Surgical Treatment of

Parkinson Disease
Dr. Humberto González
Introduction
Motor symptoms of Parkinson disease are typically managed with dopaminergic
agents

As the disease progresses, maximum medical management often proves

inadequate because of development of

Medication-refractory symptoms

Motor fluctuations

Medication-induced side effects

 INDICATIONS FOR SURGICAL
TREATMENT OF PARKINSON DISEASE
• High degree of diagnostic certainly is important.

• Atypical parkinsonian syndromes can mimic PD in their early stages

• Outcomes of reported cases of DBS for atypical parkinsonism have been

poor
INDICATIONS FOR SURGICAL
TREATMENT OF PARKINSON DISEASE
• Patients deally meet several criteria to be considered surgical candidates.

• Both surgical lesions and DBS improve medication “on” time and reduce
dyskinesia

• Clinicians may consider surgery for patients

Patients with motor fluctuations characterized by disabling “off” periods

Functionally indepent “on” periods

INDICATIONS FOR SURGICAL
TREATMENT OF PARKINSON DISEASE
• An improvement of at least 30% on the UPDRS III is a common
minimum cutoff for surgery

• levodopa- nonresponsive symptoms are not expected to improve with

surgery
 INDICATIONS FOR SURGICAL
TREATMENT OF PARKINSON DISEASE

• Exceptions to these criteria….

• Medication-limiting side effects such as excessive

nausea, brittle dyskinesia, and dystonia
• Previously shown levodopa responsiveness
 The goal of DBS in earlier stages of PD is
extension of high-functioning status as opposed
to more of a rescue therapy in later stages.
Contraindicatons
• The most notable contraindication for surgery in
PD is dementia.

• Some degree of cognitive impairment is nearly

ubiquitous in PD

• Careful historyt aking, serial patient examinations

in both on-medication and off-medication states,
and self-reporting tools
 Contraindicatons
• Outcomes are generally poor in patients with dementia, and in some cases a worsening
of cognition can occur

• Severe gait issues with prominent postural instability are also a relative contraindication
to surgery

• Patients with higher axial parkinsonism motor scores in the on-medication state show
less improvement with DBS
Contraindicatons
• Clinicians must carefully assess
patient expectations

• One strategy is to ask the

patients their top 3 reasons for
DBS

• Support at home and geographic

access to specialists
TARGETED LESIONS FOR PARKINSON
DISEASE
• Surgical lesions with thermal pallidotomies and thalamotomies for complications
of PD were first performed in the 1950s

• Lesioning procedures were put out of favor with the emergence of deep brain
stimulation

• Were limited to palliative use for patients who were deemed poor DBS candidates.

• Modern technology with use of direct image guidance and techniques that do not
require craniotomy have led to a revival of surgical lesions as a treatment option
for PD.
Gamma Knife
• Gamma Knife radiosurgery has received
mixed outcomes in recent years

• Dosing protocol to the VIM thalamus,

several groups have reported significant
improvement in tremor with minimal side
effects

• Results from Gamma Knife pallidotomy

are overall poor
Focused ultrasonography –FUS-
• Patients are placed in a stereotactic head frame with a mounted,
MRI-compatible ultrasound transducer.

• Ultrasonic energy is gradually increased to ablation temperatures at

the target

• Results have been positive in essential tremor,and exploratory studies

in PD are ongoing.

• Unilateral FUS thalamotomy in tremor-dominant PD has proved safe

and effective at tremor reduction

• Preliminary studies for PD complicated by dyskinesia has revealed

improved motor scores off medication
DEEP BRAIN STIMULATION
Increased daily
• DBS is the standard of care for appropriate “on” time without
candidates with PD. dyskinesia

• Accurate surgical placement of stimulating Improved quality

electrodes, in the motor STN or globus of life
pallidus pars interna GPi

• Several surgical techniques exist for DBS lead Reduced motor

placement disability
 Basal Ganglia Target Selection

• The ideal DBS brain target (STN or GPi) selection in PD surgery is still
debated

Some studies have shown greater improvement in

Other studies howed no differences in overall
secondary outcomes of off-medication motor
motor outcomes between the targets
disabilit and bradykinesia with STN stimulation
Basal Ganglia Target Selection
• Possible cognitive and mood side effects are often
considered

• Greater decline in visuomotor processing speed, verbal

fluency, and dementia rating scores may occur after STN

• Adverse mood effects of increased anger as well as

stimulation-induced impulsivity have both been reported
after STN

• consideration of preoperative mood and cognition as part

of a thorough neuropsychiatric evaluation
Basal Ganglia Target Selection
• STN DBS results in a greater reduction in
dopaminergic medications compared with GPi
DBS.

• Patients receiving nonmotor mood benefits from

medication may be better candidates for GPi
stimulation.

• The medication reduction offered by STN

stimulation is preferred for patients with
medication- limiting complication
Basal Ganglia Target Selection
• The VIM thalamus is occasionally targeted for tremor-dominant PD

• Unilateral VIM DBS can be considered because of possible lower risk

of cognitive side effectsand hemorrhage and overall ease of surgery
 Novel targets
• Levodopa-refractory freezing of gait does not respond well to
traditional targets and has prompted exploration of novel
targets.

• Pedunculopontine nucleus DBS results have been mixed

• Overall modest improvement in freezing of gait but with
variability in response

• Dorsal cord stimulation is currently under investiga tion as a

less invasive option for refractory gait symptoms in PD.
 Surgical Complications
Hemorrhage
• It is important to understand common
complications of DBS to guide informed consent
and determine ways to mitigate risks

• Cerebral hemorrhage, the most devastating

complication, has an overall reported incidence
etween 0.5% and 3.3% per lead

• Permanent neurologic deficits from hemorrhage

are less patients
Surgical Complications
Infection
• Infection of DBS hardware often requires at
least partial device removal and loss of
therapy

• The largest studies show infection rates

between 2.2% and 4.5 %

• Older devices are particularly predisposed

Programming Techniques/Hardware Choices
• DBS programming is the determination of optimal settings for a given
patient

• Using standard quadripolar DBS leads, clinicians typically perform

initial programming by assessing benefit for motor symptoms

Tremor

Rigidity

Bradykinesia
Electrical stimulation
Electrical stimulation
Electrical stimulation

There are over 25,000 possible combinations of programming parameters

Programming Techniques/Hardware Choices
• The vast increase in permutations of DBS settings with newer devices
creates a greater need for technology to assist programmers

• Database-driven, probabilistic, image-guided programming software

may ultimately assist in choosing

• Volume of tissue activation and tractography methods may guide

novel programming algorithms