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BACKGROUND Subthalamic nucleus (STN) and globus pallidus interna (GPi) are the most effective targets in deep brain stimulation (DBS) treatment for Parkinson disease (PD). However, the individualized selection of targets remains a clinical challenge. OBJECTIVE To combine unilateral STN and contralateral GPi stimulation (STN DBS in one brain hemisphere and GPi DBS in the other) to maximize the clinical advantages of each target while inducing fewer adverse side effects in selected patients with PD because each target has its own clinical effects and risk profiles. METHODS We reviewed the clinical outcomes of 8 patients with idiopathic PD treated with combined unilateral STN and contralateral GPi DBS. Clinical outcome assessments, focusing on motor and nonmotor symptoms, were performed at baseline and 6-mo and 12-mo follow-up. We performed the assessments under the following conditions: medication on and off (bilateral stimulation on and off and unilateral STN stimulation on). RESULTS Patients showed a significant improvement in motor symptoms, as assessed by the Unified Parkinson Disease Rating Scale III (UPDRS-III) and Timed Up-and-Go Test (TUG), in the off-medication/on-stimulation state at 6-mo and 12-mo follow-up. Also, patients reported a better quality of life, and their intake of levodopa was reduced at 12-mo follow-up. In the on-medication condition, bilateral stimulation was associated with an improvement in axial symptoms, with a 64% improvement in measures of gait and falls at 12-mo follow-up. No irreversible adverse side effects were observed. CONCLUSION Our findings suggest that combined unilateral STN and contralateral GPi DBS could offer an effective and well-tolerated DBS treatment for certain PD patients., Graphical Abstract Graphical Abstract

Background and importance Primary generalized dystonia (PGD) is a genetic form of dystonia that frequently displays pharmacological resistance and progresses quickly after onset. Deep brain stimulation (DBS) has been used successfully to treat refractory dystonia, specifically globus pallidus interna (GPi) DBS for DYT1-positive PGD patients. Long-term follow-up of the safety and efficacy falls short of the longevity seen in other diseases treated with DBS. Case presentation A male patient presented for neurosurgical evaluation with scapular winging, hand contractures, and violent truncal spasms, which forced him to be bedridden. After failing conservative therapy, the 18-yr-old patient was implanted with bilateral GPi-DBS. DBS parameter adjustments were made primarily within the first 3 yr after implantation, with nominal changes thereafter. Initial settings were contact of 3 + 0-, amplitude of 4.9 V, frequency of 185 Hz, and pulse width of 270 μsec on the left and 3 + 0-, 2.8 V, 185 Hz, and 120 μsec on the right. Current settings are 3 + 2 + 1-, 5.2 V, 130 Hz, 330 μsec on the left and 3 + 0-, 3.5 V, 185 Hz, and 180 μsec on the right and have been relatively unchanged in the past 4 yr. Unified dystonia rating scale scores reveal a significant decrease in dystonic symptoms. Conclusion While prior reports have shown that GPi-DBS is effective for dystonia, this is the first with 15 yr of long-term follow-up showing disease stabilization, suggesting that stimulation is efficacious and can potentially prevent disease progression. This report reaffirms previous reports that recommend early surgical intervention before the onset of permanent musculoskeletal deficits.

Lubag disease ( DYT3 ), an X-linked neurodegenerative condition featuring dystonia and parkinsonism, is caused by mutations in the TAF1 gene.1 DYT3 has been reported to respond to globus pallidus interna (GPi) deep brain stimulation (DBS) using frequencies above 100 Hz (table). We describe the first case of DYT3 responding to high pulse width and low-frequency stimulation.

Editors' Note: In WriteClick this week, Dr. Carpenter and authors Pinto et al. debate whether the image on the cover of the September 22, 2015, issue of Neurology® is a Lafora body or a normal organelle. In reference to “Neuropsychological outcome after deep brain stimulation for Parkinson disease,” Dr. Massano and author Bronstein discuss the literature concerning the targeting of the subthalamic nucleus vs globus pallidus interna in deep brain stimulation. —Megan Alcauskas, MD, and Robert C. Griggs, MD …

The response of dystonia to deep brain stimulation (DBS) is variable among patients, and an important factor in determining outcome is the precise location of stimulation.1 For globus pallidus interna (GPi) stimulation, the posteroventrolateral subregion is considered the optimal “target within a target” for dystonia.1

Shahed et al. describe that tics, ADHD, OCD, and depression improved following bilateral globus pallidus interna DBS in a 16-year-old patient with severe Tourette syndrome. see page 159 Commentary by Donald L. Gilbert, MD, MS This report describes short-term changes after deep brain stimulation (DBS) in a 16-year-old boy with unusually severe Tourette syndrome (TS) symptoms.1 The report illustrates important factors in considering DBS as …