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Review
. 2022 May;80(5 Suppl 1):105-115.
doi: 10.1590/0004-282X-ANP-2022-S133.

Deep brain stimulation in Parkinson's disease: state of the art and future perspectives

Carina França  1 , Rafael Bernhart Carra  1 , Juliete Melo Diniz  2 , Renato Puppi Munhoz  3 , Rubens Gisbert Cury  1
Affiliations
Review

Deep brain stimulation in Parkinson's disease: state of the art and future perspectives

Carina França et al. Arq Neuropsiquiatr. 2022 May.

Abstract
in English, Portuguese

For more than 30 years, Deep Brain Stimulation (DBS) has been a therapeutic option for Parkinson's disease (PD) treatment. However, this therapy is still underutilized mainly due to misinformation regarding risks and clinical outcomes. DBS can ameliorate several motor and non-motor symptoms, improving patients' quality of life. Furthermore, most of the improvement after DBS is long-lasting and present even in advanced PD. Adequate patient selection, precise electric leads placement, and correct DBS programming are paramount for good surgical outcomes. Nonetheless, DBS still has many limitations: axial symptoms and signs, such as speech, balance and gait, do not improve to the same extent as appendicular symptoms and can even be worsened as a direct or indirect consequence of surgery and stimulation. In addition, there are still unanswered questions regarding patient's selection, surgical planning and programming techniques, such as the role of surgicogenomics, more precise imaging-based lead placement, new brain targets, advanced programming strategies and hardware features. The net effect of these innovations should not only be to refine the beneficial effect we currently observe on selected symptoms and signs but also to improve treatment resistant facets of PD, such as axial and non-motor features. In this review, we discuss the current state of the art regarding DBS selection, implant, and programming, and explore new advances in the DBS field.

Há mais de 30 anos, a Estimulação Cerebral Profunda (ECP) é uma opção de tratamento para pessoas com doença de Parkinson (DP). Apesar disso, a ECP ainda é subutilizada, em grande parte por desinformação acerca dos riscos e dos benefícios desse tratamento. A ECP melhora os sintomas motores e não motores da DP, melhorando, assim, a qualidade de vida dos pacientes. Grande parte dos benefícios gerados pela ECP têm longa duração, estando presentes até mesmo em fases avançadas da doença. A seleção adequada dos pacientes, o preciso posicionamento dos eletrodos cerebrais, e a programação correta da ECP são fundamentais para que haja benefício após a cirurgia. Todavia, existem ainda muitas limitações em relação ao tratamento com ECP. Sintomas axiais, como fala e marcha, não melhoram tanto quanto os sintomas apendiculares, e podem até mesmo piorar após a cirurgia. Existem muitas dúvidas relacionadas à seleção de pacientes, especialmente nos aspectos de imagem e genética. Em relação à questão cirúrgica, novas técnicas de imagem podem auxiliar o posicionamento correto dos eletrodos cerebrais. Novas estratégias de programação e avanços de hardware podem melhorar desfechos que ainda são limitados. A fim de melhorar sintomas resistentes à ECP, como cognição e marcha, novos alvos cerebrais estão sendo explorados. Na presente revisão, discutimos o atual estado da arte relacionado à ECP, abordando seleção de pacientes, implante cirúrgico de eletrodos, e programação do dispositivo, além de explorarmos novos avanços em desenvolvimento.

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Conflict of interest statement

Conflict of interest: There is no conflict of interest to declare.

Figures

Figure 1.
Figure 1.. Three-dimensional reconstruction of DBS electrodes in bilateral dentate nucleus - Dentatorubrothalamic Tract was reconstructed and used to refine lead position. The 3D reconstructions and tractographies were performed with Elements software (Brainlab AG, Germany)
Figure 2.
Figure 2.. Three-dimensional reconstruction of DBS electrodes using an open-source software.
Figure 3.
Figure 3.. A. Three-dimensional reconstruction of DBS leads exposing bilateral Volume of Tissue Activated in red. Reconstruction performed with Lead DBS software. B. Three-dimensional reconstruction of DBS lead evidencing Volume of Tissue Activated in red. Reconstruction performed with Elements software-Guide XT.
Figure 4.
Figure 4.. Exploratory stimulation patterns A. conventional DBS, B. Burst-Cycling DBS, C. Variable frequency DBS, and D. Interleaving DBS. Adapted from Wong JK, Hu W, Barmore R, Lopes J, Moore K, Legacy J, et al. Safety and Tolerability of Burst-Cycling Deep Brain Stimulation for Freezing of Gait in Parkinson’s Disease. Front Hum Neurosci. 2021 Apr 26;15:651168.
See this image and copyright information in PMC

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