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Dr. Okun

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

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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.



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.



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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Hi Dr. Okun,


This post really caught my attention, because I had unilateral DBS surgery almost 3 years ago (8/2009), and the target was the GPi. STN was the planned target at first, but it was changed to GPi because of cognitive issues - specifically executive functioning.


My dominant symptom at that time was tremor in my right hand/arm. The surgery was extremely successful - to this day, my right hand and arm do not shake, 99% of the time. DBS helps in other ways too, but that was the most dramatic.


What does "more flexibility when adjusting medications for the GPi target" mean? Does it have something to do with dyskinesia and the STN?


This may sound weird, but that surgery was one of the most awesome experiences of my life. They had to try three different placements of the lead - all three placements stopped the tremor, but with the first two, it also stopped my voice - I couldn't talk! (My husband jokes that they could've stopped right there.) But when the tremor was stopped, and I could still talk normally - the atmosphere in that operating room was one of victory and smiles were everywhere. Even with a surgical mask on, you can still see a smile - it's in the eyes. :)


Thank you for the info, and for all you do on this forum...so greatly appreciated!



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You can definitely see a real smile in the eyes!


Patients who have GPi DBS will have more flexibility to go up on their levodopa and PD medications. In STN in some cases this will result in dyskinesia.

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