci . 2001; 22( 1): 87- 88. Google Scholar CrossRef Search ADS PubMed  17. Volkmann J, Allert N, Voges J, Weiss PH, Freund HJ, Sturm V. Safety and efficacy of pallidal or subthalamic nucleus stimulation in advanced PD. Neurology . 2001; 56( 4): 548- 551. Google Scholar CrossRef Search ADS PubMed  18. Odekerken VJ, van Laar T, Staal MJ et al.   Subthalamic nucleus versus globus pallidus bilateral deep brain stimulation for advanced Parkinson's disease (NSTAPS study): a randomised controlled trial. Lancet Neurol . 2013; 12( 1): 37- 44. Google Scholar CrossRef Search ADS PubMed  19. Krack P, Pollak P, Limousin P et al.   Subthalamic nucleus or internal pallidal stimulation in young onset Parkinson's disease. Brain . 1998; 121( 3): 451- 457. Google Scholar CrossRef Search ADS PubMed  20. Weaver FM, Follett KA, Stern M et al.   Randomized trial of deep brain stimulation for Parkinson disease: thirty-six-month outcomes. Neurology . 2012; 79( 1): 55- 65. Google Scholar CrossRef Search ADS PubMed  21. Krause M, Fogel W, Heck A et al.   Deep brain stimulation for the treatment of Parkinson's disease: subthalamic nucleus versus globus pallidus internus. J Neurol Neurosurg Psychiatry . 2001; 70( 4): 464- 470. Google Scholar CrossRef Search ADS PubMed  22. Volkmann J, Albanese A, Kulisevsky J et al.   Long-term effects of pallidal or subthalamic deep brain stimulation on quality of life in Parkinson's disease. Mov Disord.  2009; 24( 8): 1154- 1161. Google Scholar CrossRef Search ADS PubMed  23. Odekerken VJ, Boel JA, Geurtsen GJ et al.   Neuropsychological outcome after deep brain stimulation for Parkinson disease. Neurology . 2015; 84( 13): 1355- 1361. Google Scholar CrossRef Search ADS PubMed  24. Pillon B, Ardouin C, Damier P et al.   Neuropsychological changes between "off" and "on" STN or GPi stimulation in Parkinson's disease. Neurology . 2000; 55( 3): 411- 418. Google Scholar CrossRef Search ADS PubMed  25. Weintraub D, Duda JE, Carlson K et al.   Suicide ideation and behaviours after STN and GPi DBS surgery for Parkinson's disease: results from a randomised, controlled trial. J Neurol Neurosurg Psychiatry . 2013; 84( 10): 1113- 1118. Google Scholar CrossRef Search ADS PubMed  Neurosurgery Speaks! Audio abstracts available for this article at www.neurosurgery-online.com. Acknowledgments The guidelines task force would like to acknowledge the CNS Guidelines Committee for their contributions throughout the development of the guideline, the AANS/CNS Joint Guidelines Review Committee for their review, comments, and suggestions throughout peer review, as well as the contributions of Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for the CNS, and Mary Bodach, MLIS, for assistance with the literature searches. Throughout the review process, the reviewers and authors were blinded from one another. At this time, the guidelines task force would like to acknowledge the following individual peer reviewers for their contributions: John O’Toole, MD; Maya Babu, MD; Andrew P. Carlson, MD; Jamie Van Gompel, MD; D. Ryan Ormond, MD; Mateo Ziu, MD. The authors would like to thank Dr Eduardo Joaquin Lopes Alho for the cover illustration. Neurosurgery Speaks (Audio Abstracts) Listen to audio translations of this paper's abstract into select languages by choosing from one of the selections below. English: Oluwakemi Aderonke Badejo, MBBS, FWACS Department of Surgery, College of Medicine, University of Ibadan Ibadan, Nigeria English: Oluwakemi Aderonke Badejo, MBBS, FWACS Department of Surgery, College of Medicine, University of Ibadan Ibadan, Nigeria Close Chinese: Lin Song, MD Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University Beijing, China Chinese: Lin Song, MD Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University Beijing, China Close French: Atef Ben Nsir, MD Neurosurgery Department, Fattouma Bourguiba University Hospital, University of Medicine of Monastir Monastir, Tunisia French: Atef Ben Nsir, MD Neurosurgery Department, Fattouma Bourguiba University Hospital, University of Medicine of Monastir Monastir, Tunisia Close Greek: Andreas Zigouris, MD Department of Neurosurgery, University Hospital of Ioannina Ioannina, Greece Greek: Andreas Zigouris, MD Department of Neurosurgery, University Hospital of Ioannina Ioannina, Greece Close Italian: Andrea Ruggeri, MD, PhD Neurosurgery Department, University of Rome "La Sapienza" Rome, Italy Italian: Andrea Ruggeri, MD, PhD Neurosurgery Department, University of Rome "La Sapienza" Rome, Italy Close Japanese: Toshiaki Hayashi, MD, PhD Department of Neurosurgery, Sendai City Hospital Sendai, Japan Japanese: Toshiaki Hayashi, MD, PhD Department of Neurosurgery, Sendai City Hospital Sendai, Japan Close Korean: Sun Ha Paek, MD, PhD Department of Neurosurgery, Seoul National University, College of Medicine Seoul, Republic of Korea Korean: Sun Ha Paek, MD, PhD Department of Neurosurgery, Seoul National University, College of Medicine Seoul, Republic of Korea Close Portuguese: Marcos Dellaretti, MD Department of Neurosurgery, Santa Casa de Belo Horizonte Belo Horizonte, Brazil Portuguese: Marcos Dellaretti, MD Department of Neurosurgery, Santa Casa de Belo Horizonte Belo Horizonte, Brazil Close Russian: Sergei Kim Department of Pediatric Neurosurgery, Novosibirsk Federal Centre of Neurosurgery Novosibirsk, Russia Russian: Sergei Kim Department of Pediatric Neurosurgery, Novosibirsk Federal Centre of Neurosurgery Novosibirsk, Russia Close Spanish: Alejandro Enriquez-Marulanda, MD Department of Neurosurgery, Hospital Virgen del Rocío Sevilla, Spain Spanish: Alejandro Enriquez-Marulanda, MD Department of Neurosurgery, Hospital Virgen del Rocío Sevilla, Spain Close Copyright © 2018 by the Congress of Neurological Surgeons This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Neurosurgery Oxford University Press

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on Subthalamic Nucleus and Globus Pallidus Internus Deep Brain Stimulation for the Treatment of Patients With Parkinson's Disease: Executive Summary

Loading next page...
 
/lp/ou_press/congress-of-neurological-surgeons-systematic-review-and-evidence-based-PvEEQSrrv0
Publisher
Congress of Neurological Surgeons
Copyright
Copyright © 2018 by the Congress of Neurological Surgeons
ISSN
0148-396X
eISSN
1524-4040
D.O.I.
10.1093/neuros/nyy037
Publisher site
See Article on Publisher Site

Abstract

Abstract QUESTION 1 Is bilateral subthalamic nucleus deep brain stimulation (STN DBS) more, less, or as effective as bilateral globus pallidus internus deep brain stimulation (GPi DBS) in treating motor symptoms of Parkinson's disease, as measured by improvements in Unified Parkinson's Disease Rating Scale, part III (UPDRS-III) scores? RECOMMENDATION Given that bilateral STN DBS is at least as effective as bilateral GPi DBS in treating motor symptoms of Parkinson's disease (as measured by improvements in UPDRS-III scores), consideration can be given to the selection of either target in patients undergoing surgery to treat motor symptoms. (Level I) QUESTION 2 Is bilateral STN DBS more, less, or as effective as bilateral GPi DBS in allowing reduction of dopaminergic medication in Parkinson's disease? RECOMMENDATION When the main goal of surgery is reduction of dopaminergic medications in a patient with Parkinson's disease, then bilateral STN DBS should be performed instead of GPi DBS. (Level I) QUESTION 3 Is bilateral STN DBS more, less, or as effective as bilateral GPi DBS in treating dyskinesias associated with Parkinson's disease? RECOMMENDATION There is insufficient evidence to make a generalizable recommendation regarding the target selection for reduction of dyskinesias. However, when the reduction of medication is not anticipated and there is a goal to reduce the severity of “on” medication dyskinesias, the GPi should be targeted. (Level I) QUESTION 4 Is bilateral STN DBS more, less, or as effective as bilateral GPi DBS in improving quality of life measures in Parkinson's disease? RECOMMENDATION When considering improvements in quality of life in a patient undergoing DBS for Parkinson's disease, there is no basis to recommend bilateral DBS in 1 target over the other. (Level I) QUESTION 5 Is bilateral STN DBS associated with greater, lesser, or a similar impact on neurocognitive function than bilateral GPi DBS in Parkinson disease? RECOMMENDATION If there is significant concern about cognitive decline, particularly in regards to processing speed and working memory in a patient undergoing DBS, then the clinician should consider using GPi DBS rather than STN DBS, while taking into consideration other goals of surgery. (Level I) QUESTION 6 Is bilateral STN DBS associated with a higher, lower, or similar risk of mood disturbance than GPi DBS in Parkinson's disease? RECOMMENDATION If there is significant concern about the risk of depression in a patient undergoing DBS, then the clinician should consider using pallidal rather than STN stimulation, while taking into consideration other goals of surgery. (Level I) QUESTION 7 Is bilateral STN DBS associated with a higher, lower, or similar risk of adverse events compared to GPi DBS in Parkinson's disease? RECOMMENDATION There is insufficient evidence to recommend bilateral DBS in 1 target over the other in order to minimize the risk of surgical adverse events.  The full guideline can be found at: https://www.cns.org/guidelines/deep-brain-stimulation-parkinsons-disease. Deep brain stimulation, Globus pallidus internus, Guidelines, Neuromodulation, Parkinson's disease, Subthalamic nucleus ABBREVIATIONS ABBREVIATIONS BDI Beck Depression Inventory DBS deep brain stimulation GPi DBS globus pallidus internus deep brain stimulation PD Parkinson's disease PDQ Parkinson's Disease Questionnaire STN DBS subthalamic nucleus deep brain stimulation UPDRS-III Unified Parkinson's Disease Rating Scale, Part III VA veterans affairs The efficacy of bilateral deep brain stimulation (DBS) for the treatment of motor symptoms and levodopa-induced dyskinesias in Parkinson's Disease (PD) patients is well established.1-7 However, the effectiveness of selecting different stimulation targets is less clear. To date, 2 different targets have been proposed for the treatment of motor symptoms of PD, the subthalamic nucleus (STN) and globus pallidus internus (GPi). While there is evidence to suggest that both are effective when combined with best medical treatment vs best medical treatment alone,6 the circumstances in which 1 target should be selected over the other are still disputed. It is also unknown whether STN and GPi DBS induce similar benefits. METHODS Details of the systematic literature review are provided in the full text of this guideline (https://www.cns.org/guidelines/deep-brain-stimulation-parkinsons-disease). A PubMed search was conducted for articles published between 1966 and February, 2017. Two different search strategies were used and the results were combined, yielding 151 unique abstracts. The selected studies were classified according to criteria for evidence on therapeutic effectiveness as detailed in the Joint Guidelines Committee Guideline Development Methodology. RESULTS The combined search queries yielded a total of 151 unique abstracts, which were screened for eligibility. A total of 18 articles were included in the final analysis. For Question 1, 2 Class I,8,9 2 Class II,10,11 and 6 Class III12-17 studies found no differences between the 2 targets in motor score improvements at various time points, up to 5 yr postoperatively, in various medication and stimulation conditions. In contrast, 2 articles,18,19 including 1 Class I study,18 found that STN stimulation is associated with greater improvement in motor scores assessed in the “off” medication/“on” stimulation condition. The advantage seen in the STN cohort in this study persisted at 3-yr follow-up.11 No study to date has demonstrated a difference in the motor response to STN or GPi DBS in the “on” medication/”on” stimulation state. With respect to Question 2, compelling evidence was derived from 3 Class I studies,8,9,18 2 Class II studies,11,20 and 6 Class III studies10,12-15,17showing greater reduction in dopaminergic medications following STN than GPi DBS. For the third question, a single study provides Class I evidence18 that the severity of “on” medication dyskinesias, but not the amount of time with dyskinesias, is reduced to a greater extent following pallidal stimulation than subthalamic stimulation. The remaining 2 Class I studies showed no significant differences in the reduction of dyskinesias between these surgical targets.8,9 For Question 4, no study demonstrated a significant difference between the 2 targets regarding improvement in quality of life. Class I evidence from 3 studies have shown comparable improvements in quality of life as measured by the Unified Parkinson's Disease Rating Scale, Part II (UPDRS-II) at 1 yr,8 the composite Parkinson's Disease Questionnaire (PDQ-39) at 2 yr,9 or a quality of life questionnaire at 1 yr.18 Three-year follow-up in the veterans affairs (VA) study utilized the PDQ-39 and did not reveal a difference between the 2 surgical targets, as shown by a single Class II study.20 Six Class III studies10,12,14,15,21,22 showed improvements in quality of life following DBS without differences between the 2 targets. With respect to Question 5, neurocognitive function was formally assessed using various batteries in 5 studies.9,18,20,23,24 Class I evidence was provided by 3 of these studies, in which patients and assessors were blinded to the stimulation site.9,18,23 In 1 of these studies,9 STN DBS was associated with a significantly greater decline in processing speed and working memory compared to GPi DBS. For Question 6, Class I evidence from the VA Cooperative Study demonstrated a slight improvement in the GPi group (5.8%) compared to a slight worsening in the STN group (–11.6%) on the Beck Depression Inventory (BDI; P = .02).9 There were no differences between groups when this cohort was assessed for suicidal ideation and suicidal behaviors at 6, 12, and 24 mo postoperatively using the UPDRS-I.25 The NSTAPS 3-yr follow-up study found that there were no differences between targets when measuring with a composite of mood, cognitive, and behavioral effects (Class II).11 Class III evidence comes from 2 trials. A retrospective study of 27 patients demonstrated that both GPi and STN DBS groups were associated with a trend towards reduced Hamilton Depression Scale scores up to 12 mo postoperatively.17 Another retrospective series demonstrated decreases on the BDI score 12 mo postoperatively in both the STN DBS group (21.1%) and the GPi group (27.0%).24 Thus, there is Class I evidence from a single study suggesting that, compared to STN DBS, GPi stimulation is associated with better outcomes in terms of depression. For Question 7, no study showed a significantly higher risk of adverse events related to 1 surgical target over another. DISCUSSION AND CONCLUSION PD is characterized by many symptoms, which may vary in severity and response to medications and DBS. This clinical heterogeneity can make selection of the appropriate target for DBS somewhat complex. Based on the current literature, there are areas of agreement and disagreement over the question of target superiority in DBS for the treatment of PD. Ultimately, the selection of a specific brain target for stimulation should be tailored to the needs of the individual patient. Disclosures These evidence-based clinical practice guidelines were funded exclusively by the Congress of Neurological Surgeons (CNS) and the American Society for Stereotactic and Functional Neurosurgery, which received no funding from outside commercial sources to support the development of this document. Conflict of Interest The DBS for Parkinson's Disease Task Force members were required to report all possible COIs prior to beginning work on the guideline, using the COI disclosure form of the American Association of Neurological Surgeons (AANS)/CNS Joint Guidelines Review Committee, including potential COIs that are unrelated to the topic of the guideline. The CNS Guidelines Committee and Guideline Task Force Chair reviewed the disclosures and either approved or disapproved the nomination. The CNS Guidelines Committee and Guideline Task Force Chair are given latitude to approve nominations of Task Force members with possible conflicts and address this by restricting the writing and reviewing privileges of that person to topics unrelated to the possible COIs. The conflict of interest findings are provided in detail in the full-text introduction and methods manuscript (https://www.cns.org/guidelines/deep-brain-stimulation-parkinsons-disease). Disclaimer of Liability This clinical systematic review and evidence-based guideline was developed by a multidisciplinary physician volunteer task force and serves as an educational tool designed to provide an accurate review of the subject matter covered. These guidelines are disseminated with the understanding that the recommendations by the authors and consultants who have collaborated in their development are not meant to replace the individualized care and treatment advice from a patient's physician(s). If medical advice or assistance is required, the services of a competent physician should be sought. The proposals contained in these guidelines may not be suitable for use in all circumstances. The choice to implement any particular recommendation contained in these guidelines must be made by a managing physician in light of the situation in each particular patient and on the basis of existing resources. Notes Sponsored by: Congress of Neurological Surgeons (CNS) and the American Society for Stereotactic and Functional Neurosurgery (ASSFN) Endorsed by: Joint Guidelines Committee of the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) No part of this manuscript has been published or submitted for publication elsewhere. REFERENCES 1. Pahwa R, Factor SA, Lyons KE et al.   Practice parameter: treatment of Parkinson disease with motor fluctuations and dyskinesia (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology . 2006; 66( 7): 983- 995. Google Scholar CrossRef Search ADS PubMed  2. Perestelo-Perez L, Rivero-Santana A, Perez-Ramos J, Serrano-Perez P, Panetta J, Hilarion P. Deep brain stimulation in Parkinson's disease: meta-analysis of randomized controlled trials. J Neurol . 2014; 261( 11): 2051- 2060. Google Scholar CrossRef Search ADS PubMed  3. Okun MS, Gallo BV, Mandybur G et al.   Subthalamic deep brain stimulation with a constant-current device in Parkinson's disease: an open-label randomised controlled trial. Lancet Neurol . 2012; 11( 2): 140- 149. Google Scholar CrossRef Search ADS PubMed  4. Rodriguez-Oroz MC, Moro E, Krack P. Long-term outcomes of surgical therapies for Parkinson's disease. Mov Disord . 2012; 27( 14): 1718- 1728. Google Scholar CrossRef Search ADS PubMed  5. Deuschl G, Schade-Brittinger C, Krack P et al.   A randomized trial of deep-brain stimulation for Parkinson's disease. N Engl J Med . 2006; 355( 9): 896- 908. Google Scholar CrossRef Search ADS PubMed  6. Weaver FM, Follett K, Stern M et al.   Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA . 2009; 301( 1): 63- 73. Google Scholar CrossRef Search ADS PubMed  7. Schuepbach WM, Rau J, Knudsen K et al.   Neurostimulation for Parkinson's disease with early motor complications. N Engl J Med . 2013; 368( 7): 610- 622. Google Scholar CrossRef Search ADS PubMed  8. Anderson VC, Burchiel KJ, Hogarth P, Favre J, Hammerstad JP. Pallidal vs subthalamic nucleus deep brain stimulation in Parkinson disease. Arch Neurol . 2005; 62( 4): 554- 560. Google Scholar CrossRef Search ADS PubMed  9. Follett KA, Weaver FM, Stern M et al.   Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. N Engl J Med . 2010; 362( 22): 2077- 2091. Google Scholar CrossRef Search ADS PubMed  10. Moro E, Lozano AM, Pollak P et al.   Long-term results of a multicenter study on subthalamic and pallidal stimulation in Parkinson's disease. Mov Disord.  2010; 25( 5): 578- 586. Google Scholar CrossRef Search ADS PubMed  11. Odekerken VJ, Boel JA, Schmand BA et al.   GPi vs STN deep brain stimulation for Parkinson disease. Neurology . 2016; 86( 8): 755- 761. Google Scholar CrossRef Search ADS PubMed  12. Deep-Brain Stimulation for Parkinson's Disease Study G Obeso JA, Olanow CW et al.   Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson's disease. N Engl J Med . 2001; 345( 13): 956- 963. Google Scholar CrossRef Search ADS PubMed  13. Evidente VG, Premkumar AP, Adler CH, Caviness JN, Driver-Dunckley E, Lyons MK. Medication dose reductions after pallidal versus subthalamic stimulation in patients with Parkinson's disease. Acta Neurol Scand . 2011; 124( 3): 211- 214. Google Scholar CrossRef Search ADS PubMed  14. Minguez-Castellanos A, Escamilla-Sevilla F, Katati MJ et al.   Different patterns of medication change after subthalamic or pallidal stimulation for Parkinson's disease: target related effect or selection bias? J Neurol Neurosurg Psychiatry . 2005; 76( 1): 34- 39. Google Scholar CrossRef Search ADS PubMed  15. Rodriguez-Oroz MC, Obeso JA, Lang AE et al.   Bilateral deep brain stimulation in Parkinson's disease: a multicentre study with 4 years follow-up. Brain . 2005; 128( 10): 2240- 2249. Google Scholar CrossRef Search ADS PubMed  16. Scotto di Luzio AE, Ammannati F, Marini P, Sorbi S, Mennonna P. Which target for DBS in Parkinson's disease? Subthalamic nucleus versus globus pallidus internus. Neurol Sci . 2001; 22( 1): 87- 88. Google Scholar CrossRef Search ADS PubMed  17. Volkmann J, Allert N, Voges J, Weiss PH, Freund HJ, Sturm V. Safety and efficacy of pallidal or subthalamic nucleus stimulation in advanced PD. Neurology . 2001; 56( 4): 548- 551. Google Scholar CrossRef Search ADS PubMed  18. Odekerken VJ, van Laar T, Staal MJ et al.   Subthalamic nucleus versus globus pallidus bilateral deep brain stimulation for advanced Parkinson's disease (NSTAPS study): a randomised controlled trial. Lancet Neurol . 2013; 12( 1): 37- 44. Google Scholar CrossRef Search ADS PubMed  19. Krack P, Pollak P, Limousin P et al.   Subthalamic nucleus or internal pallidal stimulation in young onset Parkinson's disease. Brain . 1998; 121( 3): 451- 457. Google Scholar CrossRef Search ADS PubMed  20. Weaver FM, Follett KA, Stern M et al.   Randomized trial of deep brain stimulation for Parkinson disease: thirty-six-month outcomes. Neurology . 2012; 79( 1): 55- 65. Google Scholar CrossRef Search ADS PubMed  21. Krause M, Fogel W, Heck A et al.   Deep brain stimulation for the treatment of Parkinson's disease: subthalamic nucleus versus globus pallidus internus. J Neurol Neurosurg Psychiatry . 2001; 70( 4): 464- 470. Google Scholar CrossRef Search ADS PubMed  22. Volkmann J, Albanese A, Kulisevsky J et al.   Long-term effects of pallidal or subthalamic deep brain stimulation on quality of life in Parkinson's disease. Mov Disord.  2009; 24( 8): 1154- 1161. Google Scholar CrossRef Search ADS PubMed  23. Odekerken VJ, Boel JA, Geurtsen GJ et al.   Neuropsychological outcome after deep brain stimulation for Parkinson disease. Neurology . 2015; 84( 13): 1355- 1361. Google Scholar CrossRef Search ADS PubMed  24. Pillon B, Ardouin C, Damier P et al.   Neuropsychological changes between "off" and "on" STN or GPi stimulation in Parkinson's disease. Neurology . 2000; 55( 3): 411- 418. Google Scholar CrossRef Search ADS PubMed  25. Weintraub D, Duda JE, Carlson K et al.   Suicide ideation and behaviours after STN and GPi DBS surgery for Parkinson's disease: results from a randomised, controlled trial. J Neurol Neurosurg Psychiatry . 2013; 84( 10): 1113- 1118. Google Scholar CrossRef Search ADS PubMed  Neurosurgery Speaks! Audio abstracts available for this article at www.neurosurgery-online.com. Acknowledgments The guidelines task force would like to acknowledge the CNS Guidelines Committee for their contributions throughout the development of the guideline, the AANS/CNS Joint Guidelines Review Committee for their review, comments, and suggestions throughout peer review, as well as the contributions of Trish Rehring, MPH, CHES, Senior Manager of Clinical Practice Guidelines for the CNS, and Mary Bodach, MLIS, for assistance with the literature searches. Throughout the review process, the reviewers and authors were blinded from one another. At this time, the guidelines task force would like to acknowledge the following individual peer reviewers for their contributions: John O’Toole, MD; Maya Babu, MD; Andrew P. Carlson, MD; Jamie Van Gompel, MD; D. Ryan Ormond, MD; Mateo Ziu, MD. The authors would like to thank Dr Eduardo Joaquin Lopes Alho for the cover illustration. Neurosurgery Speaks (Audio Abstracts) Listen to audio translations of this paper's abstract into select languages by choosing from one of the selections below. English: Oluwakemi Aderonke Badejo, MBBS, FWACS Department of Surgery, College of Medicine, University of Ibadan Ibadan, Nigeria English: Oluwakemi Aderonke Badejo, MBBS, FWACS Department of Surgery, College of Medicine, University of Ibadan Ibadan, Nigeria Close Chinese: Lin Song, MD Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University Beijing, China Chinese: Lin Song, MD Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University Beijing, China Close French: Atef Ben Nsir, MD Neurosurgery Department, Fattouma Bourguiba University Hospital, University of Medicine of Monastir Monastir, Tunisia French: Atef Ben Nsir, MD Neurosurgery Department, Fattouma Bourguiba University Hospital, University of Medicine of Monastir Monastir, Tunisia Close Greek: Andreas Zigouris, MD Department of Neurosurgery, University Hospital of Ioannina Ioannina, Greece Greek: Andreas Zigouris, MD Department of Neurosurgery, University Hospital of Ioannina Ioannina, Greece Close Italian: Andrea Ruggeri, MD, PhD Neurosurgery Department, University of Rome "La Sapienza" Rome, Italy Italian: Andrea Ruggeri, MD, PhD Neurosurgery Department, University of Rome "La Sapienza" Rome, Italy Close Japanese: Toshiaki Hayashi, MD, PhD Department of Neurosurgery, Sendai City Hospital Sendai, Japan Japanese: Toshiaki Hayashi, MD, PhD Department of Neurosurgery, Sendai City Hospital Sendai, Japan Close Korean: Sun Ha Paek, MD, PhD Department of Neurosurgery, Seoul National University, College of Medicine Seoul, Republic of Korea Korean: Sun Ha Paek, MD, PhD Department of Neurosurgery, Seoul National University, College of Medicine Seoul, Republic of Korea Close Portuguese: Marcos Dellaretti, MD Department of Neurosurgery, Santa Casa de Belo Horizonte Belo Horizonte, Brazil Portuguese: Marcos Dellaretti, MD Department of Neurosurgery, Santa Casa de Belo Horizonte Belo Horizonte, Brazil Close Russian: Sergei Kim Department of Pediatric Neurosurgery, Novosibirsk Federal Centre of Neurosurgery Novosibirsk, Russia Russian: Sergei Kim Department of Pediatric Neurosurgery, Novosibirsk Federal Centre of Neurosurgery Novosibirsk, Russia Close Spanish: Alejandro Enriquez-Marulanda, MD Department of Neurosurgery, Hospital Virgen del Rocío Sevilla, Spain Spanish: Alejandro Enriquez-Marulanda, MD Department of Neurosurgery, Hospital Virgen del Rocío Sevilla, Spain Close Copyright © 2018 by the Congress of Neurological Surgeons This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

NeurosurgeryOxford University Press

Published: Mar 12, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off