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Dr. Okun

Post of the Week: Zi Plus PPN DBS

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Dear Forum members,


This group was interested in the additive effects of PPN DBS plus ZI DBS. The study was too small to draw general conclusions, but there has been a lot of interest in PD for gait and balance issues. We will keep following this story for you. See below for the abstract:


Neurology. 2012 Apr 3;78(14):1090-5. Epub 2012 Mar 7.

Combined pedunculopontine-subthalamic stimulation in Parkinson disease.

Khan S, Gill SS, Mooney L, White P, Whone A, Brooks DJ, Pavese N.



Correspondence & reprint requests to Dr. Pavese: nicola.pavese@imperial.ac.uk.





To assess the effect of deep brain stimulation (DBS) in the pedunculopontine nucleus (PPN) and caudal zona incerta (cZi)-both separately and in combination-on motor symptoms and regional cerebral blood flow (rCBF) in patients with Parkinson disease (PD).


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DBS electrodes were rated with the Unified Parkinson's Disease Rating Scale motor subscale (UPDRS-III) when taking and withdrawn from medication. A block of 16 [(15)O]-H(2)O PET resting measurements of rCBF were performed in 4 different states with patients withdrawn from medication: 1) no stimulation, 2) cZi stimulation alone, 3) PPN stimulationalone, 4) combined PPN/cZi stimulation.


When patients were medicated, combined PPN/cZi stimulation produced a statistically significant improvement in UPDRS-III score compared to cZi stimulation alone. In the "off" medication state, the clinical effect of combined stimulation was not significantly different from that induced by cZi stimulation alone. Concomitant PPN/cZi stimulation had a cumulative effect on levels of rCBF, effectively combining subcortical and cortical changes induced by stimulation of either target in isolation.


These findings suggest that concomitant low frequency stimulation of PPN and cZi regions induces additive brainactivation changes and provides improved control of PD symptoms when medicated. Classification of evidence: This study provides Class IV evidence that concomitant low frequency stimulation of PPN and cZI improves motor symptoms in patients with PD on dopamine replacement. It provides Class III evidence that concomitant low frequency stimulation of PPN and cZi induces additive rCBF changes in motor areas of brain.

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