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Systematic review

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Deep brain stimulation for Parkinson's disease: Meta-analysis of results of randomized trials at varying lengths of follow-up

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Journal Journal of neurosurgery
Year 2018
Links Pubmed DOI www.scopus.com

This article includes 13 Primary studies 12 Primary studies (13 references)

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OBJECTIVE Deep brain stimulation (DBS) is effective in the management of patients with advanced Parkinson's disease(PD). While both the globus pallidus pars interna (GPi) and the subthalamic nucleus (STN) are accepted targets,their relative efficacy in randomized controlled trials (RCTs) has not been established beyond 12 months. The objectiveof this study was to conduct a meta-analysis of RCTs to compare outcomes among adults with PD undergoing DBS ofGPi or STN at various time points, including 36 months of follow-up.METHODS The MEDLINE, Embase, CENTRAL, Web of Science, and CINAHL databases were searched. Registriesfor clinical trials, selected conference proceedings, and the table of contents for selected journals were also searched.Screens were conducted independently and in duplicate. Among the 623 studies initially identified (615 through databasesearch, 7 through manual review of bibliographies, and 1 through a repeat screen of literature prior to submission), 19underwent full-text review; 13 of these were included in the quantitative meta-analysis. Data were extracted independentlyand in duplicate. The Cochrane Collaboration tool was used to assess the risk of bias. The GRADE evidenceprofile tool was used to assess the quality of the evidence. Motor scores, medication dosage reduction, activities of dailyliving, depression, dyskinesias, and adverse events were compared. The influence of disease duration (a priori) and theproportion of male patients within a study (post hoc) were explored as potential subgroups.RESULTS Thirteen studies (6 original cohorts) were identified. No difference in motor scores or activities of daily livingwas identified at 36 months. Medications were significantly reduced with STN stimulation (5 studies, weighted mean difference[WMD] -365.46, 95% CI -599.48 to -131.44, p = 0.002). Beck Depression Inventory scores were significantlybetter with GPi stimulation (3 studies; WMD 2.53, 95% CI 0.99-4.06 p = 0.001). The motor benefits of GPi and STN DBSfor PD are similar.CONCLUSIONS The motor benefits achieved with GPi and STN DBS for PD are similar. DBS of STN allows for agreater reduction of medication, but not as significant an advantage as DBS of GPi with respect to mood. This differenceis sustained at 36 months. Further long-term studies are necessary.

Systematic review

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Neuropsychological performance changes following subthalamic versus pallidal deep brain stimulation in Parkinson's disease: a systematic review and metaanalysis.

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Journal CNS spectrums
Year 2018
Links Pubmed DOI www.scopus.com

This article includes 7 Primary studies 7 Primary studies (7 references)

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BACKGROUND: Studies comparing subthalamus (STN) and globus pallidus internus (GPi) deep brain stimulation (DBS) for the management of Parkinson's disease in terms of neuropsychological performance are scarce and heterogeneous. Therefore, we performed a systematic review and metaanalysis to compare neuropsychological outcomes following STN DBS versus GPi DBS. METHODS: A computer literature search of PubMed, the Web of Science, and Cochrane Central was conducted. Records were screened for eligible studies, and data were extracted and synthesized using Review Manager (v. 5.3 for Windows). RESULTS: Seven studies were included in the qualitative synthesis. Of them, four randomized controlled trials (n=345 patients) were pooled in the metaanalysis models. The standardized mean difference (SMD) of change in the Stroop color-naming test favored the GPi DBS group (SMD=-0.31, p=0.009). However, other neuropsychological outcomes did not favor either of the two groups (Stroop word-reading: SMD=-0.21, p=0.08; the Wechsler Adult Intelligence Scale (WAIS) digits forward: SMD=0.08, p=0.47; Trail Making Test Part A: SMD=-0.05, p=0.65; WAIS-R digit symbol: SMD=-0.16, p=0.29; Trail Making Test Part B: SMD=-0.14, p=0.23; Stroop color-word interference: SMD=-0.16, p=0.18; phonemic verbal fluency: bilateral DBS SMD=-0.04, p=0.73, and unilateral DBS SMD=-0.05, p=0.83; semantic verbal fluency: bilateral DBS SMD=-0.09, p=0.37, and unilateral DBS SMD=-0.29, p=0.22; Boston Naming Test: SMD=-0.11, p=0.33; Beck Depression Inventory: bilateral DBS SMD=0.15, p=0.31, and unilateral DBS SMD=0.36, p=0.11). CONCLUSIONS: There was no statistically significant difference in most of the neuropsychological outcomes. The present evidence does not favor any of the targets in terms of neuropsychological performance.

Systematic review

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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.

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Journal Neurosurgery
Year 2018
Links Pubmed DOI PubMed Central

This article includes 18 Primary studies 16 Primary studies (18 references)

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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.

Systematic review

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Subthalamic nucleus and globus pallidus internus stimulation for the treatment of Parkinson's disease: A systematic review.

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Authors Xu H , Zheng F , Krischek B , Ding W , Xiong C , Wang X , Niu C
Journal The Journal of international medical research
Year 2017
Links Pubmed DOI PubMed Central www.scopus.com

This article includes 8 Primary studies 7 Primary studies (8 references)

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Objective Deep brain stimulation (DBS) for treatment of advanced Parkinson's disease (PD) has two anatomical targets: the subthalamic nucleus (STN) and the globus pallidus internus (GPI). The clinical effectiveness of these two stimulation targets was compared in the present study. Methods A systematic review and meta-analysis was performed to evaluated the postoperative changes in the United Parkinson's Disease Rating Scale (UPDRS) on- and off-phase, on-stimulation motor scores; activities of daily living score (ADLS); and levodopa equivalent dose (LED) after STN and GPI stimulation. Randomized and nonrandomized controlled trials of PD treated by STN and GPI stimulation were considered for inclusion. Results Eight published reports of eligible studies involving 599 patients met the inclusion criteria. No significant differences were observed between the STN and GPI groups in the on-medication, on-stimulation UPDRS motor score [mean difference, 2.15; 95% confidence interval (CI), -0.96-5.27] or ADLS (mean difference, 3.40; 95% CI, 0.95-7.76). Significant differences in favor of STN stimulation were noted in the off-medication, on-stimulation UPDRS motor score (mean difference, 1.67; 95% CI, 0.98-2.37) and LED (mean difference, 130.24; 95% CI, 28.82-231.65). Conclusion The STN may be the preferred target for DBS in consideration of medication reduction, economic efficiency, and motor function improvement in the off phase. However, treatment decisions should be made according to the individual patient's symptoms and expectations.

Systematic review

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Effects of neurostimulation for advanced Parkinson's disease patients on motor symptoms: A multiple-treatments meta-analysas of randomized controlled trials.

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Authors Xie CL , Shao B , Chen J , Zhou Y , Lin SY , Wang WW
Journal Scientific reports
Year 2016
Links Pubmed DOI PubMed Central www.scopus.com

This article includes 16 Primary studies 14 Primary studies (16 references)

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Deep brain stimulation (DBS) is the surgical procedure of choice for patients with advanced Parkinson disease (PD). We aim to evaluate the efficacy of GPi (globus pallidus internus), STN (subthalamic nucleus)-DBS and medical therapy for PD. We conducted a systematic review and multiple-treatments meta-analysis to investigate the efficacy of neurostimulation and medical therapy for PD patients. Sixteen eligible studies were included in this analysis. We pooled the whole data and found obvious difference between GPi-DBS versus medical therapy and STN-DBS versus medical therapy in terms of UPDRS scores (Unified Parkinson's Disease Rating Scale). Meanwhile, we found GPi-DBS had the similar efficacy on the UPDRS scores when compared with STN-DBS. What is more, quality of life, measured by PDQ-39 (Parkinson's disease Questionnaire) showed greater improvement after GPi-DBS than STN-DBS. Five studies showed STN-DBS was more effective for reduction in medication than GPi-DBS. Overall, either GPi-DBS or STN-DBS was an effective technique to control PD patients' symptoms and improved their functionality and quality of life. Meanwhile, the UPDRS scores measuring parkinsonian symptoms revealed no significant difference between GPi-DBS and STN-DBS. STN-DBS was more effective for reduction in medication than GPi-DBS. Alternatively, GPi-DBS was more effective for improving the PDQ-39 score than STN-DBS.

Systematic review

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Efficacies of globus pallidus stimulation and subthalamic nucleus stimulation for advanced parkinson's disease: A meta-analysis of randomized controlled trials

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Authors Tan Z.-G. , Zhou Q. , Huang T. , Jiang Y.
Journal Clinical Interventions in Aging
Year 2016
Links Pubmed DOI PubMed Central www.scopus.com

This article includes 10 Primary studies 8 Primary studies (10 references)

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Deep brain stimulation (DBS) is the surgical procedure for patients with advanced Parkinson's disease. Globus pallidus internus (GPi) and subthalamic nucleus (STN) are the most targeted locations for the procedure. To investigate the variable efficiencies for the two different locations, we conducted a meta-analysis to compare both stimulation sites. MATERIALS AND METHODS: A systematic search was performed in PubMed, Embase, and the Cochrane Library databases. Randomized controlled trials comparing the efficacies of GPi and STN DBS were included. Clinical outcomes of motor function, nonmotor function, and quality of life (QOL) were collected for the meta-analysis. RESULTS: Ten eligible trials with 1,034 patients were included in the analysis. Unified Parkinson's disease rating scale III (UPDRS-III) scores were collected at 6, 12, and 24 months postsurgery separately to assess the motor function of the patients. A statistically significant effect in favor of the GPi DBS was obtained in the off-medication/on-stimulation phase of UPDRS-III at 12 months (mean difference [MD] =6.87, 95% confidence interval [95% CI]: 3.00-10.74, P=0.57, I (2)=0%). However, GPi DBS showed an opposite result at 24 months (MD =-2.46, 95% CI: -4.91 to -0.02, P=0.05, I (2)=0%). In the on-medication/on-stimulation phase, GPi DBS obtained a worse outcome compared with STN DBS (MD =-2.90, 95% CI: -5.71 to -0.09, P=0.05, I (2)=0%). Compared with STN DBS, increased dosage of levodopa equivalent doses was needed in GPi DBS (standardized MD =0.60, 95% CI: 0.46-0.74, P<0.00001, I (2)=24%). Meanwhile, Beck Depression Inventory II scores demonstrated that STN has a better performance (standardized MD =-0.31, 95% CI: -0.51 to -0.12, P=0.002, I (2)=0%). As for neurocognitive phase postsurgery, GPi DBS showed better performance in three of the nine tests, especially in verbal fluency. Use of GPi DBS was associated with a greater effect in eight of the nine subscales of QOL. CONCLUSION: GPi and STN DBS significantly improve advanced Parkinson's patients' symptoms, functionality, and QOL. Variable therapeutic efficiencies were observed in both procedures, GPi and STN DBS. GPi DBS allowed greater recovery of verbal fluency and provided greater relief of depression symptoms. Better QOL was also obtained using GPi DBS. Meanwhile, GPi DBS was also associated with increased dosage of levodopa equivalent doses. The question regarding which target is superior remained open for discussion. An understanding of the target selection still depends on individual symptoms, neurocognitive/mood status, therapeutic goals of DBS (eg, levodopa reduction), and surgical expertise.

Systematic review

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Cognitive and psychiatric effects of STN versus GPi deep brain stimulation in Parkinson's disease: A meta-analysis of randomized controlled trials.

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Journal PLoS ONE
Year 2016
Links Pubmed DOI PubMed Central www.scopus.com

This article includes 7 Primary studies 4 Primary studies (7 references)

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BACKGROUND: Deep brain stimulation (DBS) of either the subthalamic nucleus (STN) or the globus pallidus interna (GPi) can reduce motor symptoms in patients with Parkinson’s disease (PD) and improve their quality of life. However, the effects of STN DBS and GPi DBS on cognitive functions and their psychiatric effects remain controversial. The present meta-analysis was therefore performed to clarify these issues. METHODS: We searched the PUBMED, EMBASE, and the Cochrane Central Register of Controlled Trials databases. Other sources, including internet-based clinical trial registries and grey literature sources, were also searched. After searching the literature, two investigators independently performed literature screens to assess the quality of the included trials and to extract the data. The outcomes included the effects of STN DBS and GPi DBS on multiple cognitive domains, depression, anxiety, and quality of life. RESULTS: Seven articles related to four randomized controlled trials that included 521 participants were incorporated into the present meta-analysis. Compared with GPi DBS, STN DBS was associated with declines in selected cognitive domains after surgery, including attention, working memory and processing speed, phonemic fluency, learning and memory, and global cognition. However, there were no significant differences in terms of quality of life or psychiatric effects, such as depression and anxiety, between the two groups. CONCLUSIONS: A selective decline in frontal-subcortical cognitive functions is observed after STN DBS in comparison with GPi DBS, which should not be ignored in the target selection for DBS treatment in PD patients. In addition, compared to GPi DBS, STN DBS does not affect depression, anxiety, and quality of life. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Systematic review

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Deep brain stimulation and sleep-wake functions in Parkinson's disease: A systematic review.

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Journal Parkinsonism & related disorders
Year 2016
Links Pubmed DOI

This article includes 38 Primary studies 39 Primary studies (38 references)

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Sleep-wake disturbances (SWD) are common nonmotor symptoms (NMS) and have a great impact on quality of life of patients with Parkinson's disease (PD). Deep brain stimulation (DBS) is an established treatment in PD. While the beneficial effects of DBS on cardinal PD motor symptoms are indisputable, the data for several NMS, including sleep-wake functions, are limited and often controversial. Our primary objective was to review the literature on the impact of DBS on sleep-wake functions in patients with PD. A systematic review of articles, published in PubMed between January 1st, 2000 and December 31st, 2015 was performed to identify studies addressing the evolution of sleep-wake functions after DBS in patients with PD. Only 38 of 208 studies, involving a total of 1443 subjects, met the inclusion criteria. Most of them reported a positive effect of subthalamic DBS on sleep quality and consequently on quality of life. Seven studies used polysomnography to objectively assess sleep parameters. The data concerning subthalamic DBS and wake functions are controversial and studies using objective, laboratory-based measures for the assessment of wake functions are lacking. Very few studies assessed the impact of other DBS targets (e.g. pallidal stimulation) on SWD. Further prospective observational DBS studies assessing subjectively and objectively specific sleep-wake parameters in patients with PD are needed.

Systematic review

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The effect of deep brain stimulation on motor and cognitive symptoms of Parkinson's disease: A literature review.

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Authors Machado FA , Reppold CT
Journal Dementia & Neuropsychologia
Year 2015
Links Pubmed DOI PubMed Central LILACS

This article includes 19 Primary studies 14 Primary studies (19 references)

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Deep brain stimulator (DBS) implant surgery is considered a breakthrough in the treatment of Parkinson’s disease, especially in cases where motor symptoms cannot be controlled through conventional drug treatment. Its benefits have been studied extensively in the literature, particularly in relation to motor symptoms. However, the disease’s cognitive aspects have been studied to a lesser extent. OBJECTIVE: This systematic review aims to assess the effects of DBS surgery on motor and cognitive symptoms in patients with Parkinson’s disease. METHODS: The search strategy included MEDLINE, LILACs, SCIELO and the Cochrane Library. Randomized clinical trials with DBS surgical intervention and Parkinson’s disease were included. Of the 178 studies identified, 19 met the eligibility criteria. These studies were descriptively analyzed as regards to their results. RESULTS: Control of motor symptoms, as assessed by the UPDRS Part III scale, was found in all of the studies, pointing to great interest in this outcome and demonstrating an advantage of DBS over conventional drug treatment. Regarding cognitive aspects, heterogeneity in the choice of subjects studied and the use of different assessment tools for each was evident, hampering comparisons and leading to inconclusive results. CONCLUSION: This review provides a broad overview of the effects of DBS on Parkinson’s disease symptoms. However, it is suggested that future studies be conducted to establish a gold-standard protocol for neuropsychological assessment, thereby enabling data comparison and more consistent conclusions. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

Systematic review

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Which target is best for patients with Parkinson’s disease? A meta-analysis of pallidal and subthalamic stimulation.

Authors Sako W , Miyazaki Y , Izumi Y , Kaji R
Journal Journal of neurology, neurosurgery, and psychiatry
Year 2014
Links Pubmed DOI www.scopus.com

This article is included in 1 Broad synthesis 4 Broad syntheses (1 reference)

This article includes 4 Primary studies 4 Primary studies (4 references)

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BACKGROUND: There is a growing body of evidence demonstrating that deep brain stimulation (DBS) of globus pallidus internus (GPi DBS) and subthalamic nucleus (STN DBS) are effective treatment for patients with Parkinson’s disease (PD). However, it remains controversial whether the best stimulation target for a PD patient is GPi or STN. METHODS: A computer literature search of PubMed was carried out. We included randomised studies with direct comparison between targets. The outcome of unified PD rating scale (UPDRS) III was expressed as the standardised mean difference (SMD) between targets in baseline to endpoint change. Pooled risk ratio (RR) between targets was also used to assess adverse events. RESULTS: Four studies, comprising a total sample size of 502 PD patients (254 GPi DBS, 248 STN DBS), were included in this meta-analysis. The overall effect of GPi DBS on UPDRS III was not significantly different from STN DBS (SMD = 0.19, 95% CI −0.2 to 0.58, p = 0.34, four studies, n = 448). This result was heterogeneous (p = 0.03, I² = 66%). In terms of adverse events, depression was significantly less frequent in patients with GPi DBS than STN DBS with homogeneous studies ( pooled RR = 0.53, 95% CI 0.31 to 0.90, p = 0.02, three studies, n = 479, I² = 48%). CONCLUSIONS: The effect of GPi DBS was similar to STN DBS except for depression, however, only three studies described depression as adverse events. We need additional randomised trials with direct comparison between targets based on unified scoring of adverse events. (PsycINFO Database Record (c) 2016 APA, all rights reserved)