Deep brain stimulation for Parkinson's disease: surgical technique and perioperative management.
Deep brain stimulation (DBS) is a widely accepted therapy for medically refractory Parkinson's disease (PD). Both globus pallidus internus (GPi) and subthalamic nucleus (STN) stimulation are safe and effective in improving the symptoms of PD and reducing dyskinesias. STN DBS is the most commonly performed surgery for PD as compared to GPi DBS. Ventral intermediate nucleus (Vim) DBS is infrequently used as an alternative for tremor predominant PD patients. Patient selection is critical in achieving good outcomes. Differential diagnosis should be emphasized as well as neurological and nonneurological comorbidities. Good response to a levodopa challenge is an important predictor of favorable long-term outcomes. The DBS surgery is typically performed in an awake patient and involves stereotactic frame application, CT/MRI imaging, anatomical targeting, physiological confirmation, and implantation of the DBS lead and pulse generator. Anatomical targeting consists of direct visualization of the target in MR images, formula-derived coordinates based on the anterior and posterior commissures, and reformatted anatomical stereotactic atlases. Physiological verification is achieved most commonly via microelectrode recording followed by implantation of the DBS lead and intraoperative test stimulation to assess benefits and side effects. The various aspects of DBS surgery will be presented.
Machado
Andre
A
Center for Neurological Restoration, Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. machada@ccf.org
Rezai
Ali R
AR
Kopell
Brian H
BH
Gross
Robert E
RE
Sharan
Ashwini D
AD
Benabid
Alim-Louis
AL
D000978:Antiparkinson Agents / Q000627:therapeutic use; D001921:Brain / Q000033:anatomy & histology / Q000601:surgery; D001931:Brain Mapping / Q000379:methods; D046690:Deep Brain Stimulation / Q000379:methods*; D003937:Diagnosis, Differential; D004567:Electrodes, Implanted; D007839:Functional Laterality / Q000502:physiology; D006801:Humans; D007980:Levodopa / Q000627:therapeutic use; D008279:Magnetic Resonance Imaging; D019635:Neurosurgical Procedures / Q000379:methods*; D010300:Parkinson Disease / Q000175:diagnosis / Q000188:drug therapy / Q000628:therapy*; D018579:Patient Selection; D011182:Postoperative Care; D011300:Preoperative Care; D013238:Stereotaxic Techniques
D000978:Antiparkinson Agents; D007980:Levodopa