Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease.
BACKGROUND
Deep-brain stimulation is the surgical procedure of choice for patients with advanced Parkinson's disease. The globus pallidus interna and the subthalamic nucleus are accepted targets for this procedure. We compared 24-month outcomes for patients who had undergone bilateral stimulation of the globus pallidus interna (pallidal stimulation) or subthalamic nucleus (subthalamic stimulation).


METHODS
At seven Veterans Affairs and six university hospitals, we randomly assigned 299 patients with idiopathic Parkinson's disease to undergo either pallidal stimulation (152 patients) or subthalamic stimulation (147 patients). The primary outcome was the change in motor function, as blindly assessed on the Unified Parkinson's Disease Rating Scale, part III (UPDRS-III), while patients were receiving stimulation but not receiving antiparkinsonian medication. Secondary outcomes included self-reported function, quality of life, neurocognitive function, and adverse events.


RESULTS
Mean changes in the primary outcome did not differ significantly between the two study groups (P=0.50). There was also no significant difference in self-reported function. Patients undergoing subthalamic stimulation required a lower dose of dopaminergic agents than did those undergoing pallidal stimulation (P=0.02). One component of processing speed (visuomotor) declined more after subthalamic stimulation than after pallidal stimulation (P=0.03). The level of depression worsened after subthalamic stimulation and improved after pallidal stimulation (P=0.02). Serious adverse events occurred in 51% of patients undergoing pallidal stimulation and in 56% of those undergoing subthalamic stimulation, with no significant between-group differences at 24 months.


CONCLUSIONS
Patients with Parkinson's disease had similar improvement in motor function after either pallidal or subthalamic stimulation. Nonmotor factors may reasonably be included in the selection of surgical target for deep-brain stimulation. (ClinicalTrials.gov numbers, NCT00056563 and NCT01076452.)
Follett
Kenneth A
KA
Iowa City Veterans Affairs Medical Center, Iowa City, USA.
Weaver
Frances M
FM
Stern
Matthew
M
Hur
Kwan
K
Harris
Crystal L
CL
Luo
Ping
P
Marks
William J
WJ
Rothlind
Johannes
J
Sagher
Oren
O
Moy
Claudia
C
Pahwa
Rajesh
R
Burchiel
Kim
K
Hogarth
Penelope
P
Lai
Eugene C
EC
Duda
John E
JE
Holloway
Kathryn
K
Samii
Ali
A
Horn
Stacy
S
Bronstein
Jeff M
JM
Stoner
Gatana
G
Starr
Philip A
PA
Simpson
Richard
R
Baltuch
Gordon
G
De Salles
Antonio
A
Huang
Grant D
GD
Reda
Domenic J
DJ
D000203:Activities of Daily Living; D000368:Aged; D003071:Cognition; D004599:Electric Stimulation Therapy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D005917:Globus Pallidus; D006801:Humans; D057194:Intention to Treat Analysis; D008297:Male; D008875:Middle Aged; D009048:Motor Skills; D010300:Parkinson Disease / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D011788:Quality of Life; D020531:Subthalamic Nucleus; D016896:Treatment Outcome