Objective: The subthalamic nucleus (STN) and the globus pallidus internus (GPi) are the main targets of deep brain stimulation surgery (DBS) for patients with advanced Parkinson’s disease (PD) and motor fluctuations and/or invalidating dyskinesias. We present here a case of DBS rescue in both STN through surgery in both GPi

Background: DBS at the STN or GPi can both be used to treat motor symptoms of PD, but the simultaneous implantation in the two targets is rare. Additional GPi DBS has been used in patients with difficult control of diyskinesias despite of medical treatment or DBS at the STN.

Method: A 59-year-old male patient with PD associated with the G2019S mutation of LRRK2 of 15 years of evolution. He was submitted 8 years before to DBS in both STN due to invalidating motor fluctuations with a good initial response. Four years after the initial intervention it began again with motor fluctuations and severe dyskinesias both in OFF and ON that could not be controlled with medical treatment. A continuous infusion Levodopa-pump was tested without results. An apomorphine pump was implanted with a slight improvement of the OFF periods but without achieving a satisfactory situation. He suffered from severe dystonic dyskinesias that prevented him from walking or even sitting in a chair. A rescue was decided with new DBS surgery, this time in both GPi.

Results: After the intervention, the patient presented a significant improvement in dystonia from the first days, managing to stay seated in a chair without the need to be tied. In the same way and after doing rehabilitation, the patient was able to walk with only one support. Otherwise, there was a significant reduction of OFF periods.

Conclusion: Deep brain stimulation surgery in both GPi can be considered as rescue therapy in cases in which subthalamic stimulation and medical treatment do not achieve appropriate control of dyskinesias.

References: 1. Cook RJ, et al. Globus pallidus internus deep brain stimulation as rescue therapy for refractory dyskinesias following effective subthalamic nucleus stimulation. Stereotact Funct Neurosurg. 2015;93(1):25-9. 2. Nagy, A. M., & Tolleson, C. M. Rescue Procedures after Suboptimal Deep Brain Stimulation Outcomes in Common Movement Disorders. Brain sciences, 2016; 6(4), 46. 3. Matias CM, et al. “Rescue” of bilateral subthalamic stimulation by bilateral pallidal stimulation: case report. J Neurosurg. 2016 Feb;124(2):417-21

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MDS Abstracts - https://www.mdsabstracts.org/abstract/bilateral-globus-pallidus-internus-deep-brain-stimulation-as-rescue-therapy-for-ineffective-subthalamic-stimulation/