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NSTAPS

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Medication dose reductions after pallidal versus subthalamic stimulation in patients with Parkinson's disease.

Authors » Evidente VG , Premkumar AP , Adler CH , Caviness JN , Driver-Dunckley E , Lyons MK

Journal » Acta neurologica Scandinavica

Year » 2011

Links » Pubmed DOI

This article is included in 2 Systematic reviews Systematic reviews (2 references)

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OBJECTIVE: To compare the medication dose reduction between deep brain stimulation (DBS) of the globus pallidus interna (GPi) vs subthalamic nucleus (STN) in matched patients with Parkinson's disease (PD). MATERIALS AND METHODS: Records of 12 patients with PD who underwent GPi-DBS at our institution from 2002 to 2008 were matched by pre-operative PD medication doses and pre-operative motor Unified Parkinson's Disease Rating Scale (UPDRS) scores to 12 cases of STN-DBS. PD medication doses were converted to levodopa equivalent doses (LEDs). RESULTS: GPi and STN groups had similar mean pre-operative LEDs and motor UPDRS scores. At 6 months post-DBS, there was no significant difference in percent reduction in LEDs between the GPi (47.95%) and STN (37.47%) groups (P = 0.52). The mean post-operative 'medication off/stimulation on' motor UPDRS scores did not differ significantly between GPi (15.33) and STN (16.25) groups (P = 0.74). The mean percent reduction in motor UPDRS scores was also similar between GPi (58.44%) and STN (58.98%) patients (P = 0.94). CONCLUSIONS: We conclude that in disease-matched patients with PD undergoing DBS, both GPi and STN may result in similar reduction in PD medication doses.

468 Study - Phase 2 (Veterans Affairs Cooperative Studies Program (CSP) 468 study)

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COMPARE

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Effects of unilateral subthalamic and pallidal deep brain stimulation on fine motor functions in Parkinson's disease.

Authors » Nakamura K , Christine CW , Starr PA , Marks WJ

Journal » Movement disorders : official journal of the Movement Disorder Society

Year » 2007

Links » Pubmed DOI www.scopus.com

This article is included in 1 Systematic review Systematic reviews (1 reference)

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Deep brain stimulation (DBS) is an effective treatment for selected patients with disabling Parkinson's disease (PD). The two main targets are the subthalamic nucleus (STN) and the globus pallidus internus (GPi), although it has not been established whether stimulation at one target is superior to the other. This prospective randomized study assessed the effects of unilateral DBS of the STN versus GPi on fine motor skills in 33 patients with advanced PD. Stimulation of either the STN (18 subjects) or GPi (15 subjects) in the off medication state significantly improved movement time and dexterity, but had little or no effect on reaction time. Overall, the extent of improvement did not differ between the two targets. The degree of improvement in movement time, but not dexterity, was correlated with the extent of preoperative medication responsiveness. Our findings suggest that DBS of the STN or GPi results in a similar improvement in hand movements at short-term follow-up. Preoperative medication responsiveness predicts improvement in some but not other motor tasks.

Deep brain stimulation for the treatment of Parkinson's disease: subthalamic nucleus versus globus pallidus internus.

Authors » Krause M , Fogel W , Heck A , Hacke W , Bonsanto M , Trenkwalder C , Tronnier V

Journal » Journal of neurology, neurosurgery, and psychiatry

Year » 2001

Links » Pubmed DOI PubMed Central

This article is included in 4 Systematic reviews Systematic reviews (4 references)

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OBJECTIVES: Deep brain stimulation of the basal ganglia has become a promising treatment option for patients with Parkinson's disease who have side effects from drugs. Which is the best target-globus pallidus internus (GPi) or subthalamic nucleus (STN)-is still a matter of discussion. The aim of this prospective study is to compare the long term effects of GPi and STN stimulation in patients with severe Parkinson's disease. PATIENTS AND METHODS: Bilateral deep brain stimulators were implanted in the GPi in six patients and in the STN in 12 patients with severe Parkinson's disease. Presurgery and 3, 6, and 12 months postsurgery patients were scored according to the CAPIT protocol. RESULTS: Stimulation of the STN increased best Schwab and England scale score significantly from 62 before surgery to 81 at 12 months after surgery; GPi stimulation did not have an effect on the Schwab and England scale. Stimulation of the GPi reduced dyskinesias directly whereas STN stimulation seemed to reduce dyskinesias by a reduction of medication. Whereas STN stimulation increased the unified Parkinson's disease rating scale (UPDRS) motor score, GPi stimulation did not have a significant effect. Fluctuations were reduced only by STN stimulation and STN stimulation suppressed tremor very effectively. CONCLUSION: Stimulation of the GPi reduces medication side effects, which leads to a better drug tolerance. There was no direct improvement of bradykinesia or tremor by GPi stimulation. Stimulation of the STN ameliorated all parkinsonian symptoms. Daily drug intake was reduced by STN stimulation. The STN is the target of choice for treating patients with severe Parkinson's disease who have side effects from drugs.

Comparison of pallidal and subthalamic nucleus deep brain stimulation for advanced Parkinson's disease: results of a randomized, blinded pilot study.

Authors » Burchiel KJ , Anderson VC , Favre J , Hammerstad JP

Journal » Neurosurgery

Year » 1999

Links » Pubmed DOI www.scopus.com

This article is included in 10 Systematic reviews Systematic reviews (10 references)

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OBJECTIVE: Deep brain stimulation (DBS) of the globus pallidus internus (GPi) and subthalamic nucleus (STN) has been reported to be effective in alleviating the symptoms of advanced Parkinson's disease (PD). Although recent studies suggest that STN stimulation may be superior to GPi stimulation, a randomized, blinded comparison has not been reported. The present study was designed to provide a preliminary comparison of the safety and efficacy of DBS at either site. METHODS: Ten patients with idiopathic PD, L-dopa-induced dyskinesia, and response fluctuations were randomized to implantation of bilateral GPi or STN stimulators. Neurological condition was assessed preoperatively with patients on and off L-dopa and on DBS at 10 days and 3, 6, and 12 months after implantation. Patients and evaluating clinicians were blinded to stimulation site throughout the study period. Complete follow-up data were analyzed for four GPi patients and five STN patients. RESULTS: When off-L-dopa, both GPi and STN groups demonstrated a similar response, with approximately 40% improvement in Unified PD Rating Scale motor scores after 12 months of DBS. Rigidity, tremor, and bradykinesia improved in both groups. In combination with L-dopa, Unified PD Rating Scale motor scores were more improved by GPi stimulation than by STN stimulation. On-L-dopa axial symptoms were clinically improved in the GPi but not the STN group. L-Dopa-induced dyskinesia was reduced by DBS at either site, although medication requirement was reduced only in the STN group. There were no serious intraoperative complications among patients in either group. CONCLUSION: Pallidal and STN stimulation appears to be safe and efficacious for the management of advanced PD. A larger study is needed to investigate further the differences in symptom response and the interaction of L-dopa with stimulation at either site.

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Medication dose reductions after pallidal versus subthalamic stimulation in patients with Parkinson's disease.

Authors » Evidente VG , Premkumar AP , Adler CH , Caviness JN , Driver-Dunckley E , Lyons MK

Journal » Acta neurologica Scandinavica

Year » 2011

Links » Pubmed DOI

This article is included in 2 Systematic reviews Systematic reviews (2 references)

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Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease

Authors » Follett KA , Weaver FM , Stern M , Hur K , Harris CL , Luo P , Marks WJ , Rothlind J , Sagher O , Moy C , Pahwa R , Burchiel K , Hogarth P , Lai EC , Duda JE , Holloway K , Samii A , Horn S , Bronstein JM , Stoner G , Starr PA , Simpson R , Baltuch G , De Salles A , Huang GD , Reda DJ , CSP 468 Study Group

Journal » The New England journal of medicine

Year » 2010

Links » Pubmed DOI www.scopus.com

This article is included in 12 Systematic reviews Systematic reviews (12 references)

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Background: Deep-brain stimulation is the surgical procedure of choice for patients with advanced Parkinson's disease. The globus pallidus interna and the subthalamic nucleus are accepted targets for this procedure. We compared 24-month outcomes for patients who had undergone bilateral stimulation of the globus pallidus interna (pallidal stimulation) or subthalamic nucleus (subthalamic stimulation). Methods: At seven Veterans Affairs and six university hospitals, we randomly assigned 299 patients with idiopathic Parkinson's disease to undergo either pallidal stimulation (152 patients) or subthalamic stimulation (147 patients). The primary outcome was the change in motor function, as blindly assessed on the Unified Parkinson's Disease Rating Scale, part III (UPDRS-III), while patients were receiving stimulation but not receiving antiparkinsonian medication. Secondary outcomes included selfreported function, quality of life, neurocognitive function, and adverse events. Results: Mean changes in the primary outcome did not differ significantly between the two study groups (P = 0.50). There was also no significant difference in self-reported function. Patients undergoing subthalamic stimulation required a lower dose of dopaminergic agents than did those undergoing pallidal stimulation (P = 0.02). One component of processing speed (visuomotor) declined more after subthalamic stimulation than after pallidal stimulation (P = 0.03). The level of depression worsened after subthalamic stimulation and improved after pallidal stimulation (P = 0.02). Serious adverse events occurred in 51% of patients undergoing pallidal stimulation and in 56% of those undergoing subthalamic stimulation, with no significant between-group differences at 24 months. Conclusions: Patients with Parkinson's disease had similar improvement in motor function after either pallidal or subthalamic stimulation. Nonmotor factors may reasonably be included in the selection of surgical target for deep-brain stimulation. Copyright © 2010 Massachusetts Medical Society.

Greater improvement in quality of life following unilateral deep brain stimulation surgery in the globus pallidus as compared to the subthalamic nucleus

Authors » Zahodne LB , Okun MS , Foote KD , Fernandez HH , Rodriguez RL , Wu SS , Kirsch-Darrow L , Jacobson CE , Rosado C , Bowers D

Journal » Journal of neurology

Year » 2009

Links » Pubmed DOI PubMed Central www.scopus.com

This article is included in 9 Systematic reviews Systematic reviews (9 references)

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While deep brain stimulation (DBS) surgery is a well-accepted treatment for Parkinson disease (PD) that improves overall quality of life (QoL), its effects across different domains of QoL are unclear. The study reported here directly compared the effects of unilateral DBS in subthalamic nucleus (STN) or globus pallidus (GPi) on QoL in 42 non-demented patients with medication-refractory PD. Patients were enrolled in the COMPARE trial, a randomized clinical trial of cognitive and mood effects of STN versus GPi DBS conducted at the University of Florida Movement Disorders Center. Patients underwent motor, mood, verbal fluency and QoL (Parkinson disease questionnaire: PDQ-39) measures before and 6 months following surgery. Groups experienced motor and mood improvements that did not differ by target. Patients with STN DBS evidenced a slight decrement on letter fluency. On average, all patients endorsed better overall QoL after surgery. However, despite similar motor and mood improvements, GPi patients improved more than STN patients (38 vs. 14%, respectively; P = 0.03). Patients reported better QoL on subscales of mobility, activities of daily living (ADLs), emotional well-being, stigma, cognition and discomfort, but not on those of social support and communication. Improvements on the mobility, ADLs, stigma and social support subscales were greater amongst GPi patients. In regression analyses, only depression changes independently predicted changes in overall QoL as well as emotional well-being and social support changes. Within the STN group only, declining category fluency scores correlated with poorer QoL on the communication subscale. Unilateral DBS in both STN and GPi improved QoL overall and in disparate domains 6 months after surgery. Patients receiving GPi DBS reported greater improvements that cannot be explained by differential mood or motor effects; however, verbal fluency changes may have partially contributed to lesser QoL improvements amongst STN patients. © 2009 Springer-Verlag.

Cognition and mood in Parkinson's disease in subthalamic nucleus versus globus pallidus interna deep brain stimulation: the COMPARE trial.

Authors » Okun MS , Fernandez HH , Wu SS , Kirsch-Darrow L , Bowers D , Bova F , Suelter M , Jacobson CE , Wang X , Gordon CW , Zeilman P , Romrell J , Martin P , Ward H , Rodriguez RL , Foote KD

Journal » Annals of neurology

Year » 2009

Links » Pubmed DOI PubMed Central www.scopus.com

This article is included in 6 Systematic reviews Systematic reviews (6 references)

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OBJECTIVE: Our aim was to compare in a prospective blinded study the cognitive and mood effects of subthalamic nucleus (STN) vs. globus pallidus interna (GPi) deep brain stimulation (DBS) in Parkinson disease.METHODS: Fifty-two subjects were randomized to unilateral STN or GPi DBS. The co-primary outcome measures were the Visual Analog Mood Scale, and verbal fluency (semantic and letter) at 7 months post-DBS in the optimal setting compared to pre-DBS. At 7 months post-DBS, subjects were tested in four randomized/counterbalanced conditions (optimal, ventral, dorsal, and off DBS).RESULTS: Forty-five subjects (23 GPi, 22 STN) completed the protocol. The study revealed no difference between STN and GPi DBS in the change of co-primary mood and cognitive outcomes pre- to post-DBS in the optimal setting (Hotelling's T(2) test: p = 0.16 and 0.08 respectively). Subjects in both targets were less "happy", less "energetic" and more "confused" when stimulated ventrally. Comparison of the other 3 DBS conditions to pre-DBS showed a larger deterioration of letter verbal fluency in STN, especially when off DBS. There was no difference in UPDRS motor improvement between targets.INTERPRETATION: There were no significant differences in the co-primary outcome measures (mood and cognition) between STN and GPi in the optimal DBS state. Adverse mood effects occurred ventrally in both targets. A worsening of letter verbal fluency was seen in STN. The persistence of deterioration in verbal fluency in the off STN DBS state was suggestive of a surgical rather than a stimulation-induced effect. Similar motor improvement were observed with both STN and GPi DBS.

Subthalamic nucleus versus globus pallidus bilateral deep brain stimulation for advanced Parkinson's disease (NSTAPS study): a randomised controlled trial.

Authors » Odekerken VJ , van Laar T , Staal MJ , Mosch A , Hoffmann CF , Nijssen PC , Beute GN , van Vugt JP , Lenders MW , Contarino MF , Mink MS , Bour LJ , van den Munckhof P , Schmand BA , de Haan RJ , Schuurman PR , de Bie RM

Journal » Lancet neurology

Year » 2013

Links » Pubmed DOI www.scopus.com

This article is included in 11 Systematic reviews Systematic reviews (11 references)

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BACKGROUND: Patients with advanced Parkinson's disease often have rapid swings between mobility and immobility, and many respond unsatisfactorily to adjustments in pharmacological treatment. We assessed whether globus pallidus pars interna (GPi) deep brain stimulation (DBS) gives greater functional improvement than does subthalamic nucleus (STN) DBS. METHODS: We recruited patients from five centres in the Netherlands who were aged 18 years or older, had idiopathic Parkinson's disease, and had, despite optimum pharmacological treatment, at least one of the following symptoms: severe response fluctuations, dyskinesias, painful dystonias, or bradykinesia. By use of a computer-generated randomisation sequence, we randomly assigned patients to receive either GPi DBS or STN DBS (1:1), applying a minimisation procedure according to drug use (levodopa equivalent dose <1000 mg vs ≥1000 mg) and treatment centre. Patients and study assessors (but not those who assessed adverse events) were masked to treatment allocation. We had two primary outcomes: functional health as measured by the weighted Academic Medical Center Linear Disability Scale (ALDS; weighted by time spent in the off phase and on phase) and a composite score for cognitive, mood, and behavioural effects up to 1 year after surgery. Secondary outcomes were symptom scales, activities of daily living scales, a quality-of-life questionnaire, the occurrence of adverse events, and drug use. We used the intention-to-treat principle for all analyses. This trial is registered with www.controlled-trials.com, number ISRCTN85542074. FINDINGS: Between Feb 1, 2007, and March 29, 2011, we enrolled 128 patients, assigning 65 to GPi DBS and 63 to STN DBS. We found no statistically significant difference in either of our primary outcomes: mean change in weighted ALDS (3·0 [SD 14·5] in the GPi group vs 7·7 [23·2] in the STN group; p=0·28) and the number of patients with cognitive, mood, and behavioural side-effects (36 [58%] of 62 patients in the GPi group vs 35 [56%] of 63 patients in the STN group; p=0·94). Secondary outcomes showed larger improvements in off-drug phase in the STN group compared with the GPi group in the mean change in unified Parkinson's disease rating scale motor examination scores (20·3 [16·3] vs 11·4 [16·1]; p=0·03), the mean change in ALDS scores (20·3 [27·1] vs 11·8 [18·9]; p=0·04), and medication (mean levodopa equivalent drug reduction: 546 [SD 561] vs 208 [521]; p=0·01). We recorded no difference in the occurrence of adverse events between the two groups. Other secondary endpoints showed no difference between the groups. INTERPRETATION: Although there was no difference in our primary outcomes, our findings suggest that STN could be the preferred target for DBS in patients with advanced Parkinson's disease. FUNDING: Stichting Internationaal Parkinson Fonds, Prinses Beatrix Fonds, and Parkinson Vereniging.