Indication and Selection of Deep Brain Stimulation and Other Device Therapies in the Treatment of Advanced Parkinson's Disease

Abstract

  Parkinson's disease (PD) is a progressive neurodegenerative disease characterized by dopamine deficiency in the substantia nigra of the midbrain and resultant motor symptoms such as akinesia, rigidity, and tremor. As the disease progresses, motor complications including the wearing-off phenomenon and dyskinesia appear. This stage is referred to as the advanced stage. Surgical treatment and device therapy are options for treating advanced PD refractory to medication treatment. Deep brain stimulation (DBS) is a well-established treatment strategy that improves motor symptoms and quality of life for patients with advanced PD. DBS devices have undergone upgrades, expanding therapeutic options available. These include directional lead systems with fine control settings, stimulus generators with independent constant current settings, sensing technology to record local field potentials (LFP) through DBS electrodes in the target brain region, and adaptive DBS with automatic stimulation adjustment based on LFP. Device therapies for continuous drug delivery are also advancing. Levodopa-carbidopa intestinal gel therapy can improve motor symptoms but requires the patient to undergo a gastrostomy. New options such as continuous subcutaneous injections of foslevodopa and foscarbidopa have been approved, allowing for easier use of device therapy. Each therapy has its own advantages and disadvantages and is recommended based on a patient's specific clinical profile. Therefore, the most appropriate therapy should be selected after evaluating clinical profiles.