Objective: To analyze main reasons for refusing DBS in PD patients referred to Movement Disorders Center (MDC) and then to DBS-center over the period 2008–2018.

Background: Since the introduction of DBS, significant evolution in neurologists’ understanding of patient suitability for surgery occurred. However, studies show that only 4.5% of PD patients referred to specialized DBS center are good surgical candidates [1].

Method: We included PD patients referred to MDC to assess their suitability for DBS. In MDC, examination by neurologist (diagnosis clarification, assessment of  drug treatment adequacy), evaluation of motor symptoms in ON- and OFF-medication state, brain MRI, neuropsychological assessment, as well as interviewing for impulsive-compulsive and psychiatric symptoms were performed. Patients, which met selection criteria for DBS and had no contraindications for surgery, were referred to DBS-center for evaluation by multidisciplinary team. Reasons for refusal in DBS at both MDC and DBS-center levels were carefully investigated.

Results: In total, 668 PD patients were assessed in MDC, of ​​which 99(14.8%) applied on their own after learning about surgery in media and 569(85.2%) were referred by general neurologists. After screening, 525(78.6%) patients were denied DBS, 143(21.4%) were referred to DBS center, where only 80(12%) were operated. Reasons for refusal at MDC were the following: early referral (152 patients/29%), inadequate drug therapy (118/22.5%), cognitive causes (73/13.9%), atypical/secondary parkinsonism (45/8.6%), comorbidity (39/7.4%), psychiatric causes (32/6.1%), levodopa-insensitive symptoms (28/5.3%), abnormal MRI (17/3.2 %), poor response to levodopa (17/3.2%), abstaining from surgery (4/0.8%).
In DBS-center, 63 patients were not operated, 25 of them abstained from surgery and 11 were lost for contact. After assessment by a multidisciplinary team, 27 patients were refused due to cognitive impairment (10), psychiatric symptoms (5), early referral (7), or medication adjustments (5).
Over 10 years, number of independent appeals decreased, referral of eligible for DBS patients increased, DBS refusals when referring unsuitable candidates abated.

Conclusion: Comprehensive MDC screening reduces the amount of inappropriate patients referred to DBS-center and allows a more efficient selection potentially increasing availability of early DBS treatment for suitable surgical candidates.

References: 1. Morgante L, Morgante F, Moro E, Epifanio A, Girlanda P, Ragonese P, Antonini A, Barone P, Bonuccelli U, Contarino MF, Capus L, Ceravolo MG, Marconi R, Ceravolo R, D’Amelio M, Savettieri G. How many parkinsonian patients are suitable candidates for deep brain stimulation of subthalamic nucleus? Results of a questionnaire. Parkinsonism Relat Disord 2007; 13(8): 528-31. doi: 10.1016/j.parkreldis.2006.12.013

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MDS Abstracts - https://www.mdsabstracts.org/abstract/reasons-for-refusing-deep-brain-stimulation-in-patients-with-parkinsons-disease-a-retrospective-10-year-study/