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Dr. Okun

Post of the Week: GPi DBS is Making a Comeback for Parkinson's Disease

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Dr. Okun    411

Dear forum members,

 

The 36 month outcomes are now out for the STN vs. GPi large VA study.

 

 

Motor function, as reported in the original trial, improved similarly in both groups. The surprise was that the Mattis Dementia Rating Scale and other neurocognitive measures scores such as the Hopkins memory test “declined faster for STN than GPi patients.” Overall, quality of life was improved in both groups, though it was overall diminished from the previously reported 24 month follow-up on the same cohort. This worsening was hypothesized to be due mainly to disease progression.

 

 

The findings suggest that previously identified baseline cognitive issues should be considered for potential implantation into the GPi target. "The current study also confirmed the known advantage of medication reduction favoring the STN target, however it also showed that there was more flexibility in adjusting medications for the GPi target. The ability to have flexibility in medication adjustment will likely be important as DBS patients experience natural disease worsening due to progression; a known and difficult to manage part of the Parkinsonian syndrome." -Okun

 

In an accompanying editorial by Tagliati, he suggests the GPi may be making a comeback, and he cites an editorial in Archives of Neurology suggesting the same comeback in 2005 (Okun and Foote).

 

What does this all add up to for the patients? DBS targets and approaches should be tailored based on SYMPTOMS and individual patient needs! Not everyone should simply get STN DBS.

 

Here is the abstract:

 

Neurology. 2012 Jun 20. [Epub ahead of print]

Randomized trial of deep brain stimulation for Parkinson disease: Thirty-six-month outcomes.

Weaver FM, Follett KA, Stern M, Luo P, Harris CL, Hur K, Marks WJ Jr, 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; For the CSP 468 Study Group.

 

Source

From the Center for Management of Complex Chronic Care (F.W.), Hines VA Hospital, Hines, IL; Loyola University Stritch School of Medicine (F.W.), Maywood, IL; Iowa City VA Medical Center (K.F.), Iowa City, IA; University of Nebraska Medical Center (K.F.), Omaha; University of Pennsylvania Health System (M.S., S.H., G.B.), Philadelphia; Cooperative Studies Coordinating Center (P.L., K.H., D.R.), Hines VA Hospital, Hines, IL; VA Cooperative Studies Program (C.H.), Clinical Research Pharmacy, Albuquerque, NM; San Francisco VA Medical Center and University of California (W.M., J.R., P.S.), San Francisco; University of Michigan Medical Center (O.S.), Ann Arbor; National Institute of Neurological Disorders and Stroke (C.M.), Rockville, MD; University of Kansas Medical Center (R.P.), Kansas City; Oregon Health & Sciences University (K.B.), Portland; Portland VA Medical Center (K.B., P.H.), Portland, OR; Michael E. DeBakey VA Medical Center and Methodist Neurological Institute (E.C.L., R.S.), Houston, TX; Philadelphia VA Medical Center (J.D., M.S., G.B.), Philadelphia, PA; Richmond VA Medical Center (K.H.), Richmond, VA; VA Puget Sound Health Care System (A.S.), Seattle, WA; West Los Angeles VA Medical Center and David Geffen School of Medicine at UCLA (J.B., A.D.S.), Los Angeles, CA; University of Iowa Health Care (G.S.), Iowa City; and Department of Veterans Affairs Cooperative Studies Program Central Office (G.H.), Washington, DC.

 

Abstract

ObjectivesOur objective was to compare long-term outcomes of deep brain stimulation (DBS) of the globus pallidus interna (GPi) and subthalamic nucleus (STN) for patients with Parkinson disease (PD) in a multicenter randomized controlled trial.MethodsPatients randomly assigned to GPi (n = 89) or STN DBS (n = 70) were followed for 36 months. The primary outcome was motor function on stimulation/off medication using the Unified Parkinson's Disease Rating Scale motor subscale. Secondary outcomes included quality of life and neurocognitive function.ResultsMotor function improved between baseline and 36 months for GPi (41.1 to 27.1; 95% confidence interval [CI] -16.4 to -10.8; p < 0.001) and STN (42.5 to 29.7; 95% CI -15.8 to -9.4; p < 0.001); improvements were similar between targets and stable over time (p = 0.59). Health-related quality of life improved at 6 months on all subscales (all p values significant), but improvement diminished over time. Mattis Dementia Rating Scale scores declined faster for STN than GPi patients (p = 0.01); other neurocognitive measures showed gradual decline overall.ConclusionsThe beneficial effect of DBS on motor function was stable and comparable by target over 36 months. Slight declines in quality of life following initial gains and gradual decline in neurocognitive function likely reflect underlying disease progression and highlight the importance of nonmotor symptoms in determining quality of life.Classification of EvidenceThis study provides Class III evidence that improvement of motor symptoms of PD by DBS remains stable over 3 years and does not differ by surgical target.

PMID: 22722632 [PubMed - as supplied by publisher]

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dfpooos    0

Four patients with bilateral cZi and PPN DBS electrodes were rated with the Unified Parkinson's Disease Rating Scale motor subscale (UPDRS-III) when taking and withdrawn from medication. A block of 16 [(15)O]-H(2)O PET resting measurements of rCBF were performed in 4 different states with patients withdrawn from medication: 1) nostimulation, 2) cZi stimulation alone, 3) PPN stimulationalone, 4) combined PPN/cZi stimulation.

 

 

 

 

 

------------------------------

 

 

Lunette Soleil

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David Wolf    0

Please, I need help getting a recommendation for a Neural Surgeon for DBS using the GPi electrode site. I met last week with my MDS Neurologist and he suggested that next course of action for me was DBS. I am 53, diagnosed September 2007. Based on my symptoms and his review of the study referenced in this article, he recommended the GPi site rather than the STN site. HE could not suggest anyone who performs the GPi surgery and only that our Buffalo-based surgeons only offer the STN surgery.

 

I have been scouring the internet and can only find reference to surgeons that perform the GPi surgery by chance. Your group has performed the GPi surgery down in Gainesville Florida, but I do not think that is a feasible option in that the cost in time and money, commuting for 6-months, would be excessive. Plus, I would prefer, if possible, to find someone closer to Buffalo that I could get to in case of incident or problems.

 

Any suggestions as to where I may find someone closer to Buffalo, NY, who is experience with the DBS-GPi surgery? I would very much appreciate a recommendation.

 

Thanks,

 

David Wolf

Miracles appear

when the void of total darkness

is pierced by but one single ray of light.

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Dr. Okun    411

Our group and others will in select cases screen patients for the surgery (complete interdisciplinary evaluation) and do the surgery and turn the follow-up over to a local group.

 

The only caveat is that just because a surgeon thinks GPi DBS may be appropriate it does not obviate the need for a complete 1-2 day workup and discussion by an experienced team. If GPi is recommended because of cognition this is especially important. In some cases a workup can occur early week and a surgery late week. You may find a site, get the screening and if you pass stick around for the surgery. You can then do followup locally if they have a program.

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derwin88    2

I was diagnosed in 2010 with PD. Tremors are controlled with Meds but my Dystonia has been difficult to treat, up until recently Meds and botox have worked pretty good but recently last two rounds of botox has had very limited results. Dystonia is mainly on my left side effecting shoulder leg and most my foot causing severe cramping and curling in my foot. Datscan done about 10mos ago how both sides of my brain are effected. What options should I look into?

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Dr. Okun    411

Definitely you should discuss DBS if the meds and botox are not getting at your dystonia symptoms.

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graflexmaster    1,182

 

quality of life improved at 6 months on all subscales (all p values significant), but improvement diminished over time. Mattis Dementia Rating Scale scores declined faster for STN than GPi patients (p = 0.01); other neurocognitive measures showed gradual decline overall. Conclusions The beneficial effect of DBS on motor function was stable and comparable by target over 36 months. Slight declines in quality of life following initial gains and gradual decline in neurocognitive function likely reflect underlying disease progression and highlight the importance of nonmotor symptoms in determining quality of life

Ok, based on the above quote, I have a few questions here.......

 

 

quality of life improved at 6 months on all subscales (all p values significant), but improvement diminished over time

Since I'm now 6mo post-op, I'd like to know how far the improvements diminished over time?

 

 

 Mattis Dementia Rating Scale scores declined faster for STN than GPi patients (p = 0.01

Since I'm bilateral STN, I'd like to know how much faster they declined, and from what level, to what level?

 

 

 other neurocognitive measures showed gradual decline overall

What were the "other measures"? and how far was the overall decline? Again, from where, to where? (on average)

 

 

Slight declines in quality of life following initial gains and gradual decline in neurocognitive function likely reflect underlying disease progression and highlight the importance of nonmotor symptoms in determining quality of life following initial gains and gradual decline in neurocognitive function likely reflect underlying disease progression and highlight the importance of nonmotor symptoms in determining quality of life

I would like to know what parameters you(they) are using here to define "Slight declines in quality of life" and "gradual decline in neurocognitive function", I mean, are we talking going from doing ok, and living independently to maybe needing some help? or maybe Doing ok and then ending up sitting in a wheelchair, drooling on myself and flicking my malt-o-meal at everyone that walks past?

 

Basically it would be nice to have some real world parameters to base this information against...................

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Dr. Okun    411

I would direct you to the study's authors at the VA study; Matt Stern is at the NPF Center of Excellence at Penn.  This was a pooled group analysis and it is hard to extrapolate the results patient to patient.  In our center we use an interdisciplinary screening approach.  Matt may be able to address your questions directly.

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Please, I need help getting a recommendation for a Neural Surgeon for DBS using the GPi electrode site. I met last week with my MDS Neurologist and he suggested that next course of action for me was DBS. I am 53, diagnosed September 2007. Based on my symptoms and his review of the study referenced in this article, he recommended the GPi site rather than the STN site. HE could not suggest anyone who performs the GPi surgery and only that our Buffalo-based surgeons only offer the STN surgery.

 

I have been scouring the internet and can only find reference to surgeons that perform the GPi surgery by chance. Your group has performed the GPi surgery down in Gainesville Florida, but I do not think that is a feasible option in that the cost in time and money, commuting for 6-months, would be excessive. Plus, I would prefer, if possible, to find someone closer to Buffalo that I could get to in case of incident or problems.

 

Any suggestions as to where I may find someone closer to Buffalo, NY, who is experience with the DBS-GPi surgery? I would very much appreciate a recommendation.

 

Thanks,

 

David Wolf

 

Miracles appear

when the void of total darkness

is pierced by but one single ray of light.

if you can get to chicago..northwestern medicine (via Cadence in WInfield) has the best of the best dbs surgeons..

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