Developments in the prediction of cognitive changes following deep brain stimulation in persons with Parkinson’s disease

Figures & data

Figure 1. PRISMA Flowchart for literature search and inclusion.

Table 1. Properties of studies examining correlates and predictors of cognitive decline after deep brain stimulation.

Author & Year	Sample Size & Target (bilateral unless other specified)	RCT	Neuropsychological Test Battery	Follow up time	Characteristics (baseline unless other specified) associated with general or specific cognitive decline	Negative Findings (characteristics not associated with cognitive decline)
Abboud et al. 2015 [47]	Target not specified 55 unilateral 75 bilateral	No	Yes (but looked at confusion and hospitalization length as outcome)	During hospital stay	Attention	Mattis Dementia Rating Scale (DRS), mild cognitive impairment (MCI)
Alhourani et al. 2022 [48]	47 STN (44 bilateral) 43 GPi (39 bilateral)	No	Yes (but only looked at verbal fluency outcome)	6 months	Lower fluency: baseline frontal deficit, age, impulsivity, inhibition and activation behavior scores Higher fluency: education, digit span, MMSE, verbal fluency	Target (STN vs. GPi)
Askari et al. 2022 [49]	56 STN	No	Yes (but only looked at verbal fluency outcome)	3 and 9 months	Left superior frontal gyrus entry with phonemic fluency decline	Caudate penetration; anterior active contact no longer significant once superior frontal gyrus entry accounted for
Bjerknes et al. 2022 [50]	54 STN (27 single MER track, 27 multiple MER)	Yes	Yes	1 and 5 years	Multiple MER with fluency decline at 1 year	MER at 5 years
Blume et al. 2017 [51]	40 STN	No	Yes (but only in 17 STN at follow-up)	21 months for NP	Age and hallucinations with dementia; white matter lesion volume with cognitive decline	MCI, gender, disease duration, motor symptom severity
Bot et al. 2018 [52]	53 STN	No	Yes (but frontal focus)	12 months	–	Caudate penetration
Brown et al. 2022 [53]	32 STN	No	Yes (but limited battery at follow up)	3 months	Imaging marker of iron content: caudate with executive function, putamen with attention	–
Clément et al. 2022 [54]	18 STN	No	Yes (but frontal and language focus)	3 days (off stimulation) 3 months (on stimulation)	Active contact in substantia nigra with verbal fluency decline; Total energy delivered by left electrode with poor semantic fluency	Amplitude, frequency and pulse width
Costentin et al. 2019 [55]	48 STN	No	Yes (but only looked at verbal fluency outcome)	6 months	–	White matter fiber disconnection
Daniels et al. 2010 [56]	60 STN 63 BMT	Yes	Yes	6 months	Age, LEDD, axial motor symptom severity	Mattis DRS (but also was used in inclusion/exclusion), disease duration, non-axial motor symptoms
Floden et al. 2017 [57]	46 STN (23 unilateral)	No	Yes	7 months	Left medial contact location with semantic fluency; Left posterior contact with phonemic fluency; Right side stimulation amplitude with memory	–
Foley et al. 2017 [58]	28 STN (1 prior left pallidotomy)	No	Yes	20 months	Semantic fluency decline associated with apathy but predicted by change in processing speed	–
Francel et al. 2004 [59]	8 STN	No	Yes	1–4 months	Amplitude, frequency and pulse width associated with various cognitive measures	–
Fukaya et al. 2017 [60]	66 STN	No	No (functional independence)	5 years	Functional dependence/dementia associated with axial symptoms, age at disease onset, age at surgery, MMSE	–
Geevarghese et al. 2016 [61]	40 STN	No	Yes (but only looked at memory outcome)	9 months	Symptom duration, hippocampal and thalamic volumes	Severity of motor symptoms
Geraedts et al. 2021 [62]	60 STN (42 with EEG data)	No	Yes	12 months	Machine learning model using 18 EEG features	–
Greif et al. 2021 [63]	39 STN	No	Yes (but only looked at verbal fluency outcome)	9 months	Left anterior contact location	Age, gender, handedness, education, disease duration
Gruber et al. 2019 [64]	104 STN	No	Yes (but only 37 with NP at follow up)	6.3 years	Trend association between MCI and dementia	–
Hrabovsky et al. 2017 [65]	80 STN	No	No (looked only at early mental alterations)	0–3 days	Left anterior electrode position, intermammillary distance, age	Third ventricle size, disease duration, LEDD, Mattis DRS
Isler et al. 2016 [66]	30 STN	No	Yes	3 and 12 months	Caudate penetration with executive (Trailmaking) at 3 months	Caudate penetration at 12 months
John et al. 2021 [67]	23 STN (2 unilateral) 17 GPi (3 unilateral)	No	Yes (but only looked at verbal fluency outcome)	6 months	Left superior STN contact location with fluency	Amplitude, frequency, pulse width, LEDD change, target
Kim et al. 2014 [68]	103 STN	No	Yes (but cognitive decline measured with only MMSE)	6, 12, 36, 60 and 84 months	Executive function, LEDD	MCI did not influence rate of cognitive decline but associated with higher dementia risk
Kratter et al. 2021 [69]	42 STN 12 GPi	No	Yes	1.4 years	Visual hallucination history with attention and executive function declines	Impulsive and compulsive behaviors
Kratter et al. 2022 [70]	42 STN	No	Yes	1.4 years	Anterior stimulation in patients with depression; depression history with declines in fluency and list learning	Stimulation site related to decline in only 3/18 neuropsychological measures
Kübler et al. 2022 [61]	55 STN	No	Yes (but only cognitive screeners for outcome)	12 months	Nucleus basalis of Meynert volume	Motor symptom severity, number of cognitive domains impacted pre-surgery
Le Goff et al. 2015 [71]	59 STN	No	No (verbal fluency only)	6 months	Let anterior cortical entry with semantic fluency decline	No correlate of phonemic fluency decline
Mangone et al. 2020 [72]	309 STN (25 GBA+)	No	Yes (but focus on cognitive screening, frontal and verbal fluency)	12 months	GBA associated with Mattis DRS decline	GBA not associated with MMSE and frontal score declines
Markser et al. 2015 [73]	30 STN	No	No (cognitive screeners only)	4–12 months	Grand total EEG score with cognitive decline	Age, disease duration, LEDD, MMSE, DemTest, motor symptom severity
Merola et al. 2014 [74]	184 STN	No	Yes (looked at dementia risk as outcome)	1–5+ years	Age, UPDRS Parts 1 and 3, MCI (but no dementias in 1^st year)	Age at disease onset, gender, UPDRS Parts 2 and 4
Mulders et al. 2021 [75]	49 STN	No	Yes	12 months	Right coronal entry angle with Trailmaking (executive), age and Stroop (response inhibition, processing speed)	Number of MER tracks, disease duration, LEDD, education
Nimura et al. 2017 [76]	39 STN	No	Yes	6 months	Apathy, quality of life mental health score, category fluency	Age at disease onset, LEDD, disease duration, gender
Odekerken et al. 2015 [29]	56 STN 58 GPi	Yes	Yes	12 months	Age, higher semantic fluency	LEDD, disease duration, digit span, Mattis DRS
Pal et al. 2022 [77]	366 GBA± DBS±	No	No (cognitive screeners only)	36–60 months	GBA+ mutation	–
Planche et al. 2019 [78]	42 STN	No	No (cognitive screening only)	12 months	Various Mattis DRS scores related to left lateral ventricle volume, nucleus accumbens volume	–
Rothlind et al. 2022 [79]	84 STN 80 GPi	Yes	Yes	6 months	Serious adverse events, Mattis DRS, age	Gender. education, disease duration, LEDD, depression, motor symptom severity
Saint-Cyr et al. 2000 [80]	11 STN	No	Yes	3–6 and 9–12 months	Age	–
Sarno et al. 2019 [81]	48 STN 1 GPi	No	Yes	24+ months	–	Anxiety, depression
Schoenberg et al. 2008 [82]	20 STN	No	Yes	5 months	Stimulation amplitude and pulse width, anxiety (correlated with post-operative score vs. cognitive score change)	–
Smeding et al. 2011 [83]	105 STN 40 non-surgical PD	No	Yes	12 months	Attention, baseline levodopa response, age	–
Tesio et al. 2019 [84]	46 STN	No	Yes	6–18 months	–	Caudate penetration
Tramontana et al. 2015 [38]	15 STN 15 BMT (early PD)	Yes	Yes	12 and 24 months	Stroke and hardware infection	–
Tröster et al. 2017 [85]	136 STN (101 active stimulation, 35 implanted but delayed stimulation)	Yes	Yes	3 and 12 months	–	Composite of age, attention/working memory and levodopa response not related to executive and memory functions
Tsai et al. 2007 [86]	38 STN	No	Yes	12 months	Active contact in anterior STN	–
Voruz et al. 2022 [87]	52 STN 25 Healthy controls	No	Yes (but mainly executive function)	12 months	Predominantly left-sided motor symptoms	–
Voruz et al. 2023 [88]	26 STN	No	Yes (but mainly executive function)	6, 12, 36 and 60 months	Predominantly right sided motor symptoms	–
Wang & You 2023 [89]	37 STN	No	Yes	12 months	Postural instability, gait disturbance (PIGD) subtype of PD	–
Weinkle et al. 2018 [90]	43 STN	No	Yes	6 months	Right hippocampal volume with verbal recognition memory change; white matter lesion volume and visuospatial change	White matter lesion volume and most other cognitive tests, forebrain parenchymal volume, overall hippocampal volume
Witt et al. 2011 [91]	60 STN 59 BMT	Yes	Yes	6 months	Low overall cognitive function patients showed PDQ-39 Cognition decline and failure to improve in quality of life (PDQ-39)	–
Witt et al. 2013 [92]	31 STN 31 BMT	Yes	Yes	6 months	Age with global cognitive decline; caudate penetration with global cognitive and working memory decline	MER, LEDD, axial motor symptom severity
Yágüez et al. 2014 [93]	30 STN	No	Yes (but focus on memory outcome)	9 months	Intelligence and list learning with decline in immediate story recall	Age, disease duration, motor symptom severity
Yakufujiang et al. 2019 [94]	17 STN	No	Yes	12 months	EEG theta band power with visuospatial score decline	Theta band power did not affect change in attention, working memory, language or processing speed
Yakufujiang et al. 2020	35 STN	No	Yes	12 months	Baseline executive and visuospatial tests associated with visuospatial decline	–
York et al. 2009 [95]	18 STN	No	Yes (but focus on memory, verbal fluency and general mental status outcome)	6 months	Various electrode insertion points/trajectories and active contact locations associated with different outcome measures	Caudate penetration
Zhou et al. 2022 [96]	125 STN	No	No (cognitive screening only and focused on confusion/delirium outcome)	1 day to hospital discharge	Age, anxiety, overall level of cognitive function	Gender, LEDD

Abbreviations: BMT – best medical therapy, DRS – dementia rating scale, EEG – electroencephalograph, GBA – glucocerebrosidase gene mutation, GPi – globus pallidus pars interna, LEDD – baseline daily levodopa equivalent dose, MCI – mild cognitive impairment (syndrome), MER – microelectrode recording tracks, MMSE – Mini Mental State Exam, PD – Parkinson’s disease, NP – Neuropsychological evaluation, PDQ-39 – Parkinson’s Disease Questionnaire − 39, STN – subthalamic nucleus, UPDRS – Unified Parkinson’s Disease Rating Scale.

Table 2. Patient characteristics implicated in cognitive outcomes of deep brain stimulation for Parkinson’s disease and sample references*.

Demographic	Disease	Brain Morphometry	Neurophysiology/EEG	Neuropsychological
Age [29,56,65,76,79,80,83]	Overall motor symptom severity [74]	Greater intermammillary distance (indirect measure of atrophy) [65]	Grand Total EEG (GTE) score [73]	Overall level of cognitive impairment [91,96]
Education [48] (but most studies negative)	Axial symptom severity [56,60]	Lateral ventricle volume [78]	Theta power [94]	Attention/working memory [47,79,83]
	Motor symptom asymmetry [87,88]	Hippocampal volume [90,97]	Machine learning derived model [62]	Executive Function [68,76,79,98]
	Postural instability and gait disturbance (PIGD) vs. tremor predominant subtype [89]	Thalamic volume [97]		Verbal fluency [76,99]
	Pre-surgical dopaminergic medication dosage [56,68]	Nucleus accumbens volume [78]		Visuospatial [47,98]
	Pre-surgical response to levodopa [83]	Nucleus basalis of Meynert volume [61]		Learning and memory [79,93,99]
	Genetics, for example SNCA and GBA carriers [77,100]	White matter lesion burden [51,90]		Intelligence [93]
	Age at disease onset [60]	Iron in basal ganglia [53]		Anxiety [82]
				Apathy [58,76]
				Depression [70]
				Hallucinations [51,69]
				Mild cognitive impairment [64,68]

*The characteristics have been associated with cognitive outcome with variable frequency and consistency.

Table 3. Surgical and stimulation characteristics implicated in cognitive outcomes of deep brain stimulation for Parkinson’s disease and sample references*.

Electrode entry	Electrode trajectory/penetration	Microelectrode use	Serious adverse events	Stimulation
Anterior [65,71]	Caudate [66,92]	Multiple simultaneous MER tracks [50]	Stroke [38,79]	Amplitude [57,82]
Posterior-lateral quadrant of frontal lobe [95]	Left superior frontal gyrus [49]		Device or wound infection [38,79]	Pulse width [82]
Left superior [95]				Frequency [59]
				Total energy delivered [54]
				Active contact location within STN [57,67,86,125]

*The characteristics have been associated with cognitive outcome with variable frequency and consistency.

Figure 2. Common electrode stimulation configurations in DBS for Parkinson’s disease.

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