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Table of Contents    
CASE REPORT
Year : 2020  |  Volume : 68  |  Issue : 1  |  Page : 165-167

Direct Comparison of Posterior Subthalamic Area Stimulation versus Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease


1 Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
2 Department of Neuroscience, The Ohio State University Wexner Medical Center, Columbus, OH, United States

Date of Web Publication28-Feb-2020

Correspondence Address:
Dr. Kristin M Huntoon
N1014 Doan Hall, 410 W 10th Avenue, Columbus, Ohio - 43210
United States
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.279694

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 » Abstract 


In this case report, we describe successful tremor capture via stimulation of the posterior subthalamic area (PSA) for a patient with tremor-predominant Parkinson's disease. In this scenario, the patient had a deep brain stimulation (DBS) lead placed in the PSA of the right hemisphere and a DBS lead placed in the subthalmic nucleus (STN) of the left hemisphere. Therefore, we were able to directly compare tremor capture in the same patient receiving stimulation in two different brain areas. We show that both placements are equally efficacious for tremor suppression, though the DBS lead placed in the PSA required slightly higher current intensity. This comparison in the same patient confirms that stimulation of the PSA can successfully suppress tremor in Parkinson's disease.


Keywords: Deep brain stimulation, Parkinson's disease, posterior subthalamic area, subthalamic nucleus
Key Messages: This original case study demonstrates that stimulation of the posterior thalamic area (PSA) is effective for tremor suppression in Parkinson's disease.


How to cite this article:
Huntoon KM, Young NA, Look AC, Deogaonkar M. Direct Comparison of Posterior Subthalamic Area Stimulation versus Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease. Neurol India 2020;68:165-7

How to cite this URL:
Huntoon KM, Young NA, Look AC, Deogaonkar M. Direct Comparison of Posterior Subthalamic Area Stimulation versus Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease. Neurol India [serial online] 2020 [cited 2020 Mar 28];68:165-7. Available from: http://www.neurologyindia.com/text.asp?2020/68/1/165/279694




In this report we discuss a case of successful tremor control by deep brain stimulation (DBS) of the posterior subthalamic area (PSA) for a patient with tremor-predominant Parkinson's disease (PD).

The introduction of DBS has shifted the focus of PD treatment from thalamotomy and pallidotomy to stimulation of subcortical brain structures. Currently, deep brain electrodes are typically placed in the subthalamic nucleus (STN) for effective tremor capture.[1] Prior to the advent of DBS, subthalatomy of the PSA was also done for control of parkinsonian tremor and other movement disorders. Although the mechanism of action in the PSA appears unclear, DBS studies of this area have shown promising results in tremor reduction.[2]


 » Case History Top


Here, we report a case of a tremor-predominant PD patient who had DBS leads placed bilaterally, with STN lead placement in the left hemisphere and PSA lead placement in the right hemisphere. This patient was a 64-year-old male who initially presented with tremor-dependent PD that began as resting tremor of the right hand, which slowly progressed and became left side dominant. His tremor was refractory to 300 mg levodopa and anticholinergics, and thus he underwent placement of a right hemisphere STN DBS lead (Medtronic 3389) at the age of 64. He experienced excellent treatment benefit and was virtually tremor free in his left arm. He then returned for left hemisphere STN DBS lead placement 3 months later and subsequently experienced excellent benefit in his left body with stimulation. Postoperative neuroanatomical reconstruction of his two DBS leads revealed the right hemisphere lead to be posteriorly located in the PSA and the left hemisphere lead located in the STN. Three dimensional modeling indicated the second contact was located in the prelemniscal radiation (Raprl) [Figure 1]d, in concordance with the mid-commissural point (MCP) coordinates [Figure 1]b. The patient's Unified Parkinson's Disease Rating Scale (UPDRS) scores [Figure 1]c demonstrated improved tremor control with the left hemisphere stimulation, as well as half the voltage demand of the patient's right hemisphere lead [Figure 1]a.
Figure 1:(a) The voltage settings for progressive visits for the patient's two DBS leads. (b) The MCP coordinates for the two DBS leads. (c) The patient's UPDRS scores prior to the procedure (Pre-Op) and after placement (Post-Op) in all extremities; left upper extremity (LUE), left lower extremity (LLE), right upper extremity (RUE) and right lower extremity. (d) Three dimensional schematic showing the placement of the leads on the right and left in regard to the posterior commissure (PC), subthalamic nucleus (STN), red nucleus and lateral geniculate (LG)

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 » Discussion Top


This is the first report of a direct comparison between STN and PSA DBS for tremor capture in a tremor-predominant PD patient. Anatomically, the PSA is bounded anteriorly by the posterior border of the subthalamic nucleus (STN), superiorly by the ventral thalamic nuclei, inferiorly by the dorsal border of the substantia nigra, posteriorly by the medial lemniscus, posteromedially by the anterolateral border of the red nucleus, posterolaterally by the ventrocaudal nucleus, and laterally by the posterior limb of the internal capsule. It consists of zona incerta (Zi) and the Raprl, both of which lie posteriorly to the STN. Zi joins both the basal ganglia thalamocortical circuit and the cerebellar thalamocortical circuit, whereas Raprl contains fibers from the mesencephalic reticular formation that project to the thalamus, as well as ascending cerebellothalamic fibers.[3] The targeting of Zi and Raprl in the PSA is useful for tremor-predominant disorders, as it is not associated with the adverse effects of ventral intermediate nucleus stimulation, namely dysarthria, disequilibrium, or tolerance.[4],[5],[6] Earlier literature focused primarily on Zi, however, one group has published a series of 613 patients with Raprl as a primary target. Their long-term follow up subset demonstrated excellent tremor benefit with some improvement in rigidity at typical stimulation settings (130 Hz, 90 ms PW, and 1.5–3.0 V).[2] We have validated the previous observations of improved tremor control in long-term follow up (12 months). The mechanism for the preferential effect of PSA stimulation on tremor in comparison to the STN stimulation is unknown, but may be related to preferential effects on the cerebellothalamic tract compared to those affected by STN stimulation. Specific targeting of the PSA as an alternative target in PD patients has significant advantages and disadvantages, with the primary disadvantage being decreased efficacy in treating the nontremor PD symptoms of rigidity and bradykinesia. In this patient, who suffered from tremor-predominant PD, PSA stimulation provided excellent relief of his specific symptomatology with no stimulation-related side effects. This confirms the superiority of PSA as an alternative therapeutic target of DBS for tremor-predominant PD in comparison to the traditional targets, such as globus pallidus interna (GPi) and STN.

Authors' contributions

KH: drafting manuscript. NY: neurophysiology and revising of manuscript. AL: drafting and revising of manuscript. MD: surgical procedure and revising of manuscript. All authors have read and approved final manuscript.

Acknowledgements

Partial support for this work was provided by The Ohio State University Neuroscience Research Institute.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
 » References Top

1.
Siegfried J, Lippitz B. Bilateral chronic electrostimulation of ventroposterolateral pallidum: A new therapeutic approach for alleviating all parkinsonian symptoms. Neurosurgery 1994;35:1126-9; discussion 1129-1130.  Back to cited text no. 1
    
2.
Velasco F, Jimenez F, Perez ML, Carrillo-Ruiz JD, Velasco AL, Ceballos J, et al. Electrical stimulation of the prelemniscal radiation in the treatment of Parkinson's disease: An old target revised with new techniques. Neurosurgery 2001;49:293-306; discussion 306-298.  Back to cited text no. 2
    
3.
Xie T, Bernard J, Warnke P. Post subthalamic area deep brain stimulation for tremors: A mini-review. Transl Neurodegener 2012;1:20.  Back to cited text no. 3
    
4.
Blomstedt P, Hariz GM, Hariz MI, Koskinen LO. Thalamic deep brain stimulation in the treatment of essential tremor: A long-term follow-up. Br J Neurosurg 2007;21:504-9.  Back to cited text no. 4
    
5.
Blomstedt P, Hariz MI. Are complications less common in deep brain stimulation than in ablative procedures for movement disorders? Stereotact Funct Neurosurg 2006;84:72-81.  Back to cited text no. 5
    
6.
Pahwa R, Lyons KE, Wilkinson SB, Simpson RK Jr, Ondo WG, Tarsy D, et al. Long-term evaluation of deep brain stimulation of the thalamus. J Neurosurg 2006;104:506-12.  Back to cited text no. 6
    


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