Anticoagulation management of myocardial infarction after deep brain stimulation: a comparison of two cases.

Deep brain stimulation (DBS) is an established treatment of various diseases, particularly used for idiopathic Parkinson's disease. Frequently, DBS patients are multimorbid and managing them may be challenging, since postoperative complications can become more likely with age. In this article, we present two cases of myocardial infarction after DBS with different therapeutic strategies. Case 1 was anticoagulated with a heparin infusion with a target partial thromboplastine time (PTT) between 50 and 60 s after the myocardial infarction and showed 3 days later, after an initial postoperative inconspicuous cranial computer tomography, an intracerebral haematoma, which was evacuated without explanting the DBS lead. Case 2 was only treated with enoxaparine 40 mg s.c. twice a day after the myocardial infarction without any further complications. Both cases benefited from the DBS with respect to the motor fluctuations, but case 1 continued to suffer from psychomotor slowdown, mild hemiparesis of the left side, visual neglect and a gaze paresis. Unfortunately, there are no established guidelines or therapy recommendations for the management of such patients. An individual therapy regime is necessary for this patient population regarding the bleeding risk, the cardial risk and the symptoms of the patient. Retrospectively, the rejection of the intravenous application of heparin in case 2 seems to be the right decision. But regarding the small number of cases, it remains still an individual therapy. Further experience will help us to develop optimal therapy strategies for this patient population.

A randomized trial of deep-brain stimulation for Parkinson's disease.

BACKGROUND: Neurostimulation of the subthalamic nucleus reduces levodopa-related motor complications in advanced Parkinson's disease. We compared this treatment plus medication with medical management. METHODS: In this randomized-pairs trial, we enrolled 156 patients with advanced Parkinson's disease and severe motor symptoms. The primary end points were the changes from baseline to six months in the quality of life, as assessed by the Parkinson's Disease Questionnaire (PDQ-39), and the severity of symptoms without medication, according to the Unified Parkinson's Disease Rating Scale, part III (UPDRS-III). RESULTS: Pairwise comparisons showed that neurostimulation, as compared with medication alone, caused greater improvements from baseline to six months in the PDQ-39 (50 of 78 pairs, P=0.02) and the UPDRS-III (55 of 78, P<0.001), with mean improvements of 9.5 and 19.6 points, respectively. Neurostimulation resulted in improvements of 24 to 38 percent in the PDQ-39 subscales for mobility, activities of daily living, emotional well-being, stigma, and bodily discomfort. Serious adverse events were more common with neurostimulation than with medication alone (13 percent vs. 4 percent, P<0.04) and included a fatal intracerebral hemorrhage. The overall frequency of adverse events was higher in the medication group (64 percent vs. 50 percent, P=0.08). CONCLUSIONS: In this six-month study of patients under 75 years of age with severe motor complications of Parkinson's disease, neurostimulation of the subthalamic nucleus was more effective than medical management alone. (ClinicalTrials.gov number, NCT00196911 [ClinicalTrials.gov].).

Immediate effects of deep brain stimulation of the subthalamic nucleus on nonmotor symptoms in Parkinson's disease.

OBJECTIVE: To assess the immediate effects of deep brain stimulation of the subthalamic nucleus (STN-DBS) on nonmotor symptoms (NMS) in Parkinson's disease (PD). BACKGROUND: Immediate effects of STN-DBS on motor functions are well accepted, but similar data on NMS are mainly lacking. METHODS: 34 PD patients who received bilateral STN-DBS were examined in medication Off state for frequency and severity of 10 NMS (dysphagia, anxiety, depression, fatigue, excessive sweating, inner restlessness, pain, concentration/attention, dizziness, bladder urgency) using a visual analogue scale (VAS) with STN-DBS Off and On. Motor assessments were done using UPDRS part III. RESULTS: Independent of STN-DBS status, most frequent NMS was fatigue (85% of patients), followed by problems with concentration/attention (71%) and inner restlessness (53%). Frequencies of most NMS were similar in both STN-DBS statuses, while only inner restlessness was significantly decreased by STN-DBS. Severities of most NMS were significantly improved by STN-DBS on the cohort level, while only excessive sweating, pain and dizziness did not show significant severity changes. However, variable proportions of patients (15-71%, depending on the NMS) reported relevant improvements (>10% on VAS) by STN-DBS with fatigue showing the largest proportion of patients with symptom improvement (71%). There were no correlations of severity changes of NMS with motor improvement, demographic data and medication. CONCLUSION: STN-DBS does not have major immediate effects on frequencies of NMS, but improves most NMS particularly psychiatric symptoms such as depression, anxiety and fatigue in a variable subset of patients. There is no indication that STN-DBS worsens NMS.