Objective: Management of motor complications after subthalamic nucleus (STN) deep brain stimulation (DBS) with globus pallidus interna (Gpi) stimulation.

Background: Deep brain stimulation is an effective surgical therapeutic strategy in advanced patients with Parkinson’s disease (PD) complicated by motor fluctuations. Subthalamic nucleus and the Gpi are the two main and most common targets used to treat PD. Both targets provide similar, consistent, marked motor benefits with subtle differences. When the main goal is severe dyskinesias, GPi stimulation can be considered [1, 2]. Although there is a lot of data in the literature regarding the results of single target stimulation, experiences with simultaneous stimulation of both targets are inconclusive and limited. Here, we report a case with severe motor complications after 8 years with STN DBS in whom GPi implant has been done as ‘‘rescue therapy’’.

Method: A 53-year-old man with an 18-year-long history of tremor dominant PD referred to our department for management of severe motor complications. He had undergone STN DBS 8 years ago with moderate benefits. However, peak dose dyskinesias and prolonged motor off-periods revealed after five years. These motor complications could not be managed with the adjustments of the STN DBS parameters and optimal pharmacological therapy. Therefore, bilateral Gpi DBS implemented. Motor function was evaluated with the Unified Parkinson’s Disease Rating Scale (UPDRS) Part III during the on-medication/on-stimulation state and motor complications were assessed using the UPDRS Part IV before and after the surgery.

Results: After the surgery UPDRS Part III score was decreased from 38 to 11, UPDRS Part IV score was decreased from 11 to 0, the levodopa equivalent dose (LEDD) was decreased to 1198 from 1538. Three months after surgery, motor outcome (UPDRS Part III score) during on-medication/on-stimulation (STN and GPi) state was improved by 10% and UPDRS Part IV score and LEDD were the same.

Conclusion: Pallidal DBS may be a safe and useful strategy to manage motor complications of PD many years after STN stimulation. Although combined stimulation was quite successful in the reported patient, further studies with larger samples and longer follow-up periods will be necessary.

References: 1- Ramirez-Zamora A, Ostrem JL. Globus Pallidus Interna or Subthalamic Nucleus Deep Brain Stimulation for Parkinson Disease: A Review. JAMA Neurol. 2018 Mar 1;75(3):367-372. doi: 10.1001/jamaneurol.2017.4321. 2- Liu Y, Li F, Luo H, He Q, Chen L, Cheng Y, Zhang W, Xie Z. Improvement of Deep Brain Stimulation in Dyskinesia in Parkinson’s Disease: A Meta-Analysis. Front Neurol. 2019 Feb 25;10:151. doi: 10.3389/fneur.2019.00151.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/gpi-deep-brain-stimulation-after-many-years-of-subthalamic-nucleus-stimulation-case-report/