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November 07, 2017; 89 (19) Article

Clinical outcomes of asleep vs awake deep brain stimulation for Parkinson disease

Matthew A. Brodsky, Shannon Anderson, Charles Murchison, Mara Seier, Jennifer Wilhelm, Aaron Vederman, Kim J. Burchiel
First published October 6, 2017, DOI: https://doi.org/10.1212/WNL.0000000000004630
Matthew A. Brodsky
From the Departments of Neurology (M.A.B., S.A., C.M., M.S., J.W.) and Neurosurgery (A.V., K.J.B.), Oregon Health & Science University, Portland.
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Shannon Anderson
From the Departments of Neurology (M.A.B., S.A., C.M., M.S., J.W.) and Neurosurgery (A.V., K.J.B.), Oregon Health & Science University, Portland.
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Charles Murchison
From the Departments of Neurology (M.A.B., S.A., C.M., M.S., J.W.) and Neurosurgery (A.V., K.J.B.), Oregon Health & Science University, Portland.
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Mara Seier
From the Departments of Neurology (M.A.B., S.A., C.M., M.S., J.W.) and Neurosurgery (A.V., K.J.B.), Oregon Health & Science University, Portland.
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Jennifer Wilhelm
From the Departments of Neurology (M.A.B., S.A., C.M., M.S., J.W.) and Neurosurgery (A.V., K.J.B.), Oregon Health & Science University, Portland.
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Aaron Vederman
From the Departments of Neurology (M.A.B., S.A., C.M., M.S., J.W.) and Neurosurgery (A.V., K.J.B.), Oregon Health & Science University, Portland.
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Kim J. Burchiel
From the Departments of Neurology (M.A.B., S.A., C.M., M.S., J.W.) and Neurosurgery (A.V., K.J.B.), Oregon Health & Science University, Portland.
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Citation
Clinical outcomes of asleep vs awake deep brain stimulation for Parkinson disease
Matthew A. Brodsky, Shannon Anderson, Charles Murchison, Mara Seier, Jennifer Wilhelm, Aaron Vederman, Kim J. Burchiel
Neurology Nov 2017, 89 (19) 1944-1950; DOI: 10.1212/WNL.0000000000004630

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Abstract

Objective: To compare motor and nonmotor outcomes at 6 months of asleep deep brain stimulation (DBS) for Parkinson disease (PD) using intraoperative imaging guidance to confirm electrode placement vs awake DBS using microelectrode recording to confirm electrode placement.

Methods: DBS candidates with PD referred to Oregon Health & Science University underwent asleep DBS with imaging guidance. Six-month outcomes were compared to those of patients who previously underwent awake DBS by the same surgeon and center. Assessments included an “off”-levodopa Unified Parkinson’s Disease Rating Scale (UPDRS) II and III, the 39-item Parkinson's Disease Questionnaire, motor diaries, and speech fluency.

Results: Thirty participants underwent asleep DBS and 39 underwent awake DBS. No difference was observed in improvement of UPDRS III (+14.8 ± 8.9 vs +17.6 ± 12.3 points, p = 0.19) or UPDRS II (+9.3 ± 2.7 vs +7.4 ± 5.8 points, p = 0.16). Improvement in “on” time without dyskinesia was superior in asleep DBS (+6.4 ± 3.0 h/d vs +1.7 ± 1.2 h/d, p = 0.002). Quality of life scores improved in both groups (+18.8 ± 9.4 in awake, +8.9 ± 11.5 in asleep). Improvement in summary index (p = 0.004) and subscores for cognition (p = 0.011) and communication (p < 0.001) were superior in asleep DBS. Speech outcomes were superior in asleep DBS, both in category (+2.77 ± 4.3 points vs −6.31 ± 9.7 points (p = 0.0012) and phonemic fluency (+1.0 ± 8.2 points vs −5.5 ± 9.6 points, p = 0.038).

Conclusions: Asleep DBS for PD improved motor outcomes over 6 months on par with or better than awake DBS, was superior with regard to speech fluency and quality of life, and should be an option considered for all patients who are candidates for this treatment.

Clinicaltrials.gov identifier: NCT01703598.

Classification of evidence: This study provides Class III evidence that for patients with PD undergoing DBS, asleep intraoperative CT imaging–guided implantation is not significantly different from awake microelectrode recording–guided implantation in improving motor outcomes at 6 months.

GLOSSARY

ADL=
activities of daily living;
COWAT=
Controlled Oral Word Association Test;
DBS=
deep brain stimulation;
DRS-2=
Mattis Dementia Rating Scale–Second Edition;
GPi=
globus pallidus pars interna;
ICH=
intracerebral hemorrhage;
iCT=
intraoperative CT imaging;
iMRI=
intraoperative MRI;
MER=
microelectrode recording;
NSQIP=
National Surgical Quality Improvement Program;
OHSU=
Oregon Health & Science University;
OLS=
ordinary least squares;
PD=
Parkinson disease;
PDQ-39=
39-item Parkinson's Disease Questionnaire;
STN=
subthalamic nucleus;
UPDRS=
Unified Parkinson’s Disease Rating Scale

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Editorial, page 1938

  • Received April 21, 2017.
  • Accepted in final form August 4, 2017.
  • © 2017 American Academy of Neurology
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Disputes & Debates: Rapid online correspondence

  • Author response to Troster: Clinical outcomes of asleep vs awake deep brain stimulation for Parkinson disease
    • Matthew A Brodsky, Associate Professor of Neurology, Oregon Health & Science University
    Submitted March 16, 2018
  • Editorialist response to Dr. Sidiropoulos
    • Tipu Z. Aziz, Professor of Neurosurgery, John Radcliffe Hospital (Oxford, United Kingdom)
    Submitted January 23, 2018
  • RE: Clinical outcomes of asleep vs awake DBS for PD
    • Christos Sidiropoulos, Movement Disorders Neurologist, Assistant Professor of Neurology, Michigan State University
    Submitted December 17, 2017
  • Is verbal fluency really better after asleep DBS?
    • Alexander I. Troster, Professor and Chair, Department of Clinical Neuropsychology, Barrow Neurological Institutealexander.troster@dignityhealth.org
    Submitted November 21, 2017
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