Deep Brain Stimulation

Alfonso Fasano, MD, PhD

Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson’s Disease, Toronto Western Hospital and Division of Neurology, University of Toronto, Toronto, Ontario, Canada, Krembil Research Institute, Toronto, Ontario, Canada.

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Abstract: Deep brain stimulation has become widely accepted as a treatment for Parkinson's disease (PD), dystonia and tremor, and as an off-label treatment for many other movement disorders. In recent years, new official indications have been approved: obsessive-compulsive disorder and focal epilepsy with secondary generalization.
This field is expanding exponentially in two not mutually exclusive fields: clinical and technological. Clinically, we have achieved a deeper understanding of outcomes, thus facilitating the process of target and patient selection. In fact, we have gained a better understanding of established indications, particularly with respect to the debate on whether subthalamus or globus pallidus pars interna should be the target of choice for PD. In addition, the role of DBS for treating dystonia has been further defined in terms of patient selection and surgical outcome. Other established (e.g. essential tremor, epilepsy) and novel indications (e.g. Tourette syndrome) have been addressed as well. Finally, recent technological advantages in neuromodulation have opened new avenues towards new targets and indications.
Key Words: Deep brain stimulation, movement disorders, Parkinson's disease, tremor, dystonia.

Deep brain stimulation (DBS) is an established neuromodulation technique made possible by the neurosurgical placement of electrodes which deliver a mild electrical current to stimulate areas in the deep brain.
DBS has become widely accepted as a treatment for Parkinson's disease (PD), dystonia and tremor, and as an off-label treatment for many other movement disorders.
We have gained a better understanding of established indications, particularly with respect to the debate on whether subthalamus or globus pallidus pars interna should be the target of choice for PD.
In recent years, new official indications have been approved: obsessive-compulsive disorder and focal epilepsy with secondary generalization.
The advance of neuromodulation technologies has provided clinicians with new tools making targeting, programming, and overall management easier.
Nevertheless, we still fail to have reliable methods predicting the surgical outcome even in established indications, such as epilepsy or dystonia. In fact, the surgical outcome always relies on patient selection, which is mainly driven by the trade off between surgical risk and expected benefits.
DBS cannot cure or change the progression of the disease but it can help relieve symptoms and improve quality of life.
In PD, DBS can help symptoms that respond to levodopa with two exceptions: speech responds to levodopa, but does not usually improve with DBS (and might get worse) whereas tremor not responding to levodopa improves with DBS.
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This article was published as part of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource. The development of Managing the Health of Your Aging Patient: Therapies that Could Help Improve Quality of Life eCME resource was supported by an educational grant from Medtronic Canada.