Objective:  

The goal of these case series is to investigate the possibility of deep brain stimulation (DBS) prior to L-dopa treatment in young Parkinsson Disease (PD) patients.

Background:

Deep Brain Stimulation (DBS) is a safe, minimally invasive surgical procedure utilized in the treatment of Parkinson Disease (PD). Earlystim trial (1) has demostrated superiority of early dbs compared to the best farmacological treatment in improving motor symptons in PD. We present our experience in three PD patients with dbs before L-Dopa treatment

Methods:  

First patients was operated on in 2009, the others two in 2016. DBS was proposed when dopamine agonist lost efficacy and therapeutic algorithm would have requested l-dopa. Eligibility to surgery was evaluated with CAPSIT. All patients had bilateral stimulation of subthalamic nucleus (STN). We performed surgery under local anesthesia. Internal Pulse generators  was positioned few days later under general anesthesia, in a subclaveare pouch. All procedures were uneventful. .

Results:

Patient 1

Male 53 yo, professional manager , , 9 years course of PD. Pharmacological therapy before DBS : ropirinole 8 mg, rotigotine 8 mg and selegiline 20 mg .Off UPDRS III 17. 56% improvement at l-dopa challenge. Postoperative on UPDRS III 8. Postoperative therapy not changed. 6 years after surgery he underwent to IPG replacement and he noted amelioration of tremor and rigidity. However the patient’s fatigue and general bradykinesia remained unchanged. In June 2015, the patient was started with L-dopa treatment (400 mg/day). At the lastest follow-up (june 2016) therapy unchanged. UPDRS III 18

Patient 2

Male 49 yo hotel manager, 6 years course of PD. Pharmacological therapy before DBS: rasagiline 1 mg; pramipexole 1.05 mg and rotigotine 0.8 mg. Off UPDRS III 18. 67% improvement at l-dopa challenge. Post-operative on UPDRS III (7 months) 6. No drugs.

Patient 3

Male 66 yo, businessman, 5 years course of PD. Pharmacological therapy before DBS: pramipexole 1.57 mg. Off UPDRS III 17. 53% improvement at l-dopa challenge. Post-operative on UPDRS III (11 months): 8. Pharmacological therapy: pramipexole 0.52 mg.

Conclusions:  

Timing of DBS in the treatment of PD is recently being debated (1)

DBS is associated with potential surgical risks, however kept as minimal in well experienced centre .We should consider also that,even if there is’nt proved clinical evidence of l-dopa toxicity, the drug has unavoidable long-term adverse effects. After 5 years of L-dopa treatment, nearly 50%, and after 10 years of treatment, 100% of the patients complain of motor complications.

For these reasons we have considered a different therapeutic approach to PD anticipating DBS to l-dopa treatment, above all in young patientes still working and with an active social life

On top of the clinical results manteined for more than 6 years in the first patient, we could hypothesize a neuroprotective properties of DBS (2) that would be confrmed in the other two patients.

References: 1. Neurostimulation for Parkinson’s Disease with early motor complications.  Schuepbach WM et al. New England Journal of Medicine, 2013 2. Stimulation of the Rat Subthalamic Nucleus is Neuroprotective Following Significant Nigral Dopamine Neuron Loss.  A.L. Spieles-Engemann et al. Neurobiol Dis, 2010

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MDS Abstracts - https://www.mdsabstracts.org/abstract/deep-brain-stimulation-for-parkinson-disease-before-l-dopa-treatment-experience-in-three-cases/