Objective: To seek how novel programming options modify the therapeutic window in a case of off-targeting DBS.

Background: In Parkinson’s disease deep brain stimulation (DBS) the therapeutic window is significantly narrowed by off-targeting, which exposes to unwanted recruitment of surrounding neural structures.

Method: A 56 years-old man underwent bilateral STN-DBS with directional leads. One week after surgery, the monopolar review revealed low therapeutic window in particular on the left lead, because of facio-brachial tonic spams occurrence. This data was confirmed by the second monopolar review at 2 months of follow-up. Traditional programming, namely monopolar (even directional) and bipolar stimulation, did not add any significant benefit.  We thus performed patient-specific post-operative neuroimaging processing and explored the clinical effect of advanced programming strategies (low/high frequency, low pulse width, anodic stimulation).

Results: The postprocessing analysis of pre-operative MR and post-operative CT revealed the left lead off-targeting as it laid in the medial portion of the corticospinal tract, just laterally to the subthalamic nucleus. Anodic stimulation reduced the corticospinal tract engagement than cathodic stimulation. Low pulse width further widened the therapeutic window with better improvement of bradykinesia and rigidity. Bilateral high frequency stimulation led to better clinical results on tremor.

Conclusion: The fine tuning with unconventional stimulation programming strategies offers rescue approaches with a larger therapeutic window. This case highlights the potential benefits of anodic stimulation in off-targeting DBS lowering the corticospinal tract engagement.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/anodic-stimulation-reduces-corticospinal-tract-engagement-in-stn-dbs-for-parkinsons-disease-a-case-report/