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Management of Brittle Dyskinesia and Dopamine Dysregulation Syndrome in Subthalamic Deep Brain Stimulation

Deep brain stimulation (DBS) is the most commonly performed interventional therapy for advanced Parkinson disease (PD). Subthalamic nucleus (STN) is the most common target for DBS implantation. It is established that STN microlesion effect can result in dyskinesia, usually indicating a good lead placement. At times, this dyskinesia may be severe and prolonged, and it may be exaggerated with DBS adjustments and with slight increase in dopaminergic therapy, which may require antidyskinetic medications temporarily to manage it. This is called brittle dyskinesia. It is important to be aware of this phenomenon for optimal management of this condition because this may result in significant morbidity despite proper lead placement and DBS programming. Also during DBS programming, high pulse width can adversely affect speech and gait. This chapter presents a case with brittle dyskinesia and speech impairment while discussing technical troubleshooting and clinical management.