Brain, Vol 121, Issue 3 451-457, Copyright © 1998 by Oxford University Press
P Krack, P Pollak, P Limousin, D Hoffmann, J Xie, A Benazzouz and AL Benabid
The aim of this study was to compare, retrospectively, the value of chronic
bilateral stimulation of the internal globus pallidus (GPi) and the
subthalamic nucleus (STN) in patients with young onset Parkinson's disease.
We selected 13 consecutive patients with similar characteristics at the
time of surgery: age at onset < 40 years, disabling motor fluctuations
(Hoehn and Yahr stage 4 or 5 in off-drug phases) and levodopa-induced
dyskinesias (LID). Eight patients were operated on in the STN and five in
the GPi. The Unified Parkinson's Disease Rating Scale (UPDRS), timed motor
tests and a LID scale were compared in on- and off-drug conditions before
surgery and 6 months after surgery on stimulation using the chronic
electrical parameters found to improve best the motor state of the
individual patient, without adverse effects. In off-drug phases, the motor
score of the UPDRS was improved by 71% with STN stimulation and by 39% with
GPi stimulation on average. This difference was statistically significant
(P < 0.05). Whereas rigidity and tremor showed good improvement in both
groups, the decrease in the akinesia score was more pronounced in the STN
group. In the STN group, the improvement of all motor symptoms was very
close, or equal, to the best levodopa response. Thus the levodopa test was
predictive of outcome. The improvement in off-drug period motor handicap
allowed a decrease in the levodopa-equivalent dose only in the STN group
(-56%). The voltage, frequency and pulse width used for chronic stimulation
were lower in the STN group. In the on-drug phases there was a marked
improvement in LID in the GPi group, as measured by the dyskinesias score
during an acute levodopa test, whereas there was only a small decrease in
the STN group (P < 0.05). However, in the long term, the reduction of
levodopa dosage in the STN group led to an indirect reduction of LID
similar to that in the GPi group during activities of everyday life. In
conclusion, the overall results favour the neurosurgical treatment of
Parkinson's disease by stimulating the STN rather than the GPi.
ARTICLES
Subthalamic nucleus or internal pallidal stimulation in young onset Parkinson's disease
Department of Clinical and Biological Neurosciences, Joseph Fourier University of Grenoble, France.
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