A Transatlantic Viewpoint on the Role of Pallidal Stimulation for Parkinson's Disease

For many neurologists, crossing borders during training is part of the trajectory to becoming a movement disorders specialist and offers novel insights.In this viewpoint, we discuss how crossing the Atlantic Ocean, moving from Europe to North America, changed our approach to choosing a deep brain stimulation (DBS) target for the treatment of Parkinson's disease (PD).Although the debate on whether the subthalamic nucleus (STN) or the globus pallidus internus (GPi) is the preferred target for DBS is no longer a hot topic and is possibly considered a solved controversy, a new debate has recently emerged, after the publication of the European guidelines on advanced therapies for PD.[1][2][3] Moreover, with the recent implementation of magnetic resonance imaging-guided focused ultrasound (MRgFUS), 4 which can also be used to target the GPi, pallidotomy (performed using either radiofrequency or MRgFUS) may gain traction again.Therefore, we believe that sharing our view would be of interest to readers on both sides of the Atlantic.STN DBS just celebrated its 30th anniversary in Grenoble, France, where it was introduced in the early 1990s.5 Pallidotomies were the preferred stereotactic intervention for advanced PD before the introduction of DBS. 6 Despite the fact that shortly after the first report of STN DBS was published, 5 a series of patients treated with GPi DBS were reported, 7 STN quickly became the target of choice for PD, and GPi DBS was performed primarily for dystonia.8 This was true especially in Europe, where DBS entered the clinical space prior to U.S. Food and Drug Administration approval.In the past decade, several important clinical trials comparing STN to GPi were published.[9][10][11][12] Even though evidence has confirmed that both STN and GPi are effective targets in PD, 13 in Europe STN is still perceived as the DBS target of choice for PD, substantially outnumbering DBS procedures targeting the GPi.Despite our European training with STN being the preferred target, since arriving and practicing in Canada, each GPi case we have cared for has made us recognize why GPi as a target has been embraced in North America.Although the majority of patients respond well to STN DBS, 14 every DBS expert would concur that the potential outcome ranges between the miraculous effect often portrayed by the media, usually young tremordominant patients, and the disappointed patients in whom surgery and/or stimulation had a profound detrimental effect on speech, 15 cognition, 16 gait, and balance.17 Despite definite improvement in tremor and motor complications, 18 which is generally observed, the impact of these problems on function and quality of life makes these gains less significant.In contrast, the effect --------------------------

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