Objective: To examine the clinical benefits and side effects of combined stereotactic surgery, namely ventralis intermedius (VIM) thalamotomy and bilateral asymmetric GPi/STN DBS, for Parkinson’s disease (PD).

Background: PD symptoms are heterogeneous and asymmetric, such that a symptom-tailored therapy might be more beneficial. Clinically, GPi-DBS, STN-DBS and VIM thalamotomy are all used for advanced PD, with each treatment having its own advantages and limitations. STN-DBS suppresses tremor and is associated with a substantial medication reduction, but this treatment may deteriorate dyskinesia. GPi-DBS usually results in a strong suppression of dyskinesia. VIM thalamotomy is only used for tremor suppression, but this surgical treatment is irreversible. Combination of these procedures may optimize their clinical benefits while minimizing their limitations.

Methods: Patient YZ, a 68-year-old male and retired engineer, was diagnosed with PD in 2005, exhibiting severe left limb tremor at the medication-off state and severe right limb dyskinesia at the medication-on state. The patients also experienced freezing of gait and postural instability. To target these PD symptoms, we applied left VIM thalamotomy and GPi-DBS for the right limb tremor and dyskinesia, as well as applying right STN-DBS for his left limb’s tremor. The patient was clinically assessed before treatment and at 6 months after treatment, using the Unified Parkinson Disease Rating Scale (UPDRS) and Gait and Falls Questionnaire (GFQ).

Results: Six months after treatment (medication-off/stimulation-on), the patient showed a 21% improvement in motor symptoms. Specifically, at follow-up, the patient displayed little or no tremor (14 to 0, UPDRS-Ⅲ) and dyskinesia (5 to 0, UPDRS-Ⅳ). Also, axial symptoms were improved (3 to 2, UPDRS-Ⅲ), but bradykinesia worsened (10 to 17, UPDRS-Ⅲ). Moreover, the patient took fewer medications (700 to 200 mg, LED) and showed improvements in relation to gait and falls (23 to 8, GFQ).

Conclusions: This combined neurosurgical treatment could offer a valuable approach to targeting specific PD symptoms in a given patient. Side effects appear tolerable but remain an issue of concern.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/symptom-specified-target-and-procedure-selection-for-parkinsons-disease-a-case-report/