Deep Brain Stimulation Target Selection in an Advanced Parkinson's Disease Patient with Significant Tremor and Comorbid Depression

Abstract

Clinical Vignette: A 67-year-old female with advanced Parkinson's disease (PD), medically refractory tremor, and a history of significant depression presents for evaluation of deep brain stimulation (DBS) candidacy. Clinical Dilemma: Traditionally, stimulation of the subthalamic nucleus (STN) has been the preferred target for patients with significant PD tremor. However, STN stimulation is avoided in patients with a significant pre-surgical history of mood disorder. Clinical Solution: Bilateral DBS of the globus pallidus interna led to significant short term improvement in PD motor symptoms, including significant tremor reduction. Gap in Knowledge: There is insufficient evidence to support or refute clinicians' traditional preference for STN stimulation in treating refractory PD tremor. Similarly, the available evidence for risk of worsening depression and/or suicidality after STN DBS is mixed. Both questions require further clarification to guide patient and clinician decision-making.