Deep brain stimulation in Parkinson’s disease: state of the art and future perspectives

ABSTRACT For more than 30 years, Deep Brain Stimulation (DBS) has been a therapeutic option for Parkinson’s disease (PD) treatment. However, this therapy is still underutilized mainly due to misinformation regarding risks and clinical outcomes. DBS can ameliorate several motor and non-motor symptoms, improving patients’ quality of life. Furthermore, most of the improvement after DBS is long-lasting and present even in advanced PD. Adequate patient selection, precise electric leads placement, and correct DBS programming are paramount for good surgical outcomes. Nonetheless, DBS still has many limitations: axial symptoms and signs, such as speech, balance and gait, do not improve to the same extent as appendicular symptoms and can even be worsened as a direct or indirect consequence of surgery and stimulation. In addition, there are still unanswered questions regarding patient’s selection, surgical planning and programming techniques, such as the role of surgicogenomics, more precise imaging-based lead placement, new brain targets, advanced programming strategies and hardware features. The net effect of these innovations should not only be to refine the beneficial effect we currently observe on selected symptoms and signs but also to improve treatment resistant facets of PD, such as axial and non-motor features. In this review, we discuss the current state of the art regarding DBS selection, implant, and programming, and explore new advances in the DBS field.

摘要 三十余年来，脑深部电刺激（Deep Brain Stimulation, DBS）一直是帕金森病（Parkinson’s disease, PD）的临床治疗选择之一。然而，该疗法的临床应用仍未得到充分推广，其核心诱因在于公众对其风险与临床结局存在认知误区。DBS可有效改善多种运动与非运动症状，提升患者的生活质量。此外，DBS术后的症状改善大多持久稳定，即便在晚期帕金森病患者中仍可显现。严格的患者筛选、精准的电极植入定位以及正确的DBS程控参数设置，是获得良好手术预后的关键前提。尽管如此，DBS仍存在诸多局限：诸如言语、平衡与步态异常等轴性症状的改善程度远不及肢体症状，甚至可能因手术与刺激的直接或间接作用而加重。此外，在患者筛选、手术规划与程控技术领域仍存在诸多未解决的问题，例如外科基因组学（surgicogenomics）的临床作用、更精准的基于影像学的电极植入定位技术、新型脑靶点、先进的程控策略以及硬件特性优化等。上述创新的最终目标，不应仅局限于优化当前针对特定症状的治疗效果，还应攻克帕金森病中对治疗抵抗的症状维度，例如轴性症状与非运动症状。在本综述中，我们将探讨DBS在患者筛选、植入手术与程控环节的当前研究前沿，并梳理该领域的最新进展。