Deep Brain Stimulation (DBS)

Key Facts

  • DBSi is used in patients whose motor symptoms are difficult to manage with medications.
  • DBS does not stop progression of the disease.
  • Patients who have a good improvement with levodopa in the “on” stage are good candidates.
  • DBS has adverse effects on cognition.
  • DBS can be turned off if needed.
  • Post-surgery recommendations are very important, not only for the patient but also the caregiver.

Clinical Best Practices

  • DBSi should be considered for non-demented advanced PD patients.
  • DBS should be performed by an experienced surgical-neurological team in well selected patients.

Deep Brain Stimulation is a surgical therapy that can improve motor symptoms. Deep brain stimulation should be considered for non-demented advanced PD patients with tremor, dyskinesias, and significant motor fluctuations with considerable "off" time.

Highlights of DBSi

  • DBS is a surgical therapy for PD that can lesson symptoms.
  • How DBS reduces symptoms is not exactly known, but it may work by blocking faulty signals.
  • A lead is implanted to target small specific areas of the brain.
  • Leads can be unilateral or bilateral. Depending on symptoms the target may be the subthalmic nucleus (STN), globus pallidus (GPi) or thalamus (Vim).
  • Thalamic DBS is only targeted for tremor, and both GPi and STN DBS are the preferred targets for all of the motor features of PD.
  • The DBS device can be removed if necessary.
  • DBS does not stop progression of disease.

Likely to improve with DBS

May worsen with DBS

Tremor/bradykinesia/rigidity

Speech

Dyskinesias

Cognition (verbal fluency)

“Off” time

Gait

 

Candidate Selection

  • Consider DBS for PD patients with:
    • Dyskinesias, severe pain in "off" state, severe "off" state, marked tremor
    • Excellent response to levodopa
    • Intact cognition  

Procedure

  • DBS is sometimes performed in a staged manner with one side operated on first, followed by the other side later.  Some centers may perform a bilateral procedure.
  • The impulse generator is typically put under the skin in the right chest to drive stimulation of both sides of the brain.
  • The batteries require changing every 3 to 5 years, depending on programming settings; but newer, longer-lasting batteries are being developed as is a rechargeable battery.
  • DBS requires periodic adjustments by an experienced programmer to achieve optimal results.
  • Good electrode placement in the brain target is key in achieving good programming results for patient benefit.
  • Surgery lasts from 2-4 hours. Initial hospital stay may be days to one week. Immediate benefit from a lesion-effect with electrode placement.
  • Programming begins as benefit wears off.
  • Medications may be reduced.
  • If levodopa is reduced too much or discontinnued, some patients experience depression.

Post-surgery

  • Patients are often given small, simple access devices that can tell them if their DBS is off or on. 
  • An important consideration in DBS patients is to warn them that their impulse generator can be turned off with exposure to magnets (speakers, at the airport, etc) and that they should not have an MRI unless using special precautions (avoid a body coil).
  • Diathermyi is also contraindicated.
References: 

Deuschl G, Schade-Brittinger C, Krack 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.

Weaver FM, Follett K, Stern 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.

Williams A, Gill S, Varma T, et al. PS SURG Collaborative Group. Deep brain stimulation plus best medical therapy versus best medical therapy alone for advanced Parkinson’s disease (PD SURG trial):  a randomized, open-label trial.  Lancet Neurol.; 2010:9(6):581-591.