Deep brain stimulation versus pallidotomy for status dystonicus: a single-center case series

Vincenzo Levi; Giovanna Zorzi; Giuseppe Messina; Luigi Romito; Irene Tramacere; Ivano Dones; Nardo Nardocci; Angelo Franzini

doi:10.3171/2019.10.JNS191691

Deep brain stimulation versus pallidotomy for status dystonicus: a single-center case series

J Neurosurg. 2019 Dec 20;134(1):197-207. doi: 10.3171/2019.10.JNS191691.

Authors

Vincenzo Levi^{1

2}, Giovanna Zorzi³, Giuseppe Messina¹, Luigi Romito⁴, Irene Tramacere⁵, Ivano Dones¹, Nardo Nardocci³, Angelo Franzini¹

Affiliations

¹ 1Neurosurgery Department, Functional Neurosurgery Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta.
² 2Department of Electronics, Information and Bioengineering, Polytechnic University of Milan.
³ 3Pediatric Neuroscience Department, Child Neuropsychiatry Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta.
⁴ 4Neurology Department, Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta; and.
⁵ 5Department of Research and Clinical Development, Scientific Directorate, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.

PMID: 31860826
DOI: 10.3171/2019.10.JNS191691

Abstract

Objective: First-line pharmacological therapies have shown limited efficacy in status dystonicus (SD), while surgery is increasingly reported as remediable in refractory cases. In this context, there is no evidence regarding which neurosurgical approach is the safest and most effective. The aim of this study was to assess the clinical outcomes and surgery-related complications of globus pallidus internus deep brain stimulation (GPi DBS) and pallidotomy for the treatment of drug-resistant SD.

Methods: The authors reviewed the records of patients with drug-resistant SD who had undergone GPi DBS or pallidotomy at their institution between 2003 and 2017. The severity of the dystonia was evaluated using the Barry-Albright Dystonia (BAD) Scale. Surgical procedures were performed bilaterally in all cases.

Results: Fourteen patients were eligible for inclusion in the study. After surgery, the mean follow-up was 40.6 ± 30 months. DBS ended the dystonic storm in 87.5% of cases (7/8), while pallidotomy had a success rate of 83.3% (5/6). No significant differences were observed between the two techniques in terms of failure rates (risk difference DBS vs pallidotomy -0.03, 95% CI -0.36 to 0.30), SD mean resolution time (DBS 34.8 ± 19 days, pallidotomy 21.8 ± 20.2 days, p > 0.05), or BAD scores at each postoperative follow-up (p > 0.05). The long-term hardware complication rate after DBS was 37.5%, whereas no surgery-related complications were noted following pallidotomy.

Conclusions: The study data suggest that DBS and pallidotomy are equally safe and effective therapies for drug-resistant SD. The choice between the two techniques should be tailored on a case-by-case basis, depending on factors such as the etiology and evolution pattern of the underlying dystonia and the clinical conditions at the moment of SD onset. Given the limitation of the low statistical power of this study, further multicentric investigations are needed to confirm its findings.

Keywords: DBS; ablative surgery; deep brain stimulation; dystonia; dystonic storm; functional neurosurgery; pallidotomy; status dystonicus.