Objective: To explore the hypothesis that flexible stimulation (multiple independent current control over 8 contacts/hemisphere) is superior to standard stimulation (standard stimulation over 4 contacts) in improving the outcome of patients with Parkinson disease (PD) receiving subthalamus nucleus stimulation in terms of motor control and side effects.

Background: In PD patients, DBS of the STN is recognised in reducing motor fluctuations, dyskinesia and medications. Stimulation of nearby structures can obtain further improvement: zona incerta (Zi) to suppress dyskinesia, improve action and proximal tremors and the substantia nigra pars reticulata (SNr) to improve axial symptoms like freezing and postural imbalance. The 4 contact standard electrode is limited by spread to unwanted locations resulting in side effects and suboptimal treatment of motor symptoms. Also, relevant adjacent structures are often far from the available contacts. It has been shown that the Boston Scientific 8-contact electrode (Vercise™ system) allows a longer stimulation span in each lead and more flexible distribution of electricity. This was seen in a single case study of a PD patient and in another prospective multicentred, non-randomized open-label intervention study (the Vantage study).1,2.

Methods: 10 patients were recruited to undergo DBS of the STN. After 3 months of open label programming, patients were randomized to undergo 3 months standard stimulation or 3 months of flexible stimulation before crossing over to the other arm. They underwent assessments (UPDRS I-IV, Gait analysis, BDI, PDQ-39, global impression of change, motor and falls diaries) at the end of each phase. Patients and assessors were blinded.

Results: Assessments at the end of the open label phase showed a reduction in UPDRS I-IV scores in the ON state, improvement in ON time during waking hours and less number of falls. Gait analysis also showed improvement of cadence, velocity, stride and step length and single and double support. Compared to standard stimulation, the use of flexible stimulation was superior in terms of efficacy and tolerability.

Conclusions: This study is the first randomized double-blinded study looking at the combination of subthalamic nucleus, Zi and SNr stimulation in the treatment of PD. The Vercise™ system allows flexible stimulation using a single electrode targeting 2 or more areas with the ability to use different stimulation parameters in a safe and feasible manner.

References: 1. Barbe MT, Maarouf M, Alesch F, Timmermann L. Multiple source current steering – A novel deep brain stimulation concept for customized programming in a Parkinson’s disease patient. Parkinsonism Relat Disord. 2013 Sep 14. pii: S1353-8020(13)00275-7. 2. Timmermann, L., Jain, R., Chen, L., Maarouf, M., Barbe, M.T., Allert, N., Brucke, T., Kaiser, I., Beirer, S., Seijo, F., Suarez, E., Lozano, B., Haegelen, C., Verin, M., Porta,. M., Servello, D., Gill, G., Whone, A., Dyck, N., Alesch, F. Multiple-source current steering in subthalamic nucleus deep brain stimulation for Perkinson’s disease (the VANTAGE study): a non-randomised, prospective, multicentre open label study. Lancer Neurol. 2015; 14: 693-701.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/8-contact-multiple-independent-current-control-vs-4-contact-standard-deep-brain-stimulation-of-subthalamus-in-parkinsons-disease-a-double-blind-cross-over-trial/