Deep Brain Stimulation for Parkinson’s Disease—A Narrative Review

Deep brain stimulation (DBS) is an established neurosurgical treatment for Parkinson’s disease (PD), mainly targeting motor symptoms resistant to pharmacological therapy. This review examines strategies to optimize DBS using advanced anatomical, functional, and imaging approaches. The subthalamic nucleus (STN) remains the principal target for alleviating bradykinesia and rigidity, while recent evidence highlights the dentato-rubro-thalamic tract (DRTt) as an additional promising target, especially for tremor control. Clinical data demonstrate that co-stimulation of both STN and DRTt via electrode electric fields results in superior motor outcomes, including greater reductions in UPDRS-III scores and lower levodopa requirements. The review highlights the use of high-resolution MRI and diffusion tensor imaging tractography in visualizing STN and DRTt with high precision. These methods support accurate targeting and individualized treatment planning. Electric field modelling is discussed as a tool to quantify stimulation overlap with target structures and predict clinical efficacy. Anatomical variability in DRTt positioning relative to the STN is emphasized, supporting the need for patient-specific DBS approaches. Alternative and emerging DBS targets—including the pedunculopontine nucleus, zona incerta, globus pallidus internus, and nucleus basalis of Meynert—are discussed for their potential in treating axial and cognitive symptoms. The review concludes with a forward-looking discussion on network-based DBS paradigms, the integration of adaptive stimulation technologies, and the potential of multimodal imaging and electrophysiological biomarkers to guide therapy. Together, these advances support a paradigm shift from focal to network-based neuromodulation in PD management.