Category: Surgical Therapy: Parkinson's Disease
Objective: We sought to investigate the percentage of “poor stimulation responders” among late-stage Parkinson’s disease (LSPD) patients for elaborating an algorithm to decide whether and when subthalamic deep brain stimulation (STN-DBS) interruption may be considered.
Background: STN-DBS effects may decrease with Parkinson’s disease (PD) progression . There is no indication if, when and how to consider the interruption of DBS treatment in LSPD.
Method: LSPD patients (Hoehn Yahr Stage > or = 4 and Schwab and England Scale <50  in Med On/Stim On condition) treated with STN-DBS for at least 5 years underwent a cross-over, double-blind, randomized evaluation of acute effects of stimulation. Physicians, caregivers and patients were blinded to stimulation conditions (Figure 1). Poor stimulation responders (MDS-UPDRS part III change < 10% between Stim On/Med Off and Stim Off/Med Off) maintained the Stim Off/Med On condition during one month for open label assessment.
Results: Thirty-six patients were included (Table 1). The acute effect of stimulation was significant (17% MDS-UPDRS part III improvement at the Stim On/Med Off vs. Stim Off/Med Off) (Figure 2 and Table 2). Seven patients were classified as “poor stimulation responders” and the stimulation was switched-off, but in four cases the stimulation was switched back “On” due to worsening of parkinsonism and dysphagia with a variable time delay (up to 10 days). No serious adverse effects occurred (Table 3).
Conclusion: The large majority of LSPD patients under chronic STN-DBS still benefit from stimulation, even if they are severely disabled in activities of daily living due to marked motor impairment and cognitive decline. Stimulation effect, when present, is usually well perceivable during an acute stimulation challenge test, but its entire effect may take days to fully disappear after interruption. Our study offers a safe and effective decisional algorithm (Figure 3) that could guide physicians, patients and caregivers in taking challenging therapeutic decisions in the latest stage of PD.
References:  Limousin P, Foltynie T. Long-term outcomes of deep brain stimulation in Parkinson disease. Nature reviews Neurology 2019;15:234-242.  Coelho M, Ferreira JJ. Late-stage Parkinson disease. 2012.
To cite this abstract in AMA style:M. Fabbri, M. Zibetti, m. Rizzone, G. Giannini, L. Borellini, A. Stefani, F. Bove, A. Bruno, G. Calandra-buonaura, N. Modugno, C. Piano, A. Peppe, G. Ardolino, A. Romagnolo, C. Artusi, P. Berchialla, E. Montanaro, P. Cortelli, L. Romito, R. Eleopra, B. Minafra, C. Pacchetti, L. Lopiano. When and how to stop subthalamic deep brain stimulation in late-stage Parkinson’s disease [abstract]. Mov Disord. 2020; 35 (suppl 1). https://www.mdsabstracts.org/abstract/when-and-how-to-stop-subthalamic-deep-brain-stimulation-in-late-stage-parkinsons-disease/. Accessed December 6, 2023.
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