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Neurological Review |

Deep Brain Stimulation for Parkinson Disease:  An Expert Consensus and Review of Key Issues FREE

Jeff M. Bronstein, MD, PhD; Michele Tagliati, MD; Ron L. Alterman, MD; Andres M. Lozano, MD, PhD; Jens Volkmann, MD, PhD; Alessandro Stefani, MD; Fay B. Horak, PhD; Michael S. Okun, MD; Kelly D. Foote, MD; Paul Krack, MD, PhD; Rajesh Pahwa, MD; Jaimie M. Henderson, MD; Marwan I. Hariz, MD, PhD; Roy A. Bakay, MD; Ali Rezai, MD; William J. Marks Jr, MD; Elena Moro, MD, PhD; Jerrold L. Vitek, MD, PhD; Frances M. Weaver, PhD; Robert E. Gross, MD, PhD; Mahlon R. DeLong, MD
[+] Author Affiliations

Author Affiliations: University of California, Los Angeles (UCLA), School of Medicine (Dr Bronstein); Mount Sinai School of Medicine, New York, New York (Drs Tagliati and Alterman); University of Toronto, Toronto, Ontario, Canada (Drs Lozano and Moro); Christian-Albrechts-Universit, Kiel, Germany (Dr Volkmann); University of Rome Tor Vergata, Rome, Italy (Dr Stefani); Oregon Health and Science University, Portland (Dr Horak); University of Florida, Gainesville (Drs Okun and Foote); Centre Hospitalier Universitaire, University of Grenoble, Grenoble, France (Dr Krack); Kansas University School of Medicine, Kansas City (Dr Pahwa); Stanford University School of Medicine, Stanford, California (Dr Henderson); Institute of Neurology, National Hospital for Neurology and Neurosurgery, London, England (Dr Hariz); Rush Medical College, Chicago, Illinois (Dr Bakay); Cleveland Clinic, Cleveland, Ohio (Drs Rezai and Vitek); University of California, San Francisco, School of Medicine (Dr Marks); Hines Veterans Affairs Hospital, Hines, Illinois (Dr Weaver); Emory University School of Medicine, Decatur, Georgia (Drs Gross and DeLong).


Section Editor: David E. Pleasure, MD

More Author Information
Arch Neurol. 2011;68(2):165. doi:10.1001/archneurol.2010.260.
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Published online

Surgical treatment of Parkinson disease (PD) was described as early as 1940 and, until recently, had focused on ablative procedures of the thalamus and globus pallidus pars interna (GPi). These surgical treatments (especially pallidotomy) rose to prominence in the era before levodopa (LD) but later reemerged as popular approaches in the 1990s. They were rapidly replaced in the late 1990s by deep brain stimulation (DBS), mainly as a result of concerns for adverse effects resulting from bilateral lesions as well as the irreversible effects resulting from poorly placed lesions. Furthermore, a new target, the subthalamic nuclei (STN) was identified to be an effective target and quickly became the most common site for DBS electrode placement.13

Since its approval by the Food and Drug Administration for PD in 2002, more than 70 000 patients have undergone DBS surgery, according to Medtronic Inc. Despite the widespread use of this treatment, several aspects of DBS therapy remain controversial. The purpose of this consensus workshop was to bring together many of the leading experts in the field to address certain issues involving the procedure that remain unresolved.

Panel Selection

Participants were invited based on their extensive practice at centers that perform a high volume of DBS procedures, having been extensively involved in research in PD and DBS, and have published in peer-reviewed journals in the field. Seventy six percent of those invited attended the workshop (33 neurologists, 13 neurosurgeons, a psychiatrist, a speech researcher, 2 neuropsychologists, a rehabilitation specialist, and a research scientist).

Agenda

The organizing committee distributed a proposed agenda, and participants were encouraged to suggest changes. Two topic leaders for each area were selected to review and distribute key focused articles in advance, briefly review the topic, and lead a discussion.

Meeting

Topic leaders introduced their subject and led a discussion open to all participants. Detailed notes of the discussions were taken, and the meeting was recorded. Prior to the end of the meeting, a preliminary statement was prepared by the topic leaders, presented to all attendees, and discussed again to achieve consensus. The final statement was prepared by the organizing committee based on the documented final discussion, and the manuscript was sent to all participants for their review, comments, and approval.

The most important step toward consistent DBS outcomes remains careful patient selection. More than 30% of DBS failures can be ascribed to inappropriate indication(s) for surgery.4 Patient selection is based on an individual risk-benefit evaluation for each patient that, in most expert centers, has been delivered via a multidisciplinary approach involving a movement disorder neurologist, a neurosurgeon, a neuropsychologist, an internist, and in many cases, a psychiatrist. Best results have been reported in patients with advanced PD and (1) excellent LD response, (2) younger age, (3) no or few axial non–LD-responsive motor symptoms, (4) no or very mild cognitive impairment, and (5) absence of or well-controlled psychiatric disease. However, the rigid application of these criteria may lead to the exclusion of a substantial number of persons with PD.5 While there was consensus on their importance for the selection process, there was less agreement on how to accurately measure them or the cutoff values that should be respected for DBS eligibility.

Diagnosis

Advanced PD complicated by disability from motor fluctuations, dyskinesias, or tremor despite optimal drug therapy is universally accepted as a reasonable indication for DBS.68 Patients with atypical parkinsonism usually have less favorable outcomes and therefore are not generally considered good candidates for DBS.9

Age

The value of age as an independent outcome predictor for DBS has been debated,10,11 although there are insufficient data to establish a clear age cutoff. The major concerns with age have been the associated comorbidities, cognitive decline,12 higher incidence of LD-resistant symptoms,1315 and higher overall risk of surgical complications.16

Disease Duration

Disease duration has not been a primary factor in dictating the selection of patients with PD for DBS therapy. There is currently no evidence of a neuroprotective effect of DBS to provide a clear rationale for earlier DBS surgery. Historically, patients with PD who have DBS have had disease durations of 10 to 15 years; however, preliminary evidence suggest that DBS may have a greater beneficial effect on quality of life for patients with less advanced disease.17 There has been a concern that operating on patients earlier than 5 years following diagnosis would lead to the inclusion of patients with atypical parkinsonism.

Disease Severity

There are data showing that disease severity has been correlated with clinical outcome11 but there remains no consensus on a specific severity measure and/or cutoff. Disease severity that leads to disability is influenced by individual factors such as professional status and social function and should be considered.

LD Responsiveness

Response to LD has been universally accepted as the single best outcome predictor for response to DBS.18,19 Most centers use a formal LD challenge, and a 30% improvement in the Unified Parkinson Disease Rating Scale III score has been used as one useful marker of LD responsiveness but should not be considered an absolute criterion. In addition, severe tremor resistance to LD therapy is considered an accepted exception to this.

Cognitive Impairment

Dementia is the most frequent exclusion criterion for DBS surgery. There was no consensus on the type of testing to establish cognitive impairment in patients with PD or on the level of performance including mild cognitive impairment that would exclude patients from receiving DBS. There are limited data suggesting that advanced age may be associated with higher risk of frontal and related executive deterioration following STN DBS.12

Psychiatric Issues

There was no consensus on individual psychiatric symptoms as exclusion criteria for DBS surgery.11 Surgery is generally deferred in patients with unstable psychiatric conditions until their symptoms have been adequately managed. The reported increased rate of suicide in patients with PD who have undergone STN DBS underscores the need for a more accurate preoperative psychiatric assessment and treatment of depression as well as the need for careful and detailed postoperative follow-up.20

The surgical techniques for implanting DBS devices are constantly evolving, and surgeons select their preferred technique based on training, experience, and the capabilities of their institution. There are few studies that have directly compared the safety or effectiveness of various surgical techniques. Thus, the best technique for performing DBS surgery remains a source of debate. Nevertheless, the experts agreed on the following: (1) DBS surgery is best performed by an experienced surgeon with specific expertise in stereotactic and functional neurosurgery who should be working as part of an interprofessional team that includes a movement disorder neurologist, neuropsychologist, psychiatrist, and neurophysiologist; (2) both frame-based and so-called frameless navigation techniques are acceptable as long as the surgeon is experienced with the chosen method; (3) there is no best means of targeting for DBS surgery. Acceptable imaging modalities for targeting include magnetic resonance imaging (MRI), computed tomography, ventriculography, and various combinations thereof; (4) some form of intraoperative neurophysiological monitoring is useful for guiding proper lead placement (microelectrode recording, semi–microelectrode recording, microelectrode or macroelectrode stimulation, and/or tissue impedance monitoring); (4) some form of postoperative brain imaging (computed tomography or MRI) is performed by most surgeons to check the position of the implanted DBS leads and to evaluate for hemorrhage and pneumocephalus; and (5) the DBS leads may be implanted during 1 surgery or in 2 separate procedures. The extension cables and pulse generators may be implanted on the same day as the electrodes or days to weeks after, depending on the center's preference. The value of staging or doing unilateral-only implants in a subset of patients, particularly elderly patients or those with cognitive impairment, is of interest but currently not known.

The rates of surgical complications are quite variable in the literature and include intracranial hemorrhage (0%-10%), stroke (0%-2%), infection (0%-15%), lead erosion without infection (1%-2.5%), lead fracture (0%-15%), lead migration (0%-19%), and death (0%-4.4%).10,2125 There was consensus that the incidence of symptomatic intracranial hemorrhage is likely less than 2% for most centers and that lead fracture and migration are likely much lower in recent times owing to improved technology. Hardware infection is the most common reported serious surgical complication, although there was no general consensus on methods to reduce the risk despite agreement on the necessity for the use of perioperative antibiotics.

Several potential factors were discussed that might influence surgical complication rates. Although clear data are lacking, there was general consensus that advanced age and comorbidities of the patient add risk but these should not exclude someone from consideration. There was general consensus that the experience of the surgical team is a key factor in lowering the risk of surgical complications and there is a critical need for prospective standardized reporting of complications.

The hardware complications of DBS are not infrequent but the absence of standardized reporting of adverse events makes it impossible to accurately determine the adverse event profile. Although a revision may be limited to part of the system such as the implantable pulse generator, quite often the revision includes the whole DBS system. The most commonly reported hardware-related complications are infection, migration or misplacement of the leads, lead fractures, and skin erosion. While improved surgical techniques may help reduce adverse events, the primary improvement must come from the manufacturer to produce more durable and redundant leads. We also encourage new designs in leads to further improve performance, minimize complications from errant lead placement, and reduce programming time. In addition, the pulse generator should be improved by decreasing its size, increasing the battery life, allowing different patterns of stimulation, and shielding it from electromagnetic interference.

The group agreed that MRI procedures are necessary for some patients with DBS systems for evaluation of new or existing intracranial pathology, assessments of DBS lead location in cases with limited benefit or adverse effects, and performing additional DBS surgery. The following areas related to DBS and MRI were considered important considerations: heating, magnetic field interactions and movements, induced currents, and operational/functional disruption of DBS components. Heating was determined to be the most important factor with respect to safety of MRI in patients with DBS implants and have been reviewed elsewhere.2630

The current Food and Drug Administration approved manufacturer (Medtronic) recommendations are interrogation of the system prior to the MRI examination; assessment of impedance to rule out short or open circuits (MRI cannot be performed if the system integrity is compromised); that the DBS system must be turned Off, programmed at 0 V, and to be in a bipolar mode with the magnetic switch disabled; only a 1.5-T MRI and a head transmit/receive coil should be used; and radio frequency power cannot exceed specific absorption rate of 0.1 W/kg in the head.

The group expressed concerns about these recommendations being too restrictive with respect to MR scanning of patients. More common and higher resolution sequences are not allowed, and many centers routinely perform various MR sequences that do not adhere to the manufacturer's criteria and have had a large experience without complications. Larson et al demonstrated safety in more than 1000 MR examinations, many of which were outside the manufacturer's criteria.31 The National Parkinson Foundation Center of Excellence experience was also discussed and included 3304 patients without any safety risks.32 It was also noted that, at some centers, the radiologists are still prohibiting MR scanning with DBS.

The group discussed the 2 case reports pertaining to safety issues with respect to MRI and DBS.33 The cases occurred during unique scenarios, and there have been no additional reports of safety-related issues.

The group recommended additional studies and discussions with the Food and Drug Administration and Medtronic to potentially modify the restrictive recommendations and allow for more flexibility in MR scanning. There were no issues of concern with respect to current induction, device functionality, and magnetic field interactions with DBS systems.

Deep brain stimulation programming is best accomplished by a highly trained clinician (eg, neurologist, neurosurgeon, nurse, physician assistant) who understands not only the technical aspects of DBS but also PD-related issues and pharmacological management. While the use of the intraoperative data and postoperative imaging can be useful in guiding choice of electrodes, it is recommended to systematically test the effects of stimulation (adverse and beneficial) for all electrodes during the initial programming session. There was general agreement that the initial parameters of stimulation, which should be studied, are pulse width, frequency, voltage, and electrode configuration. Rigidity and tremor were the most frequent clinical signs targeted for improvement during the first programming session; however, measurement of motor speed and gait assessment may also be useful. Optimization of DBS parameters is usually attained within 3 to 6 months during 4 to 5 programming sessions. Anti-PD medication reduction should be performed gradually and excessive early reduction avoided. Assessment and management of adverse events due to stimulation (speech, gait, balance, neuropsychiatric, etc) is best approached systematically to optimize benefits and minimize adverse effects. Other programming strategies such as low-frequency stimulation and alternative electrode configurations can be considered to treat problems not adequately managed by more standard approaches.34

Gait and Speech

Balance and gait are gradually and nearly always impaired as PD progresses, resulting in significant disability, decreased quality of life, morbidity, and mortality.35,36 The effects of DBS on balance and gait are difficult to interpret because they are complex behaviors that may or may not be sensitive to LD or DBS, and many postoperative observations are anecdotal.37,38 In general, aspects of gait and speech that improve with LD therapy improve with DBS; however, these may later worsen with disease progression. There was consensus that STN DBS can worsen speech and gait in some patients whose symptoms may be improved by altering stimulation parameters. Finally, in the recently reported Veterans Affairs/National Institute of Neurological Disorders and Stroke Cooperative DBS Study (Co-op Study), an increase in the number of falls was reported with STN DBS compared with GPi DBS39 and medical therapy.10

Cognition and Behavior

Recognition of psychiatric and cognitive comorbidities, especially depression, anxiety, apathy, psychosis, and impulsivity prior to surgery is critical because they confound assessment of surgical results. Depression and impulsivity have been reported following DBS and may represent a consequence of stimulation or emergence of symptoms that may have been present preoperatively.12,4044 Altering stimulation parameters can often help mitigate stimulation-induced behavioral problems. In the recently reported Co-op Study, depression worsened with STN DBS but was improved with GPi DBS, suggesting that either STN stimulation or reduction of PD medications can contribute to depression.39 There are also reports of worsened verbal fluency, executive dysfunction,12,41 and processing speed39 following STN DBS.

Long-term improvements have been demonstrated for up to 5 years for both STN and GPi DBS, especially on motor fluctuations4549 and for tremor with STN, GPi, and ventral intermediate nucleus of the thalamus DBS.47,50,51 The stimulation parameters in all 3 targets seem to remain relatively stable, and there is little current evidence for tolerance. However, there are 2 preliminary reports of delayed failures of GPi stimulation in a few patients who were improved by STN stimulation, suggesting the possibility that both treatments may have a different efficacy in the long-term.52

Despite these positive results, PD continues to progress after DBS, and there is little evidence that DBS alters disease progression. Over time, patients who have DBS often develop LD-resistant symptoms including freezing of gait, postural instability, and cognitive decline.

Similar benefits for both STN and GPi DBS have been reported in only a few randomized studies.5355 In a recent randomized study, unilateral stimulation of the STN and GPi DBS resulted in similar effects on mood and cognition but GPi stimulation resulted in improved quality of life compared with STN stimulation.56,57 The most definitive study on this subject comes from the recently reported Co-op Study.39 Two hundred ninety-nine patients with PD were randomized to STN or GPi DBS with the primary outcome of Unified Parkinson Disease Rating Scale Part III assessed in a blinded manner. Similar improvements were found at 2-year follow-up for both surgical sites. Dopaminergic medication was decreased more for the STN group but visuomotor processing speed declined less after GPi DBS. Furthermore, subjects who had GPi DBS showed improvement in depression, whereas subjects who had STN DBS worsened. Severe adverse events were common but similar for the 2 targets.39 Taken together, both STN and GPI DBS improve motor function but the target selection should be individualized considering the differences in nonmotor outcomes.

Although thalamotomy and pallidotomy have been largely abandoned and replaced by DBS, ablative therapies may yet have a role in certain patients such as those with an increased risk of infection or a history of recurrent infection of their DBS systems; with limited access to centers specializing in DBS surgery; and not desiring implanted hardware, as well as being unwilling to commit to long-term programming. Potential disadvantages of ablative surgery include mistargeted lesions with permanent neurological deficit(s), suboptimal benefits requiring repeat procedures, and risk of bilateral lesions. The effectiveness and risks of ablative surgery are reviewed elsewhere.5860

Radiosurgical ablative surgery such as γ knife surgery is not considered an established or safe therapy for the GPi or STN. In a selected group who have a poor risk/benefit ratio for DBS, unilateral radiosurgical thalamotomy may be performed but the risk/benefit ratio is still being examined.

In our deliberations, we reached consensus on several issues involving DBS for the treatment of PD. Good candidates are patients with PD with disabling motor fluctuations and/or medically intractable tremor without significant cognitive or psychiatric problems. It is recommended that DBS be performed at centers with an experienced team of experts. Both STN and GPi appear to be equally effective targets for treating motor symptoms; STN DBS allows for greater reduction in medication but may be associated with worsening of nonmotor symptoms and falls. With the exception of tremor, DBS treats primarily LD-responsive symptoms, and the benefits of DBS are sustained for several years. Postoperative brain MRIs can be safely performed and are useful. Finally, there is still a role for ablative lesions for select patients.

Correspondence: Jeff M. Bronstein, MD, PhD, UCLA Department of Neurology, 710 Westwood Plaza, Los Angeles, CA 90095 (jbronste@ucla.edu).

Published Online: October 11, 2010. doi:10.1001/archneurol.2010.260

Accepted for Publication: August 16, 2010.

Author Contributions:Study concept and design: Bronstein, Tagliati, Alterman, Lozano, Horak, Foote, and Pahwa. Acquisition of data: Bronstein, Tagliati, Stefani, Okun, Foote, Hariz, Bakay, Rezai, Marks, Moro, Vitek, Weaver, and Gross. Analysis and interpretation of data: Bronstein, Alterman, Lozano, Volkmann, Okun, Foote, Krack, Henderson, Hariz, Bakay, Rezai, Marks, Vitek, Gross, and DeLong. Drafting of the manuscript: Bronstein, Tagliati, Alterman, Lozano, Volkmann, Marks, Weaver, and Gross. Critical revision of the manuscript for important intellectual content: Tagliati, Alterman, Lozano, Stefani, Horak, Okun, Foote, Krack, Pahwa, Henderson, Hariz, Bakay, Rezai, Marks, Moro, Vitek, Gross, and DeLong. Statistical analysis: Bakay. Obtained funding: Bronstein. Administrative, technical, and material support: Bronstein, Alterman, Lozano, Bakay, Rezai, Marks, Weaver, Gross, and DeLong. Study supervision: Bronstein, Stefani, Horak, and Hariz.

Financial Disclosure: Drs Tagliati, Alterman, Lozano, Volkmann, Okun, Foote, Krack, Pahwa, Henderson, Hariz, Bakay, Rezai, Mark, Moro, Gross, and DeLong report receiving compensation for various activities from Medtronic Inc, a manufacturer of the deep brain stimulation (DBS) device; Drs Gross and Tagliati, receiving compensation as consultants for, and Dr Foote, receiving research grants from St Jude's Medical Corporation; Dr Gross, receiving compensation from Boston Scientific Corporation, Bayer AG, Medrad, and GeneGrafts; Dr Tagliati, receiving research support from Allergan, Ceregene, Solvay, and speaking honoraria from Galaxo, Novartis, Boehringer Ingelheim, and Allergan; Dr Volkmann, receiving compensation from GlaxoSmithKline and Solvay; Drs Okun and Foote, potential royalty interest in the COMPRESS tool for DBS; Dr Henderson, being on the Scientific Advisory Boards of Nevro Corp and Intelect (stock options); Dr DeLong, receiving compensation from the Sacoor Medical Group, Effcon Laboratories, and Boston Scientific; Dr Rezai, having potential equity interest in Intelect Medical and stocks in Sullivision; and Dr Foote, receiving research grants from Neuropace.

Additional Contributions: The following participants attended the workshop, participated in discussions, and agreed to all statements made in this manuscript. Francois Alesch, MD, Neurochirurgische Universitätsklinik, Vienna, Austria; Ron Alterman, MD, Mount Sinai School of Medicine, New York, New York; Gordon Baltuch, MD, PhD, and Matthew Stern, MD, University of Pennsylvania Health System, Philadelphia; Helen Bronte-Stewart, MD, Stanford University School of Medicine, Stanford, California; Kim Burchiel, MD, Oregon Health and Science University, Portland; David Charles, MD, Vanderbilt University Medical Center, Nashville, Tennessee; David Devos, MD, PhD, University of Lille Nord de France, Lille; Jonathan Dostrovsky, PhD, University of Toronto, Toronto, Canada; Kenneth Follet, MD, University Nebraska Medical Center, Omaha; Blair Ford, MD, Columbia University, New York, New York; Michael Frank, PhD, Brown University, Providence, Rhode Island; Rudiger Hilker, MD, Goethe-University, Frankfurt, Germany; Amy Howard, Davis Phinney Foundation, Boulder, Colorado; Laura Marsh, MD, Johns Hopkins School of Medicine, Baltimore, Maryland; William McDonald, MD, Emory University School of Medicine, Atlanta, Georgia; Marcelo Merello, MD, PhD, Institute for Neurological Research, Buenos Aires, Argentina; Erwin Montgomery, MD, University of Alabama School of Medicine, Birmingham; Joseph Pancrazio, PhD, National Institute of Neurological Disorders and Stroke, Bethesda, Maryland; Joel Perlmutter, MD, Washington University, Saint Louis, Missouri; Lorraine Ramig, PhD, CCC-SLP, University of Colorado, Boulder; Michael Schüpbach, MD, Centre d'Investigation Clinique, Pitié-Salpêtrière Hospital, Paris, France, and Movement Disorders Center, Department of Neurology, University Hospital, Bern, Switzerland; Todd Sherer, PhD, Michael J. Fox Foundation, New York, New York; Jay Shils, PhD, Lahey Clinic, Burlington, Massachusetts; Tanya Simuni, MD, Northwestern University School of Medicine, Chicago, Illinois; Daniel Tarsy, MD, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Leo Verhagen, MD, PhD, Rush University Medical Center, Chicago, Illinois; Jurgen Voges, MD, University of Cologne, Koln, Germany; Carol Walton and Jeffrey Wertheimer, PhD, The Parkinson Alliance, Kingston, New Jersey.

Funding/Support: This study was supported primarily by The Parkinson Alliance but also received funding from the Davis Phinney Foundation, National Parkinson's Disease Foundation, the Lee Silverman Voice Treatment Foundation; and the National Institutes of Health (Dr Foote).

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Moreau  CDefebvre  LDestée  A  et al.  STN-DBS frequency effects on freezing of gait in advanced Parkinson disease. Neurology 2008;71 (2) 80- 84
PubMed Link to Article
Forsaa  EBLarsen  JPWentzel-Larsen  THerlofson  KAlves  G Predictors and course of health-related quality of life in Parkinson's disease. Mov Disord 2008;23 (10) 1420- 1427
PubMed Link to Article
Pickering  RMGrimbergen  YARigney  U  et al.  A meta-analysis of six prospective studies of falling in Parkinson's disease. Mov Disord 2007;22 (13) 1892- 1900
PubMed Link to Article
Horak  FBFrank  JNutt  J Effects of dopamine on postural control in parkinsonian subjects: scaling, set, and tone. J Neurophysiol 1996;75 (6) 2380- 2396
PubMed
Lyoo  CHAalto  SRinne  JO  et al.  Different cerebral cortical areas influence the effect of subthalamic nucleus stimulation on parkinsonian motor deficits and freezing of gait. Mov Disord 2007;22 (15) 2176- 2182
PubMed Link to Article
Follett  KAWeaver  FMStern  M  et al. CSP 468 Study Group, Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. N Engl J Med 2010;362 (22) 2077- 2091
PubMed Link to Article
Hälbig  TDTse  WFrisina  PG  et al.  Subthalamic deep brain stimulation and impulse control in Parkinson's disease. Eur J Neurol 2009;16 (4) 493- 497
PubMed Link to Article
Smeding  HMSpeelman  JDKoning-Haanstra  M  et al.  Neuropsychological effects of bilateral STN stimulation in Parkinson disease: a controlled study. Neurology 2006;66 (12) 1830- 1836
PubMed Link to Article
Houeto  JLMesnage  VMallet  L  et al.  Behavioural disorders, Parkinson's disease and subthalamic stimulation. J Neurol Neurosurg Psychiatry 2002;72 (6) 701- 707
PubMed Link to Article
Schüpbach  MGargiulo  MWelter  ML  et al.  Neurosurgery in Parkinson disease: a distressed mind in a repaired body? Neurology 2006;66 (12) 1811- 1816
PubMed Link to Article
Frank  MJSamanta  JMoustafa  AASherman  SJ Hold your horses: impulsivity, deep brain stimulation, and medication in parkinsonism. Science 2007;318 (5854) 1309- 1312
PubMed Link to Article
Rodriguez-Oroz  MCObeso  JALang  AE  et al.  Bilateral deep brain stimulation in Parkinson's disease: a multicentre study with 4 years follow-up. Brain 2005;128 (pt 10) 2240- 2249
PubMed Link to Article
Krack  PBatir  AVan Blercom  N  et al.  Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson's disease. N Engl J Med 2003;349 (20) 1925- 1934
PubMed Link to Article
Volkmann  JAlbanese  AKulisevsky  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
PubMed Link to Article
Volkmann  JAllert  NVoges  JSturm  VSchnitzler  AFreund  HJ Long-term results of bilateral pallidal stimulation in Parkinson's disease. Ann Neurol 2004;55 (6) 871- 875
PubMed Link to Article
Schüpbach  WMChastan  NWelter  ML  et al.  Stimulation of the subthalamic nucleus in Parkinson's disease: a 5 year follow up. J Neurol Neurosurg Psychiatry 2005;76 (12) 1640- 1644
PubMed Link to Article
Hariz  MIKrack  PAlesch  F  et al.  Multicentre European study of thalamic stimulation for parkinsonian tremor: a 6 year follow-up. J Neurol Neurosurg Psychiatry 2008;79 (6) 694- 699
PubMed Link to Article
Gervais-Bernard  HXie-Brustolin  JMertens  P  et al.  Bilateral subthalamic nucleus stimulation in advanced Parkinson's disease: five year follow-up. J Neurol 2009;256 (2) 225- 233
PubMed Link to Article
Houeto  JLBejjani  PBDamier  P  et al.  Failure of long-term pallidal stimulation corrected by subthalamic stimulation in PD. Neurology 2000;55 (5) 728- 730
PubMed Link to Article
Weaver  FFollett  KHur  KIppolito  DStern  M Deep brain stimulation in Parkinson disease: a metaanalysis of patient outcomes. J Neurosurg 2005;103 (6) 956- 967
PubMed Link to Article
Nakamura  KChristine  CWStarr  PAMarks  WJ  Jr Effects of unilateral subthalamic and pallidal deep brain stimulation on fine motor functions in Parkinson's disease. Mov Disord 2007;22 (5) 619- 626
PubMed Link to Article
Anderson  VCBurchiel  KJHogarth  PFavre  JHammerstad  JP Pallidal vs subthalamic nucleus deep brain stimulation in Parkinson disease. Arch Neurol 2005;62 (4) 554- 560
PubMed Link to Article
Zahodne  LBOkun  MSFoote  KD  et al.  Greater improvement in quality of life following unilateral deep brain stimulation surgery in the globus pallidus as compared to the subthalamic nucleus. J Neurol 2009;256 (8) 1321- 1329
PubMed Link to Article
Okun  MSFernandez  HHWu  SS  et al.  Cognition and mood in Parkinson's disease in subthalamic nucleus versus globus pallidus interna deep brain stimulation: the COMPARE trial. Ann Neurol 2009;65 (5) 586- 595
PubMed Link to Article
Starr  PAVitek  JLBakay  RA Ablative surgery and deep brain stimulation for Parkinson's disease. Neurosurgery 1998;43 (5) 989- 1015
PubMed Link to Article
Alvarez  LMacias  RPavón  N  et al.  Therapeutic efficacy of unilateral subthalamotomy in Parkinson's disease: results in 89 patients followed for up to 36 months. J Neurol Neurosurg Psychiatry 2009;80 (9) 979- 985
PubMed Link to Article
Gross  RE What happened to posteroventral pallidotomy for Parkinson's disease and dystonia? Neurotherapeutics 2008;5 (2) 281- 293
PubMed Link to Article

Figures

Tables

References

Bergman  HWichmann  TDeLong  MR Reversal of experimental parkinsonism by lesions of the subthalamic nucleus. Science 1990;249 (4975) 1436- 1438
PubMed Link to Article
DeLong  MR Primate models of movement disorders of basal ganglia origin. Trends Neurosci 1990;13 (7) 281- 285
PubMed Link to Article
Aziz  TZPeggs  DSambrook  MACrossman  AR Lesion of the subthalamic nucleus for the alleviation of 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced parkinsonism in the primate. Mov Disord 1991;6 (4) 288- 292
PubMed Link to Article
Okun  MSTagliati  MPourfar  M  et al.  Management of referred deep brain stimulation failures: a retrospective analysis from 2 movement disorders centers. Arch Neurol 2005;62 (8) 1250- 1255
PubMed Link to Article
Morgante  LMorgante  FMoro  E  et al.  How many parkinsonian patients are suitable candidates for deep brain stimulation of subthalamic nucleus? results of a questionnaire. Parkinsonism Relat Disord 2007;13 (8) 528- 531
PubMed Link to Article
Moro  EVolkmann  JKönig  IR  et al.  Bilateral subthalamic stimulation in Parkin and PINK1 parkinsonism. Neurology 2008;70 (14) 1186- 1191
PubMed Link to Article
Schüpbach  MLohmann  EAnheim  M  et al.  Subthalamic nucleus stimulation is efficacious in patients with Parkinsonism and LRRK2 mutations. Mov Disord 2007;22 (1) 119- 122
PubMed Link to Article
Lohmann  EWelter  MLFraix  V  et al. French Parkinson's Disease Genetics study group, Are parkin patients particularly suited for deep-brain stimulation? Mov Disord 2008;23 (5) 740- 743
PubMed Link to Article
Shih  LCTarsy  D Deep brain stimulation for the treatment of atypical parkinsonism. Mov Disord 2007;22 (15) 2149- 2155
PubMed Link to Article
Weaver  FMFollett  KStern  M  et al. CSP 468 Study Group, Bilateral deep brain stimulation vs best medical therapy for patients with advanced Parkinson disease: a randomized controlled trial. JAMA 2009;301 (1) 63- 73
PubMed Link to Article
Lang  AEHoueto  JLKrack  P  et al.  Deep brain stimulation: preoperative issues. Mov Disord 2006;21 ((suppl 14)) S171- S196
PubMed Link to Article
Saint-Cyr  JATrépanier  LLKumar  RLozano  AMLang  AE Neuropsychological consequences of chronic bilateral stimulation of the subthalamic nucleus in Parkinson's disease. Brain 2000;123 (pt 10) 2091- 2108
PubMed Link to Article
Ory-Magne  FBrefel-Courbon  CSimonetta-Moreau  M  et al.  Does ageing influence deep brain stimulation outcomes in Parkinson's disease? Mov Disord 2007;22 (10) 1457- 1463
PubMed Link to Article
Russmann  HGhika  JVillemure  JG  et al.  Subthalamic nucleus deep brain stimulation in Parkinson disease patients over age 70 years. Neurology 2004;63 (10) 1952- 1954
PubMed Link to Article
Derost  PPOuchchane  LMorand  D  et al.  Is DBS-STN appropriate to treat severe Parkinson disease in an elderly population? Neurology 2007;68 (17) 1345- 1355
PubMed Link to Article
Sansur  CAFrysinger  RCPouratian  N  et al.  Incidence of symptomatic hemorrhage after stereotactic electrode placement. J Neurosurg 2007;107 (5) 998- 1003
PubMed Link to Article
Schüpbach  WMMaltête  DHoueto  JL  et al.  Neurosurgery at an earlier stage of Parkinson disease: a randomized, controlled trial. Neurology 2007;68 (4) 267- 271
PubMed Link to Article
Charles  PDVan Blercom  NKrack  P  et al.  Predictors of effective bilateral subthalamic nucleus stimulation for PD. Neurology 2002;59 (6) 932- 934
PubMed Link to Article
Kleiner-Fisman  GHerzog  JFisman  DN  et al.  Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes. Mov Disord 2006;21 ((suppl 14)) S290- S304
PubMed Link to Article
Voon  VKrack  PLang  AE  et al.  A multicentre study on suicide outcomes following subthalamic stimulation for Parkinson's disease. Brain 2008;131 (pt 10) 2720- 2728
PubMed Link to Article
Blomstedt  PHariz  MI Hardware-related complications of deep brain stimulation: a ten year experience. Acta Neurochir (Wien) 2005;147 (10) 1061- 1064
PubMed Link to Article
Videnovic  AMetman  LV Deep brain stimulation for Parkinson's disease: prevalence of adverse events and need for standardized reporting. Mov Disord 2008;23 (3) 343- 349
PubMed Link to Article
Deep-Brain Stimulation for Parkinson's Disease Study Group, 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
PubMed Link to Article
Hamani  CLozano  AM Hardware-related complications of deep brain stimulation: a review of the published literature. Stereotact Funct Neurosurg 2006;84 (5-6) 248- 251
PubMed Link to Article
Deuschl  GSchade-Brittinger  CKrack  P  et al. German Parkinson Study Group, Neurostimulation Section, A randomized trial of deep-brain stimulation for Parkinson's disease. N Engl J Med 2006;355 (9) 896- 908
PubMed Link to Article
Rezai  ARPhillips  MBaker  KB  et al.  Neurostimulation system used for deep brain stimulation (DBS): MR safety issues and implications of failing to follow safety recommendations. Invest Radiol 2004;39 (5) 300- 303
PubMed Link to Article
Rezai  ARBaker  KBTkach  JA  et al.  Is magnetic resonance imaging safe for patients with neurostimulation systems used for deep brain stimulation? Neurosurgery 2005;57 (5) 1056- 1062
PubMed Link to Article
Phillips  MDBaker  KBLowe  MJ  et al.  Parkinson disease: pattern of functional MR imaging activation during deep brain stimulation of subthalamic nucleus:initial experience. Radiology 2006;239 (1) 209- 216
PubMed Link to Article
Baker  KBTkach  JHall  JDNyenhuis  JAShellock  FGRezai  AR Reduction of magnetic resonance imaging-related heating in deep brain stimulation leads using a lead management device. Neurosurgery 2005;57 (4) ((suppl)) 392- 397
PubMed Link to Article
Bhidayasiri  RBronstein  JMSinha  S  et al.  Bilateral neurostimulation systems used for deep brain stimulation: in vitro study of MRI-related heating at 1.5 T and implications for clinical imaging of the brain. Magn Reson Imaging 2005;23 (4) 549- 555
PubMed Link to Article
Larson  PSRichardson  RMStarr  PAMartin  AJ Magnetic resonance imaging of implanted deep brain stimulators: experience in a large series. Stereotact Funct Neurosurg 2008;86 (2) 92- 100
PubMed Link to Article
Tagliati  MJankovic  JPagan  FSusatia  FIsaias  IUOkun  MSNational Parkinson Foundation DBS Working Group, Safety of MRI in patients with implanted deep brain stimulation devices. Neuroimage 2009;47 ((suppl 2)) T53- T57
PubMed Link to Article
Henderson  JMTkach  JPhillips  MBaker  KShellock  FGRezai  AR Permanent neurological deficit related to magnetic resonance imaging in a patient with implanted deep brain stimulation electrodes for Parkinson's disease: case report. Neurosurgery 2005;57 (5) E1063
PubMed Link to Article
Moreau  CDefebvre  LDestée  A  et al.  STN-DBS frequency effects on freezing of gait in advanced Parkinson disease. Neurology 2008;71 (2) 80- 84
PubMed Link to Article
Forsaa  EBLarsen  JPWentzel-Larsen  THerlofson  KAlves  G Predictors and course of health-related quality of life in Parkinson's disease. Mov Disord 2008;23 (10) 1420- 1427
PubMed Link to Article
Pickering  RMGrimbergen  YARigney  U  et al.  A meta-analysis of six prospective studies of falling in Parkinson's disease. Mov Disord 2007;22 (13) 1892- 1900
PubMed Link to Article
Horak  FBFrank  JNutt  J Effects of dopamine on postural control in parkinsonian subjects: scaling, set, and tone. J Neurophysiol 1996;75 (6) 2380- 2396
PubMed
Lyoo  CHAalto  SRinne  JO  et al.  Different cerebral cortical areas influence the effect of subthalamic nucleus stimulation on parkinsonian motor deficits and freezing of gait. Mov Disord 2007;22 (15) 2176- 2182
PubMed Link to Article
Follett  KAWeaver  FMStern  M  et al. CSP 468 Study Group, Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. N Engl J Med 2010;362 (22) 2077- 2091
PubMed Link to Article
Hälbig  TDTse  WFrisina  PG  et al.  Subthalamic deep brain stimulation and impulse control in Parkinson's disease. Eur J Neurol 2009;16 (4) 493- 497
PubMed Link to Article
Smeding  HMSpeelman  JDKoning-Haanstra  M  et al.  Neuropsychological effects of bilateral STN stimulation in Parkinson disease: a controlled study. Neurology 2006;66 (12) 1830- 1836
PubMed Link to Article
Houeto  JLMesnage  VMallet  L  et al.  Behavioural disorders, Parkinson's disease and subthalamic stimulation. J Neurol Neurosurg Psychiatry 2002;72 (6) 701- 707
PubMed Link to Article
Schüpbach  MGargiulo  MWelter  ML  et al.  Neurosurgery in Parkinson disease: a distressed mind in a repaired body? Neurology 2006;66 (12) 1811- 1816
PubMed Link to Article
Frank  MJSamanta  JMoustafa  AASherman  SJ Hold your horses: impulsivity, deep brain stimulation, and medication in parkinsonism. Science 2007;318 (5854) 1309- 1312
PubMed Link to Article
Rodriguez-Oroz  MCObeso  JALang  AE  et al.  Bilateral deep brain stimulation in Parkinson's disease: a multicentre study with 4 years follow-up. Brain 2005;128 (pt 10) 2240- 2249
PubMed Link to Article
Krack  PBatir  AVan Blercom  N  et al.  Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson's disease. N Engl J Med 2003;349 (20) 1925- 1934
PubMed Link to Article
Volkmann  JAlbanese  AKulisevsky  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
PubMed Link to Article
Volkmann  JAllert  NVoges  JSturm  VSchnitzler  AFreund  HJ Long-term results of bilateral pallidal stimulation in Parkinson's disease. Ann Neurol 2004;55 (6) 871- 875
PubMed Link to Article
Schüpbach  WMChastan  NWelter  ML  et al.  Stimulation of the subthalamic nucleus in Parkinson's disease: a 5 year follow up. J Neurol Neurosurg Psychiatry 2005;76 (12) 1640- 1644
PubMed Link to Article
Hariz  MIKrack  PAlesch  F  et al.  Multicentre European study of thalamic stimulation for parkinsonian tremor: a 6 year follow-up. J Neurol Neurosurg Psychiatry 2008;79 (6) 694- 699
PubMed Link to Article
Gervais-Bernard  HXie-Brustolin  JMertens  P  et al.  Bilateral subthalamic nucleus stimulation in advanced Parkinson's disease: five year follow-up. J Neurol 2009;256 (2) 225- 233
PubMed Link to Article
Houeto  JLBejjani  PBDamier  P  et al.  Failure of long-term pallidal stimulation corrected by subthalamic stimulation in PD. Neurology 2000;55 (5) 728- 730
PubMed Link to Article
Weaver  FFollett  KHur  KIppolito  DStern  M Deep brain stimulation in Parkinson disease: a metaanalysis of patient outcomes. J Neurosurg 2005;103 (6) 956- 967
PubMed Link to Article
Nakamura  KChristine  CWStarr  PAMarks  WJ  Jr Effects of unilateral subthalamic and pallidal deep brain stimulation on fine motor functions in Parkinson's disease. Mov Disord 2007;22 (5) 619- 626
PubMed Link to Article
Anderson  VCBurchiel  KJHogarth  PFavre  JHammerstad  JP Pallidal vs subthalamic nucleus deep brain stimulation in Parkinson disease. Arch Neurol 2005;62 (4) 554- 560
PubMed Link to Article
Zahodne  LBOkun  MSFoote  KD  et al.  Greater improvement in quality of life following unilateral deep brain stimulation surgery in the globus pallidus as compared to the subthalamic nucleus. J Neurol 2009;256 (8) 1321- 1329
PubMed Link to Article
Okun  MSFernandez  HHWu  SS  et al.  Cognition and mood in Parkinson's disease in subthalamic nucleus versus globus pallidus interna deep brain stimulation: the COMPARE trial. Ann Neurol 2009;65 (5) 586- 595
PubMed Link to Article
Starr  PAVitek  JLBakay  RA Ablative surgery and deep brain stimulation for Parkinson's disease. Neurosurgery 1998;43 (5) 989- 1015
PubMed Link to Article
Alvarez  LMacias  RPavón  N  et al.  Therapeutic efficacy of unilateral subthalamotomy in Parkinson's disease: results in 89 patients followed for up to 36 months. J Neurol Neurosurg Psychiatry 2009;80 (9) 979- 985
PubMed Link to Article
Gross  RE What happened to posteroventral pallidotomy for Parkinson's disease and dystonia? Neurotherapeutics 2008;5 (2) 281- 293
PubMed Link to Article

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