Should We Consider Deep Brain Stimulation Discontinuation in <scp>Late‐Stage</scp> Parkinson's Disease?
Margherita Fabbri, Maurizio Zibetti, Mario Giorgio Rizzone, Giulia Giannini, Linda Borellini, Alessandro Stefani, Francesco Bove, Andrea Bruno, Giovanna Calandra–Buonaura, Nicola Modugno, Carla Piano, Antonella Peppe, Gianluca Ardolino, Alberto Romagnolo, Carlo Alberto Artusi, Paola Berchialla, Elisa Montanaro, Pietro Cortelli, Luigi Romito, Roberto Eleopra, Brigida Minafra, Claudio Pacchetti, Tommaso Tufo, Filippo Cogiamanian, Leonardo Lopiano
Abstract
BACKGROUND: Subthalamic deep brain stimulation (STN-DBS) effects may decrease with Parkinson's disease (PD) progression. There is no indication if, when, and how to consider the interruption of DBS treatment in late-stage PD. The objective of the current study was to investigate the percentage of "poor stimulation responders" among late-stage PD patients for elaborating an algorithm to decide whether and when DBS discontinuation may be considered. METHODS: Late-stage PD patients (Hoehn Yahr stage ≥4 and Schwab and England Scale <50 in medication on/stimulation on condition) treated with STN-DBS for at least 5 years underwent a crossover, double-blind, randomized evaluation of acute effects of stimulation. Physicians, caregivers, and patients were blinded to stimulation conditions. Poor stimulation responders (MDS-UPDRS part III change <10% between stimulation on/medication off and stimulation off/medication off) maintained the stimulation off/medication on condition for 1 month for open-label assessment. RESULTS: Thirty-six patients were included. The acute effect of stimulation was significant (17% MDS-UPDRS part III), with 80% of patients classified as "good responders." Seven patients were classified as "poor stimulation responders," and the stimulation was switched off, but in 4 cases the stimulation was switched back "on" because of worsening of parkinsonism and dysphagia with a variable time delay (up to 10 days). No serious adverse effects occurred. CONCLUSIONS: The vast majority of late-stage PD patients (92%) show a meaningful response to STN-DBS. Effects of stimulation may take days to disappear after its discontinuation. We present a safe and effective decisional algorithm that could guide physicians and caregivers in making challenging therapeutic decisions in late-stage PD. © 2020 International Parkinson and Movement Disorder Society.