Predictors of second-sided deep brain stimulation for Parkinson’s disease

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OBJECTIVE

Parkinson’s disease (PD) is a progressive neurological movement disorder that is commonly treated with deep brain stimulation (DBS) surgery in advanced stages. The purpose of this study was to investigate factors that affect time to placement of a second-sided DBS lead for PD when a unilateral lead is initially placed for asymmetrical presentation. The decision whether to initially perform unilateral or bilateral DBS is largely based on physician and/or patient preference.

METHODS

This study was a retrospective cohort analysis of patients with PD undergoing initial unilateral DBS for asymmetrical disease between January 1999 and December 2017 at the authors’ institution. Patients treated with DBS for essential tremor or other conditions were excluded. Variables collected included demographics at surgery, time since diagnosis, Unified Parkinson’s Disease Rating Scale motor scores (UPDRS-III), patient-reported quality-of-life outcomes, side of operation, DBS target, intraoperative complications, and date of follow-up. Paired t-tests were used to assess mean changes in UPDRS-III. Cox proportional hazards analysis and the Kaplan-Meier method were used to determine factors associated with time to second lead insertion over 5 years.

RESULTS

The final cohort included 105 patients who underwent initial unilateral DBS for asymmetrical PD; 59% of patients had a second-sided lead placed within 5 years with a median time of 34 months. Factors found to be significantly associated with early second-sided DBS included patient age 65 years or younger, globus pallidus internus (GPi) target, and greater off-medication reduction in UPDRS-III score following initial surgery. Older age was also found to be associated with a smaller preoperative UPDRS-III levodopa responsiveness score and with a smaller preoperative to postoperative medication-off UPDRS-III change.

CONCLUSIONS

Younger patients, those undergoing GPi-targeted unilateral DBS, and patients who responded better to the initial DBS were more likely to undergo early second-sided lead placement. Therefore, these patients, and patients who are more responsive to medication preoperatively (as a proxy for DBS responsiveness), may benefit from consideration of initial bilateral DBS.

ABBREVIATIONS BMI = body mass index; DBS = deep brain stimulation; EQ-5D = EuroQol–5 Dimensions; GPi = globus pallidus internus; L-dopa = levodopa; MDS-UPDRS = Movement Disorder Society revision of Unified Parkinson’s Disease Rating Scale; PD = Parkinson’s disease; PHQ-9 = Patient Health Questionnaire–9; QOL = quality of life; STN = subthalamic nucleus; UPDRS-II = Unified Parkinson’s Disease Rating Scale self-evaluation score; UPDRS-III = UPDRS motor score.
Article Information

Contributor Notes

Correspondence Joshua L. Golubovsky: Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH. goluboj@ccf.org.INCLUDE WHEN CITING Published online February 14, 2020; DOI: 10.3171/2019.12.JNS19638.Disclosures Dr. Machado receives consulting/speaking fees from St. Jude Medical, Inc., and may receive future financial benefits from CardioNomics, Autonomic Technologies, Inc., and Enspire DBS related to intellectual property. Dr. Walter receives consulting/speaking fees from Medtronic, Inc., Adamas Pharmaceuticals, Inc., Neurocrine Biosciences, Inc., US WorldMeds, LLC, and Teva Neuroscience.
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