Patient selection for surgery: Parkinson s disease

Transcription

1 Patient selection for surgery: Parkinson s disease Dr. María C. Rodríguez-Oroz Neurology and Neuroscience. University Hospital Donostia, Research Institute BioDonostia, Ikerbasque Senior Researcher San Sebastian. Spain Santander. Noviembre 2016

2 Criteria for DBS PD motor complications: fluctuations severe dyskinesias tremor refractory to optimal medical treatment important enough (severity/duration) to justify surgical risk Intolerance to dopaminergic drugs

3 Factors assessed before surgery diagnosis, disease duration, age levodopa responsivenes: type and severity of levodopa-unresponsive symptoms cognitive and psychiatric issues comorbid disorders brain magnetic resonance imaging (MRI)

4 CAPSIT-PD protocol PD: duration of at least 5 years Age: no specific age cutoff 70 y.o. Older: individual evaluation of risk-benefit ratio (comorbidities, cognitive state, prevalence levodopa-resistant symptoms and severity, overall risk of surgical complications) Unilateral GPi

5 Pre-operative L-dopa responsiveness: L-dopa challenge (150%) of the first dose in the morning, in the defined Off state (12 h without dopaminergic treatment) At least a 33% decrease in the UPDRS- III score L-dopa-resistant features: gait and balance, dysarthria, dysphagia, usually do not improve or may even worsen after DBS. Careful evaluation at the peak of optimal L- dopa benefit. Careful weighing of residual disability, and risks Tremor is an exception.

6 Cognitive evaluation Dementia is an absolute contraindication for surgery. There are no clear recommendations regarding mild cognitive impairment.

7 Motor outcome of PD patients with and without MCI No differences between the two groups Merola et al, J Neurol 2014

8 Cognitive outcome of PD patients with and without MCI No patient became demented after 1 year Merola et al, J Neurol 2014

9 Predictors of dementia and mortality Merola et al, J Neurol 2014

10 Abboud et al, Park and Related disoders, 2015

11 Psychiatric evaluation Unstable psychiatric conditions (depression and psychosis): deffered surgery until they improve. Severe depression with suicidal ideation is an absolute contraindication GPi may be safer than STN for patients with either mild cognitive or behavioural issues

12 Physical condition Serious comorbidities: contraindication to DBS (bad risk-benefit ratio) preoperative MRI: Aside from obvious structural lesions, imaging findings alone should not be considered absolute contraindications to DBS Severe cortical atrophy increases the risk of postoperative subdural hematomas. extensive atrophy and cerebral vasculopathy: conclusive data are lacking.

13 Expectations and social support Careful weighing of expected benefits Change in PDQ-39 domain scores and satisfaction Hasegawa et al, World Neurosurg 2014

14 Relationship between expected change and actual change in PDQ-39 scores Relationship between expectations and satisfaction Hasegawa et al, World Neurosurg 2014

15 Expectations and social support Careful weighing of expected benefits Careful evaluation of personal, professional, and social issues is fundamental. A great amount of cooperation and motivation from patients and caregivers is needad before, during and after surgery. The absence of a solid support from a caregiver should be considered a reason to preclude DBS.

16 When PD with motor complications should be considered for DBS? PD with motor complications refractory to optimal medical treatment important enough (severity/duration) to justify surgical risk. When is this? At the beginning of motor complications or after having tried been all/many other pharmacological strategies? Considering surgery sooner in the course of the disease would prevent or delay motor, social, and psychological disability.

17 Randomized STN 124 BMT years Blinded assessment Schuepbach NEMJ 2013

18 STN Schuepbach NEMJ 2013

19 Impulse control disorders

20 Rodríguez-Oroz et al, Brain, 2011 ICD, was suppressed in six patients, improved in three and unchanged in one. UPDRS-III reduction in off =69.8% Thobois et al, Brain, 2011

21 Impulse control behaviors and subthalamic deep brain stimulation in Parkinson disease. Merola et al. J Neurol Over an average follow-up of 4.3 ± 2.1 years of chronic STN-DBS there was an overall trend for reduction in ICBs (from 17.3 to 12.7 %; p = 0.095) with significant improvement in hypersexuality ( %; p = 0.047), gambling ( %; p = 0.033), and DDS (4.7-0 %; p < 0.001). ICB remitted in 18/26 patients (69 %) and persisted in 8/26 (31 %); the latter group was characterized by higher levodopa equivalent daily dose.

22 Multidisciplinary team experienced in DBS movement disorders specialist neurosurgeon neuropsychologist Psychiatrist neuroradiologist nurses

23 Conclusions Best results in patients with excellent L -Dopa response, younger age, no or few axial non-l -Dopa-responsive motor signs, no or very mild cognitive impairment. Psichiatric comorbidites have to be controlled before surgery. Adequacy of expections to the real outcomes, personal features of the patient and social support favor a better outcome. A thorough and personalized evaluation of the riskbenefit by a specialized multidisciplinary team is mandatory in all cases