Clinical Research
Combined Deep Brain Stimulation of Subthalamic Nucleus and Ventral Intermediate Thalamic Nucleus in Tremor-Dominant Parkinson’s Disease Using a Parietal Approach

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Objectives

Despite its efficacy in tremor-suppression, the ventral intermediate thalamic (VIM) nucleus has largely been neglected in deep brain stimulation (DBS) for tremor-dominant Parkinson’s disease (tdPD). The employment of a parietal approach, however, allows stimulation of VIM and subthalamic nucleus (STN) using one trajectory only and thus constitutes a promising alternative to existing strategies. In the present study, we investigate safety and efficacy of combined lead implantation and stimulation of STN and VIM using a parietal approach.

Materials and Methods

Retrospective analysis of five patients with tdPD was performed who underwent DBS using a parietal approach. Changes in symptom severity, disease-specific health-related quality of life and l-dopa equivalent doses (LED) were evaluated over a total time course of 12 months.

Results

DBS within both targets yielded significant improvement of parkinsonian symptoms (median: 40.0%, p = 0.04) in the first 6 months of continuous stimulation and remained stable thereafter (median improvement at 12 months: 43.2%, p = 0.07). Sustained improvement of tremor (median at 6 months: 100.0%, p = 0.04; median at 12 months 83.3%, p = 0.04) and quality of life scores (median at 6 months: 29.8%, p = 0.04; median at 12 months: 32.6%, p = 0.04) was noted throughout the follow-up period. No significant change of LEDs was observed by the end of follow-up (median decrease: 2.2%, p = 0.89).

Conclusions

Simultaneous DBS of VIM and STN using one trajectory is safe, yielding good control of parkinsonian tremors. Further studies, however, are necessary to determine whether a parietal trajectory affords better control over tremor symptoms than established strategies and hence justifies the potential risks associated with the alternative approach.

Section snippets

INTRODUCTION

Since its introduction in the early 1990s, deep brain stimulation (DBS) of the subthalamic nucleus (STN) has become an established treatment option in therapy-refractory Parkinson’s disease (PD) (1,2). So far, multiple studies, including randomized-controlled trials, have demonstrated the efficacy of electrical stimulation within this neuroanatomical target (3). However, an increasing body of literature has accumulated in recent years challenging the notion of stimulation within the STN proper,

Subjects and Rationale

From October 2015 to October 2016, 18 patients suffering from severe therapy-refractory PD underwent DBS treatment in the STN at our department. From this cohort, five patients (5:0 male/female) with a tdPD history ranging from 4 to 9 years that received DBS of STN and VIM via a parietal approach were retrospectively evaluated (Table 1). Their median age at the time of surgery was 66.00 years (range: 50–62 years); the median tdPD history was 7.00 years (range: 5–9 years). In all cases,

RESULTS

DBS was performed successfully in all five patients (N = 10 leads). While electrode contacts could be placed in both STN and VIM in patients 1–4, anteroventral positioning of DBS leads in patient 5 prevented impeded stimulation within VIM. No adverse events related to electrode placement were observed.

Tables 3 and 4 give an overview of patients’ baseline characteristics and outcome of simultaneous STN/VIM stimulation during follow-up as measured by clinical scales. Severity of motor symptoms as

DISCUSSION

To date, different approaches have been undertaken to target both STN and the cerebellothalamic system in tdPD. Herein, the employment of a parietal approach is not a new concept, but finds anecdotal mention throughout the lesional era as well as in the current context of DBS. In the late 1950s, Guiot first described the employment of a single trajectory in the treatment of PD aiming to lesion both, the thalamus and the pallidum (25). In subsequent procedures, Gillingham et al. replicated the

CONCLUSION

Overall, the employment of a parietal approach proved feasible and safe in all patients in this retrospective study. However, further research and studies including larger patient populations are necessary to clearly and reliably determine whether combined VIM/STN stimulation affords better control over tremor symptoms than DBS in alternative targets (namely PSA and Fields of Forel) and hence justifies the increased potential risks associated with the alternative approach.

Acknowledgements

We are grateful to Brainlab for their courtesy on the use of 3D software under clinical investigation. We thank Gavin Elias for help in preparing the schematic representations.

Authorship Statement

Dr. Neudorfer designed the study, collected and analyzed the data, wrote the manuscript, reviewed, and approved the final version. Drs. Hinzke, Hunsche, and El Majdoub analyzed the data, reviewed, and approved the final version of the manuscript. Dr. Lozano reviewed and approved the final version of the manuscript. Dr.

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    Source(s) of Financial Support: Clemens Neudorfer is supported by a grant provided by the German Research Foundation (Deutsche Forschungsgemeinschaft, DFG NE 2276/1–1). The authors have no personal financial or institutional interest in any of the drugs, materials, or devices described in this article.

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