Directional deep brain stimulation electrodes in Parkinson's disease: meta-analysis and systematic review of the literature

Victor Hvingelby; Fareha Khalil; Flavia Massey; Alexander Hoyningen; San San Xu; Joseph Candelario-Mckeown; Harith Akram; Thomas Foltynie; Patricia Limousin; Ludvic Zrinzo; Marie T. Krüger

doi:10.1136/jnnp-2024-333947

Directional deep brain stimulation electrodes in Parkinson's disease: meta-analysis and systematic review of the literature

Victor Hvingelby, Fareha Khalil, Flavia Massey, Alexander Hoyningen, San San Xu, Joseph Candelario-Mckeown, Harith Akram, Thomas Foltynie, Patricia Limousin, Ludvic Zrinzo, Marie T. Krüger^*

^*Corresponding author for this work

Research output: Contribution to journal/Conference contribution in journal/Contribution to newspaper › Journal article › Research › peer-review

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Abstract

Background Since their introduction in 2015, directional leads have practically replaced conventional leads for deep brain stimulation (DBS) in Parkinson's disease (PD). Yet, the benefits of directional DBS (dDBS) over omnidirectional DBS (oDBS) remain unclear. This meta-analysis and systematic review compares the literature on dDBS and oDBS for PD. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Database searches included Pubmed, Cochrane (CENTRAL) and EmBase, using relevant keywords such as 'directional', 'segmented', 'brain stimulation' and 'neuromodulation'. The screening was based on the title and abstract. Results 23 papers reporting on 1273 participants (1542 leads) were included. The therapeutic window was 0.70 mA wider when using dDBS (95% CI 0.13 to 1.26 mA, p=0.02), with a lower therapeutic current (0.41 mA, 95% CI 0.27 to 0.54 mA, p=0.01) and a higher side-effect threshold (0.56 mA, 95% CI 0.38 to 0.73 mA, p<0.01). However, there was no relevant difference in mean Unified Parkinson's Disease Rating Scale III change after dDBS (45.8%, 95% CI 30.7% to 60.9%) compared with oDBS (39.0%, 95% CI 36.9% to 41.2%, p=0.39), in the medication-OFF state. Median follow-up time for dDBS and oDBS studies was 6 months and 3 months, respectively (range 3-12 for both). The use of directionality often improves dyskinesia, dysarthria, dysesthesia and pyramidal side effects. Directionality was used in 55% of directional leads at 3-6 months, remaining stable over time (56% at a mean of 14.1 months). Conclusions These findings suggest that stimulation parameters favour dDBS. However, these do not appear to have a significant impact on motor scores, and the availability of long-term data is limited. dDBS is widely accepted, but clinical data justifying its increased complexity and cost are currently sparse.

Original language	English
Journal	Journal of Neurology, Neurosurgery and Psychiatry
Volume	96
Issue	2
Pages (from-to)	188-198
Number of pages	11
ISSN	0022-3050
DOIs	https://doi.org/10.1136/jnnp-2024-333947
Publication status	Published - Jan 2025

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10.1136/jnnp-2024-333947

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Hvingelby, V., Khalil, F., Massey, F., Hoyningen, A., Xu, S. S., Candelario-Mckeown, J., Akram, H., Foltynie, T., Limousin, P., Zrinzo, L., & Krüger, M. T. (2025). Directional deep brain stimulation electrodes in Parkinson's disease: meta-analysis and systematic review of the literature. Journal of Neurology, Neurosurgery and Psychiatry, 96(2), 188-198. https://doi.org/10.1136/jnnp-2024-333947

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title = "Directional deep brain stimulation electrodes in Parkinson's disease: meta-analysis and systematic review of the literature",

abstract = "Background Since their introduction in 2015, directional leads have practically replaced conventional leads for deep brain stimulation (DBS) in Parkinson's disease (PD). Yet, the benefits of directional DBS (dDBS) over omnidirectional DBS (oDBS) remain unclear. This meta-analysis and systematic review compares the literature on dDBS and oDBS for PD. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Database searches included Pubmed, Cochrane (CENTRAL) and EmBase, using relevant keywords such as 'directional', 'segmented', 'brain stimulation' and 'neuromodulation'. The screening was based on the title and abstract. Results 23 papers reporting on 1273 participants (1542 leads) were included. The therapeutic window was 0.70 mA wider when using dDBS (95% CI 0.13 to 1.26 mA, p=0.02), with a lower therapeutic current (0.41 mA, 95% CI 0.27 to 0.54 mA, p=0.01) and a higher side-effect threshold (0.56 mA, 95% CI 0.38 to 0.73 mA, p<0.01). However, there was no relevant difference in mean Unified Parkinson's Disease Rating Scale III change after dDBS (45.8%, 95% CI 30.7% to 60.9%) compared with oDBS (39.0%, 95% CI 36.9% to 41.2%, p=0.39), in the medication-OFF state. Median follow-up time for dDBS and oDBS studies was 6 months and 3 months, respectively (range 3-12 for both). The use of directionality often improves dyskinesia, dysarthria, dysesthesia and pyramidal side effects. Directionality was used in 55% of directional leads at 3-6 months, remaining stable over time (56% at a mean of 14.1 months). Conclusions These findings suggest that stimulation parameters favour dDBS. However, these do not appear to have a significant impact on motor scores, and the availability of long-term data is limited. dDBS is widely accepted, but clinical data justifying its increased complexity and cost are currently sparse.",

author = "Victor Hvingelby and Fareha Khalil and Flavia Massey and Alexander Hoyningen and Xu, {San San} and Joseph Candelario-Mckeown and Harith Akram and Thomas Foltynie and Patricia Limousin and Ludvic Zrinzo and Kr{\"u}ger, {Marie T.}",

year = "2025",

month = jan,

doi = "10.1136/jnnp-2024-333947",

language = "English",

volume = "96",

pages = "188--198",

journal = "Journal of Neurology, Neurosurgery and Psychiatry",

issn = "0022-3050",

publisher = "BMJ Publishing Group",

number = "2",

}

Hvingelby, V, Khalil, F, Massey, F, Hoyningen, A, Xu, SS, Candelario-Mckeown, J, Akram, H, Foltynie, T, Limousin, P, Zrinzo, L & Krüger, MT 2025, 'Directional deep brain stimulation electrodes in Parkinson's disease: meta-analysis and systematic review of the literature', Journal of Neurology, Neurosurgery and Psychiatry, vol. 96, no. 2, pp. 188-198. https://doi.org/10.1136/jnnp-2024-333947

Directional deep brain stimulation electrodes in Parkinson's disease: meta-analysis and systematic review of the literature. / Hvingelby, Victor; Khalil, Fareha; Massey, Flavia et al.
In: Journal of Neurology, Neurosurgery and Psychiatry, Vol. 96, No. 2, 01.2025, p. 188-198.

Research output: Contribution to journal/Conference contribution in journal/Contribution to newspaper › Journal article › Research › peer-review

TY - JOUR

T1 - Directional deep brain stimulation electrodes in Parkinson's disease

T2 - meta-analysis and systematic review of the literature

AU - Hvingelby, Victor

AU - Khalil, Fareha

AU - Massey, Flavia

AU - Hoyningen, Alexander

AU - Xu, San San

AU - Candelario-Mckeown, Joseph

AU - Akram, Harith

AU - Foltynie, Thomas

AU - Limousin, Patricia

AU - Zrinzo, Ludvic

AU - Krüger, Marie T.

PY - 2025/1

Y1 - 2025/1

N2 - Background Since their introduction in 2015, directional leads have practically replaced conventional leads for deep brain stimulation (DBS) in Parkinson's disease (PD). Yet, the benefits of directional DBS (dDBS) over omnidirectional DBS (oDBS) remain unclear. This meta-analysis and systematic review compares the literature on dDBS and oDBS for PD. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Database searches included Pubmed, Cochrane (CENTRAL) and EmBase, using relevant keywords such as 'directional', 'segmented', 'brain stimulation' and 'neuromodulation'. The screening was based on the title and abstract. Results 23 papers reporting on 1273 participants (1542 leads) were included. The therapeutic window was 0.70 mA wider when using dDBS (95% CI 0.13 to 1.26 mA, p=0.02), with a lower therapeutic current (0.41 mA, 95% CI 0.27 to 0.54 mA, p=0.01) and a higher side-effect threshold (0.56 mA, 95% CI 0.38 to 0.73 mA, p<0.01). However, there was no relevant difference in mean Unified Parkinson's Disease Rating Scale III change after dDBS (45.8%, 95% CI 30.7% to 60.9%) compared with oDBS (39.0%, 95% CI 36.9% to 41.2%, p=0.39), in the medication-OFF state. Median follow-up time for dDBS and oDBS studies was 6 months and 3 months, respectively (range 3-12 for both). The use of directionality often improves dyskinesia, dysarthria, dysesthesia and pyramidal side effects. Directionality was used in 55% of directional leads at 3-6 months, remaining stable over time (56% at a mean of 14.1 months). Conclusions These findings suggest that stimulation parameters favour dDBS. However, these do not appear to have a significant impact on motor scores, and the availability of long-term data is limited. dDBS is widely accepted, but clinical data justifying its increased complexity and cost are currently sparse.

AB - Background Since their introduction in 2015, directional leads have practically replaced conventional leads for deep brain stimulation (DBS) in Parkinson's disease (PD). Yet, the benefits of directional DBS (dDBS) over omnidirectional DBS (oDBS) remain unclear. This meta-analysis and systematic review compares the literature on dDBS and oDBS for PD. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Database searches included Pubmed, Cochrane (CENTRAL) and EmBase, using relevant keywords such as 'directional', 'segmented', 'brain stimulation' and 'neuromodulation'. The screening was based on the title and abstract. Results 23 papers reporting on 1273 participants (1542 leads) were included. The therapeutic window was 0.70 mA wider when using dDBS (95% CI 0.13 to 1.26 mA, p=0.02), with a lower therapeutic current (0.41 mA, 95% CI 0.27 to 0.54 mA, p=0.01) and a higher side-effect threshold (0.56 mA, 95% CI 0.38 to 0.73 mA, p<0.01). However, there was no relevant difference in mean Unified Parkinson's Disease Rating Scale III change after dDBS (45.8%, 95% CI 30.7% to 60.9%) compared with oDBS (39.0%, 95% CI 36.9% to 41.2%, p=0.39), in the medication-OFF state. Median follow-up time for dDBS and oDBS studies was 6 months and 3 months, respectively (range 3-12 for both). The use of directionality often improves dyskinesia, dysarthria, dysesthesia and pyramidal side effects. Directionality was used in 55% of directional leads at 3-6 months, remaining stable over time (56% at a mean of 14.1 months). Conclusions These findings suggest that stimulation parameters favour dDBS. However, these do not appear to have a significant impact on motor scores, and the availability of long-term data is limited. dDBS is widely accepted, but clinical data justifying its increased complexity and cost are currently sparse.

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U2 - 10.1136/jnnp-2024-333947

DO - 10.1136/jnnp-2024-333947

M3 - Journal article

C2 - 39304337

AN - SCOPUS:85205149812

SN - 0022-3050

VL - 96

SP - 188

EP - 198

JO - Journal of Neurology, Neurosurgery and Psychiatry

JF - Journal of Neurology, Neurosurgery and Psychiatry

IS - 2

ER -

Directional deep brain stimulation electrodes in Parkinson's disease: meta-analysis and systematic review of the literature

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