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Long-term outcomes of deep brain stimulation in Parkinson disease

Abstract

The efficacy of deep brain stimulation (DBS) for Parkinson disease (PD) is well established for up to 1 or 2 years, but long-term outcome data are still limited. In this Review, we critically discuss the evidence on the long-term outcomes of DBS and consider the clinical implications. Although many patients are lost to follow-up, the evidence indicates that subthalamic nucleus DBS improves motor function for up to 10 years, although the magnitude of improvement tends to decline over time. Functional scores recorded during on-medication periods worsen more quickly than those recorded in off periods, consistent with the degeneration of non-dopaminergic pathways. Dyskinesia, motor fluctuations and activities of daily living in off periods remain improved at 5 years, but quality-of-life scores have usually fallen below preoperative levels. The incidence and severity of dementia among patients receiving DBS are comparable to those among patients who receive medical treatment. Severe adverse events are rare, but adverse events such as dysarthria are common and probably under-reported. Long-term data on the outcomes of globus pallidus interna DBS are limited and mostly confirm the efficacy for dyskinesia. A trend towards offering DBS in the earlier stages of PD creates a need to identify factors that predict long-term outcomes and to discuss realistic expectations with patients preoperatively.

Key points

  • Subthalamic nucleus (STN) deep brain stimulation (DBS) can provide long-term improvements in motor function for patients with Parkinson disease (PD).

  • STN DBS does not prevent the neurodegenerative processes of PD; therefore, quality-of-life scores have usually fallen to preoperative levels by the 5-year time point.

  • Deterioration in quality of life often reflects the emergence of 3,4-dihydroxyphenylalanine (l-DOPA)-refractory or stimulation-resistant motor and non-motor features of PD, particularly impairments of gait, balance and speech.

  • Distinguishing stimulation-induced adverse effects from disease progression requires experience, a systematic approach to adjusting stimulation parameters and awareness of possible relationships with changes in dopaminergic medication.

  • Important factors in long-term outcomes of DBS are patient selection, precision of electrode targeting and experienced stimulation and medication adjustments.

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Fig. 1: Summary of long-term deep brain stimulation outcome studies.

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Acknowledgements

Review criteria

A PubMed search was performed using the terms “Deep Brain Stimulation”, “Subthalamic nucleus” and/or “STN”, “Globus Pallidus Interna” and/or “GPi” “Parkinson disease” and “Long-term”. From the 284 articles obtained from this search, we identified studies that included clinical scores at 5 years of follow-up or longer. Further studies were identified from article bibliographies. To avoid duplication caused by several articles published by the same DBS unit, only articles providing the most recent relevant data were referenced. Multicentre studies that overlapped with published data from single centres were not included. From each eligible study, directly comparable data were extracted to enable calculation of mean changes in motor and non-motor outcome measures from baseline to 1 year, 5 year and longer (8–11 year) follow-up periods.

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Nature Reviews Neurology thanks J. Volkmann and other anonymous reviewer(s) for their contribution to the peer review of this work.

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Correspondence to Patricia Limousin.

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P.L. and T.F. have received honoraria and travel expenses for lectures from Boston Scientific and Medtronic. T.F. has also received honoraria from BIAL, Britannia and Profile Pharma.

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Limousin, P., Foltynie, T. Long-term outcomes of deep brain stimulation in Parkinson disease. Nat Rev Neurol 15, 234–242 (2019). https://doi.org/10.1038/s41582-019-0145-9

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