Effect of bilateral subthalamic nucleus stimulation on levodopa-unresponsive axial symptoms in Parkinson’s disease Authors
First Online: 10 January 2008 Received: 07 August 2007 Accepted: 01 October 2007 DOI:
Cite this article as: Yamada, K., Goto, S., Hamasaki, T. et al. Acta Neurochir (Wien) (2008) 150: 15. doi:10.1007/s00701-007-1451-3 Summary Background. The levodopa responsiveness of motor, particularly axial symptoms is a good predictor of the effectiveness of subthalamic nucleus (STN) stimulation in patients with Parkinson’s disease (PD). However, many Japanese PD patients are intolerant of higher doses of antiparkinsonian drugs and some aspects of their axial symptoms may remain unresponsive to treatment. We retrospectively investigated the effects of bilateral STN stimulation on the axial signs unresponsive to levodopa in Japanese patients with PD. Methods. We enrolled 29 consecutive patients into this study. Six independent axial symptoms, i.e. falling, freezing, gait, standing, posture, and postural instability, were scored on the Unified Parkinson’s Disease Rating Scale (UPDRS), before and 3 months after bilateral STN stimulation and differences were statistically analysed. Findings. Postoperatively, the mean levodopa dosage was decreased by 27%. The preoperative responsiveness to antiparkinsonian drugs with respect to freezing, gait, posture, and postural instability were positively correlated with postoperative off-medication improvement ( p < 0.05). For each individual axial symptom, some patients showed an excellent response to STN stimulation, despite preoperative unresponsiveness to levodopa. These selected patients were not always treated with lower doses of antiparkinsonian drugs preoperatively, but they had milder preoperative scores on the UPDRS with respect to daily activities and overall axial function. Conclusions. The axial symptoms of PD unresponsive to levodopa were ameliorated by bilateral STN stimulation in patients manifesting a milder degree of preoperative axial signs. Our findings suggest that STN stimulation exerted a definite but limited effect on levodopa-unresponsive axial features, pointing to the need to identify different target structures that control axial functions via non-dopaminergic systems. Keywords: Axial symptoms; deep brain stimulation; levodopa; parkinson’s disease; subthalamic nucleus.
Correspondence: Kazumichi Yamada, M.D., Ph.D., Department of Neurosurgery, Graduate School of Medical Sciences, Kumamoto University, 1-1-1 Honjo, Kumamoto City, 860-8556 Kumamoto, Japan.
Download to read the full article text References Bejjani, B-P, Gervais, D, Arnulf, I, Papadopoulos, S, Demeret, S, Bonnet, A-M, Cornu, P, Damier, P, Agid, Y 2000 Axial parkinsonian symptoms can be improved: the role of levodopa and bilateral subthalamic stimulation J Neurol Neurosurg Psychiatry 68 595 600 PubMed CrossRef Bonnet, A-M, Loria, Y, Saint-Hilaire, MH, et al. 1987 Does long-term aggravation of Parkinson’s disease result from nondopaminergic lesions? Neurology 37 1539 1542 PubMed Charles, PD, Van Blercom, N, Krack, P, Lee, SL, Xie, J, Besson, G, Benabid, A-L, Pollak, P 2002 Predictors of effective bilateral subthalamic nucleus stimulation for PD Neurology 59 932 934 PubMed Erola, T, Heikkinen, ER, Haapaniemi, T, Tuominen, J, Juolasmaa, A, Myllylä, VV 2006 Efficacy of bilateral subthalamic nucleus stimulation in Parkinson’s disease Acta Neurochir (Wien) 148 389 394 CrossRef Granata, AR, Kitai, ST 1989 Intracellular analysis of excitatory subthalamic inputs to the pedunculopontine neurons Brain Res 488 57 72 PubMed CrossRef Hallett, M, Litvan, I 1999 The task force on surgery for Parkinson’s Disease. Evaluation of surgery for Parkinson’s disease. A report of the therapeutic and technology assessment subcommittee of the American Academy of neurology Neurology 53 1910 1921 PubMed Houeto, JL, Damier, P, Bejjani, PB, Staedler, C, Bonnet, AM, Arnulf, I, Pidoux, B, Dormont, D, Cornu, P, Agid, Y 2000 Subthalamic stimulation in Parkinson disease: a multidisciplinary approach Arch Neurol 57 461 465 PubMed CrossRef Katayama, Y, Kasai, M, Oshima, H, Fukaya, C, Yamamato, T, Ogawa, K, Mizutani, T 2001 Subthalamic nucleus stimulation for Parkinson disease: benefits observed in levodopa-intolerant patients J Neurosurg 95 213 221 PubMed Klawans, HL 1986 Individual manifestations of Parkinson’s disease after 10 or more years of levodopa Mov Disord 1 187 192 PubMed CrossRef Kleiner-Fisman, G, Fisman, DN, Sime, E, Saint-Cyr, JA, Lozano, AM, Lang, AE 2003 Long-term follow up of bilateral deep brain stimulation of the subthalamic nucleus in patients with advanced Parkinson disease J Neurosurg 99 489 495 PubMed Krack, P, Batir, A, van Blercom, N, Chabardes, S, Fraix, V, Ardouin, C, Koudsie, A, Limousin, P, Benazzouz, A, LeBas, JF, Benabid, A-L, Pollak, P 2003 Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson’s disease N Eng J Med 349 1925 1934 CrossRef Lang, A, Lozano, AM 1998 Parkinson’s disease. First of two parts N Engl J Med 339 1044 1053 PubMed CrossRef Limousin, P, Krack, P, Pollak, P, Benazzouz, A, Ardouin, C, Hoffmann, D, Benabid, A-L 1998 Electrical stimulation of the subthalamic nucleus in advanced Parkinson’s disease N Eng J Med 339 1105 1111 CrossRef Lyons, KE, Davis, JT, Pahwa, R 2007 Subthalamic stimulation in Parkinson’s disease patients intolerant to levodopa Stereotact Funct Neurosurg 85 169 174 PubMed CrossRef Mazzone, P, Lozano, A, Stanzione, P, Galati, S, Scarnati, E, Peppe, A, Stefani, A 2005 Implantation of human pedunculopontine nucleus: a safe and clinically relevant target in Parkinson’s disease NeuroReport 16 1877 1881 PubMed CrossRef Moro, E, Esselink, RJA, Benabid, AL, Pollak, P 2002 Response to levodopa in parkinsonian patients with bilateral subthalamic stimulation Brain 125 2408 2417 PubMed CrossRef Moro, E, Scerrati, M, Romito, LMA, Roselli, R, Tonali, P, Albanese, A 1999 Chronic subthalamic nucleus stimulation reduces medication requirements in Parkinson’s disease Neurology 53 85 90 PubMed Østergaard, K, Sunde, N, Dupont, E 2002 Effects of bilateral stimulation of the subthalamic nucleus in patients with severe Parkinson’s disease and motor fluctuations Mov Disord 17 693 700 PubMed CrossRef Pahapill, P, Lozano, AM 2000 The pedunculopontine nucleus and Parkinson’s disease Brain 123 1767 1783 PubMed CrossRef Plaha, P, Gill, SS 2005 Bilateral deep brain stimulation of the pedunculopontine nucleus for Parkinson’s disease NeuroReport 16 1883 1887 PubMed CrossRef Rivera-Calimlim, L, Reilly, DK 1984 Difference in erythrocyte catechol-O-methyltransferase activity between Orientals and Caucasians: difference in levodopa tolerance Clin Pharmacol Ther 35 804 809 PubMed CrossRef Romito, LM, Scerrati, M, Contarino, MF, Bentivoglio, AR, Tonali, P, Albanese, A 2002 Long-term follow up of subthalamic nucleus stimulation in Parkinson’s disease Neurology 58 1546 1550 PubMed Simuni, T, Jaggi, JL, Mulholland, H, Hurtig, H, Colcher, A, Siderowf, AD, Ravina, B, Skolnick, BE, Goldstein, R, Stern, MB, Baltuch, GH 2002 Bilateral stimulation of the subthalamic nucleus in patients with Parkinson’s disease: a study of efficacy and safety J Neurosurg 96 666 672 PubMed CrossRef Steininger, TL, Rye, DB, Wainer, BH 1992 Afferent projections to the cholinergic pedunculopontine tegmental nucleus and adjacent midbrain extrapyramidal area in the albino rat I. Retrograde tracing studies J Comp Neurol 321 515 543 PubMed CrossRef The deep-brain stimulation for Parkinson’s disease study group 2001 Deep-brain stimulation of the subthalamic nucleus or the pars interna of the globus pallidus in Parkinson’s disease N Eng J Med 345 956 963 CrossRef Welter, ML, Houeto, JL, Tezenas du Montcel, S, Mesnage, V, Bonnet, AM, Pillon, B, Arnulf, I, Pidoux, B, Dormont, D, Cornu, P, Agid, Y 2002 Clinical predictive factors of subthalamic stimulation in Parkinson’s disease Brain 125 575 583 PubMed CrossRef Yamada, K, Goto, S, Matsuzaki, K, Nagahiro, S, Murase, N, Shimazu, H, Kaji, R, Kuratsu, J, Ushio, Y 2006 Psychiatric symptoms and subthalamic nucleus stimulation in Parkinson’s disease. A retrospective study in our Japanese patients Neuromodulation 9 107 114 CrossRef Yamada, K, Goto, S, Kuratsu, J, Matsuzaki, K, Nagahiro, S, Shimazu, H, Kaji, R 2007 General anesthesia for stereotactic implantation of stimulating electrodes within the subthalamic nucleus Parkinsonism Relat Disord 13 101 107 PubMed CrossRef