Pain control by vagus nerve stimulation: from animal to man...and back

Vagus nerve stimulation (VNS), already used as a treatment for refractory epilepsy, has also been assessed for its analgesic effect. Numerous studies report that electrical stimulation of vagal afferents inhibits spinal nociceptive reflexes and transmission. However, results are partly contradictory, showing that the VNS effects depend on the stimulation parameters. Clinical data have been collected from VNS-implanted epileptic patients in whom pain thresholds were measured and the VNS effect on co-existing headaches was assessed. In addition, in 2 pilot studies of a few patients, VNS was used to treat resistant chronic headaches and migraines. Taken together these clinical studies tend to confirm the analgesic effect of VNS and to suggest its potential utility in chronic headache patients. In order to better define the nature of neuronal and behavioural changes induced by VNS with devices used in humans and to determine the most adequate stimulation stimulation protocols, we have used a commercially available stimulator (NCP-Cyberonics) for prolonged VNS in rats. Our results show a clear antinociceptive effect of VNS in models of acute or inflammatory pain with different stimulation protocols including the one used in epileptic patients. Using immunocytochemical methods, we find that activity changes in spinal trigeminal nucleus neurons could underlie at least part of the VNS-induced analgesia.

Chronic implantation of deep brain stimulation leads in animal models of neurological disorders

Deep brain stimulation (DBS) has routinely been used as a treatment option in Parkinson's disease (PD), tremor disorders and, more recently, dystonia. Here, we describe a method of implantation of DBS leads in the monkey model of PD. By adapting procedures used in human patients, we have devised implantation techniques that can be readily applied to any animal model in which stimulation of subcortical structures is desired. The procedure for implantation consists of microelectrode mapping of the target structure, DBS lead preparation and implantation, and verification of lead placement. The stimulation system described in this paper allows for simultaneous recording of neuronal activity (during stimulation) and observation of animal behavior without restriction of the subject's head or body. In addition, we detail techniques for stimulation and recording from distant structures (utilizing either a one or two chamber system) to facilitate examination of the effects of DBS on neural activity. Thus, the correlation of changes in neuronal activity with behavior during stimulation of subcortical structures can be accomplished. In addition, the use of leads in primates which are analogous in size to human devices allows for close reproduction of the effects of stimulation as observed in humans.

An economical multi-channel cortical electrode array for extended periods of recording during behavior

We report the development of a low-cost chronic multi-channel microwire electrode array for recording multi-unit cortical responses in behaving rodents. The design was motivated by three issues. First, standard connector systems tended to disconnect from the head-stage during extended periods of behavior. Disconnections resulted in a loss of data and an interruption of the animals' behavior. Second, the use of low insertion force connectors with locking mechanisms was cost prohibitive. Finally, connecting the head-stage to a skull-mounted connector on an unrestrained animal was highly stressful for both the researcher and animal. The design developed uses a high insertion force DIP socket separated from the skullcap that prevents inadvertent disconnects, is inexpensive, and simplifies connecting unrestrained rodents. Electrodes were implanted in layer IV of primary auditory cortex in 11 Sprague-Dawley rats. Performance of the electrodes was monitored for 6 weeks. None of the behaving animals became disconnected from the recording system during recording sessions lasting 6 h. The mean signal-to-noise ratio on all channels (154) following surgery was 3.9+/-0.2. Of the 154 channels implanted, 130 exhibited driven activity following surgery. Forty percent of the arrays continued to exhibit driven neural activity at 6 weeks.

In vivo voltammetry: from wire to wireless measurements

A novel telemetric system based on either differential pulse voltammetry (DPV) or direct current amperometry (DCA) by using a diffused infrared transmission channel is presented. Unlike similar pre-existing instruments based on infrared transmission, the present system works on a single-way communication, thus avoiding problems related to cross-talking between two-way channels. The infrared channel is also immune from electromagnetic interferences from the surrounding environment. Further advancement is the development of an original miniaturised system (dimension 1cm x 1.2 cm x 0.5 cm) with reduced weight (5-6 g), suitable for affixing to the rat head and allowing real time telemetric monitoring using DCA sampling of neurotransmitters such as dopamine or serotonin every 100 ms. The set-up is based on a transmitter (TX) circuit mounted on the animal's head and connected to the electrodes inserted into its brain. The TX circuit generates the proper electrical signals for DPV or DCA, collects the electrical response of the brain and transmits it, via an infrared channel, to a receiving station (RX) interfaced with a personal computer. The PC performs the sampling and elaboration of polarographic traces in a flexible and programmable way.

Dipole Modeling of Epileptic Spikes Can Be Accurate or Misleading

PURPOSE

We investigated the accuracy and potential for serious error when representing cortical generators of epileptic spikes with the common single-dipole model. Spike generators were realistically simulated with cortical areas of different extents.

METHODS

The source was simulated by using a patch that comprised small triangles on the cortical surface, each triangle having an elementary dipole generator with a moment corresponding to real intracerebral fields of spikes. The source-patch covered various clinically important parts of the temporal and frontal lobes, with an area ranging from 6 to 120 cm2. The scalp field was computed for each source-patch by using a realistic head model and was fitted by the single-dipole model to determine the best-fit dipole and the intracerebral distribution of residual variance (RV). Dipole modeling also was performed for the simulated scalp field with additional real EEG background.

RESULTS

The RV after fitting a dipole to the scalp field without noise was at most 1.34%. Scalp spikes arising from sources of 6 cm2 were of small amplitude, and the dipoles estimated for these spikes were inconsistent. Extension of the source area was associated with increase of scalp potential amplitude, only very small increase of RV, and increased consistency of the estimated dipoles. When the source was very large, the dipoles clustered at very misleading locations.

CONCLUSIONS

Pitfalls in dipole source localization are caused by the procedure of fitting the simplistic dipole model to real cortical sources with spatial extent and complex configuration.

Use of chronic sacral nerve stimulation in neurological voiding disorders

AIM

Neurogenic low urinary tract dysfunctions unresponsive to medical and conservative therapy are difficult to manage. Nowadays they can be treated with Sacral Nerve Stimulation (SNS), even if clinical experiences reported in literature are still limited.

METHODS

We performed SNS in 6 patients with neurogenic bladder: 3 patients had incontinence-urgency (1 myelitis, 1 multiple sclerosis, 1 autonomic polineuropathy) and 3 patients had urinary retention (1 incomplete spinal cord lesion, 1 operation for discal hernia T5-T6, 1 hysterectomy).

RESULTS

Among cases with incontinence-urgency we achieved complete control of the bladder in 2 patients while in 1 patient the number of urinary losses was reduced of the 80%. In 2 patients with urinary retention we obtained complete recovery of the bladder function, while in 1 patient the number of cateterisms/die reduced of 50%, the urinary volume for micturion increased and residual urinary volume decreased. Results were unchanged during the follow-up (maximum 26 months), except for 1 patient in which a partial loss of effectiveness occurred.

CONCLUSIONS

Chronic electric stimulation of S3 sacral roots via an implanted neuroprotesis is therefore an effectiveness, save and promising therapeutic option in treatment of neurogenic bladder dysfunctions.

BOLD response to direct thalamic stimulation reveals a functional connection between the medial thalamus and the anterior cingulate cortex in the rat

Recent functional neuroimaging studies in humans and rodents have shown that the anterior cingulate cortex (ACC) is activated by painful stimuli, and plays an important role in the affective aspect of pain sensation. The aim of the present study was to develop a suitable stimulation method for direct activation of the brain in fMRI studies and to investigate the functional connectivity in the thalamo-cingulate pathway. In the first part of the study, tungsten, stainless steel, or glass-coated carbon fiber microelectrodes were implanted in the left medial thalamus (MT) of anesthetized rats, and T2*-weighted gradient-echo (GE) images were obtained in the sagittal plane on a 4.7 T system (Biospec BMT 47/40). Only the images obtained with the carbon fiber electrode were acceptable without a reduction of the signal-to-noise ratio (SNR) and image distortion. In the second part of the study, a series of two-slice GE images were acquired during electrical stimulation of the MT with the use of a carbon fiber electrode. A cross-correlation analysis showed that the signal intensities of activated areas in the ipsilateral ACC were significantly increased by about 4.5% during MT stimulation. Functional activation, as assessed by the distribution of c-Fos immunoreactivity, showed strong c-Fos expression in neurons in the ipsilateral ACC. The present study shows that glass-coated carbon fiber electrodes are suitable for fMRI studies and can be used to investigate functional thalamocortical activation.

The quality of intrapartum fetal heart rate monitoring

OBJECTIVE

To determine the quality of fetal heart rate (FHR) recordings during the first and second stage of labor by quantifying the amount of fetal signal loss in relation to the method of monitoring: external ultrasound or directly via a scalp electrode.

STUDY DESIGN

Analysis of 239 intrapartum recordings stored between 1 January 2001 and 1 July 2001 from consecutive deliveries at the Vrije Universiteit Medical Center in Amsterdam. Singletons delivered via the vaginal route were included in the study. FHR recordings had duration of at least 1h prior to birth of the infant. Subdivision in three groups took place on the basis of the recording technique which had been used; i.e. ultrasound, scalp electrode or a combination of both methods. FHR data was obtained using HP-M1350 cardiotocographs. The status (pen on, pen off, maternal signal) and the mode of the signals were acquired. The duration of pen lifts and maternal signals was divided by the total duration of the recording. Statistical analyses were performed with the Mann-Whitney U-test and the Wilcoxon signed ranks test.

RESULTS

Recordings obtained via ultrasound demonstrated significantly more fetal signal loss than those obtained via the direct mode, particularly in the second stage. The FIGO criteria for fetal signal loss with external ultrasound were not fulfilled during this stage for about half the cases.

CONCLUSION

Intrapartum FHR monitoring via a scalp electrode provides far better quality FHR signals than external ultrasound and deserves a more prominent position in fetal surveillance than it currently has.

CORTICAL NEURAL PROSTHETICS

Control of prostheses using cortical signals is based on three elements: chronic microelectrode arrays, extraction algorithms, and prosthetic effectors. Arrays of microelectrodes are permanently implanted in cerebral cortex. These arrays must record populations of single- and multiunit activity indefinitely. Information containing position and velocity correlates of animate movement needs to be extracted continuously in real time from the recorded activity. Prosthetic arms, the current effectors used in this work, need to have the agility and configuration of natural arms. Demonstrations using closed-loop control show that subjects change their neural activity to improve performance with these devices. Adaptive-learning algorithms that capitalize on these improvements show that this technology has the capability of restoring much of the arm movement lost with immobilizing deficits.

Neural prostheses for vision: designing a functional interface with retinal neurons

A number of prevalent eye diseases exist which may lead to partial or total blindness, and for which there are currently no cures or means by which to restore lost sight. Based on recent progress, it has become apparent that artificial prosthetic devices, which would use electrical stimulation of neurons in the visual pathway to elicit visual percepts, are likely to some day become a viable treatment for patients blinded by these diseases. A number of recent scientific reviews have summarized general functional electrical stimulation (FES) approaches related to the visual system, and many of the technical considerations regarding fabrication, biocompatibility, stimulation thresholds and electrotoxicity. This review will address a principal outstanding question in retinal prosthesis development: the design and implementation of a functional interface with the retina. A functional interface between electrodes and retinal neurons will be stable, biocompatible, and will convey useful information to the visual system. Several parameters related to both the artificial and biological aspects of the interface must be considered; this paper will emphasize electrode design. Additional issues central to the development of prosthesis interface design, including retinal physiology, eye diseases, and existing animal models of retinal degeneration, are also summarized.

Mechanical failure of the electrode wire in deep brain stimulation

The feasibility and efficacy of deep brain stimulation (DBS) has offered new possibilities for treatment of movement disorders. Mechanical failure of the DBS system is a potential complication. Here we report five patients who presented with mechanical failure of the DBS system. Radiographs of the skull and cervical spine were analyzed for disruptions. Seven instances of lead breakage near the connection of the DBS electrode with the extension wire were identified. In one patient this was in the paramastoid area over the skull, while in all others were in the supraclavicular location. The patients consisted of three men and two women ranging in age from 24 to 78 (at the time of first operation), one person suffering three breakages. The length of spanned time from implantation to presentation ranged from 8 to 32 months. Palpation of the electrode lead wire in the neck for breakage proved unreliable. Radiography localized the site of breakage in all but one patient who required intraoperative exploration, which revealed that although the lead wire was disrupted, the two ends remained in contact. The fact that all breakages occurred near the connection wire suggests that to-and-fro motion of the DBS electrode with repeated head turning leads to fatigue and eventual disruption.

Design, construction and mechanical optimisation process of electrode with radial current flow in the scala tympani

A 48 contact cochlear implant electrode has been constructed for electrical stimulation of the auditory nerve. The stimulating contacts of this electrode are organised in two layers: 31 contacts on the upper surface directed towards the habenula perforata and 17 contacts connected together as one longitudinal contact on the underside. The design of the electrode carrier aims to make radial current flow possible in the cochlea. The mechanical structure of the newly designed electrode was optimised to obtain maximal insertion depth. Electrode insertion tests were performed in a transparent acrylic model of the human cochlea.

Microdialysis of dopamine interpreted with quantitative model incorporating probe implantation trauma

Although microdialysis is widely used to sample endogenous and exogenous substances in vivo, interpretation of the results obtained by this technique remains controversial. The goal of the present study was to examine recent criticism of microdialysis in the specific case of dopamine (DA) measurements in the brain extracellular microenvironment. The apparent steady-state basal extracellular concentration and extraction fraction of DA were determined in anesthetized rat striatum by the concentration difference (no-net-flux) microdialysis technique. A rate constant for extracellular clearance of DA calculated from the extraction fraction was smaller than the previously determined estimate by fast-scan cyclic voltammetry for cellular uptake of DA. Because the relatively small size of the voltammetric microsensor produces little tissue damage, the discrepancy between the uptake rate constants may be a consequence of trauma from microdialysis probe implantation. The trauma layer has previously been identified by histology and proposed to distort measurements of extracellular DA levels by the no-net-flux method. To address this issue, an existing quantitative mathematical model for microdialysis was modified to incorporate a traumatized tissue layer interposed between the probe and surrounding normal tissue. The tissue layers are hypothesized to differ in their rates of neurotransmitter release and uptake. A post-implantation traumatized layer with reduced uptake and no release can reconcile the discrepancy between DA uptake measured by microdialysis and voltammetry. The model predicts that this trauma layer would cause the DA extraction fraction obtained from microdialysis in vivo calibration techniques, such as no-net-flux, to differ from the DA relative recovery and lead to an underestimation of the DA extracellular concentration in the surrounding normal tissue.

Evaluation of methods for eliciting somatosensory-evoked potentials in the awake, freely moving rat

To standardise the method of eliciting somatosensory-evoked potentials (SEPs), SEPs were generated by electrical stimulation of different stimulus sites and recorded bilaterally from the primary somatosensory cortex (S1) and from midline in awake, freely moving rats. Increasing stimulus intensity enhanced amplitudes of all SEPs. At supramaximal stimulation, SEPs following vibrissae and tail stimulation (V-SEP and Ta-SEP, respectively) but not following trunk stimulation (Tr-SEP), fulfilled our criterion of signal-to-noise ratio >or=4. The first V-SEP component coincided with a stimulus artefact, disqualifying these recordings for a standard stimulation protocol. The Ta-SEP generated stable and reproducible recordings and was considered to be the preferred technique. Early components of the contralateral S1 recorded V-SEP and Tr-SEP occurred at latencies different from the other recordings. Increasing stimulus repetition rate (SRR) decreased amplitudes of all SEPs. At the highest obtainable SRR, the amplitude between the V-SEP second positive and second negative components in all recordings was 70-80% of the amplitude at 0.1 Hz, whereas peak amplitudes of subsequent components and those of the Tr-SEP and Ta-SEP were 20-50%. These results indicate that the different SEP components might be generated by different ascending neural pathways.

Brain-machine interfaces: computational demands and clinical needs meet basic neuroscience

As long as 150 years ago, when Fritz and Hitzig demonstrated the electrical excitability of the motor cortex, scientists and fiction writers were considering the possibility of interfacing a machine with the human brain. Modern attempts have been driven by concrete technological and clinical goals. The most advanced of these has brought the perception of sound to thousands of deaf individuals by means of electrodes implanted in the cochlea. Similar attempts are underway to provide images to the visual cortex and to allow the brains of paralyzed patients to re-establish control of the external environment via recording electrodes. This review focuses on two challenges: (1) establishing a 'closed loop' between sensory input and motor output and (2) controlling neural plasticity to achieve the desired behavior of the brain-machine system. Meeting these challenges is the key to extending the impact of the brain-machine interface.

The accuracy of needle placement in lower-limb muscles: a blinded study

OBJECTIVE

To assess the accuracy of common anatomic guides for electromyographic needle placement in muscles.

DESIGN

Blinded study. The dissector identified different needle placements by a random number attached to a wire in the insertion site.

SETTING

A university anatomy laboratory.

CADAVERS

Ten cadaver lower limbs.

INTERVENTIONS

By using techniques published in texts by Gieringer and Delagi and Perotto, clinical electromyographers palpated and measured appropriate locations for needle placement. A thin wire was inserted through the needle into 36 different muscles in 10 cadavers, resulting in 263 targeted muscles. An anatomist blinded to intended location dissected and recorded muscles and other tissues that the wire pierced or passed near.

MAIN OUTCOME MEASURES

Targeted muscle penetration, final resting place of the wire tip, and proximity to vital structures.

RESULTS

Fifty-seven percent of insertions penetrated the intended muscle. The wire tip was in the intended muscle 45% of the time. Seventeen percent of insertions penetrated or passed within 5mm of an important structure, including nerve (9.1%), tendon (3.0%), named artery (2.7%), vein (2.7%), or joint (0.8%). Specific muscle accuracy was highly variable, from 0% for 12 tries in various deep hip muscles to 100% of 10 tries in the vastus medialis.

CONCLUSION

The accuracy of blind needle placement varied according to muscle. With the blind insertion technique, more accurate and safe needle placement strategies can be developed.

Clinical advantage of neutral anode positioning feature in recent pacemaker generator

Recent advances in pacemaker technology such as a thinner lead body, smaller size of pacemaker generators and pacemaker pulse generators with the neutral anode positioning (NAP) feature, have made pacemaker implantation easier. To date, however, the clinical disadvantages of this NAP feature have not been investigated. We investigated whether there are any clinically disadvantages in pacing and sensing thresholds, myopotential tracking thresholds and myopotential inhibition thresholds in 62 pacemaker patients with the NAP feature. All measured data from the NAP devices when the pacemaker was set to the bipolar system were acceptable and normal. In the unipolar system with NAP feature, no differences were observed in the numerous parameters measured compared to previously reported measured data in the unipolar system without the NAP feature. We concluded that the physician can also benefit from this feature since any pulse generator with the NAP feature is suitable for implant on either side of the body, without any disadvantages. Therefore, left- or right-sided pacers need no longer be ordered, stocked, or specified at the time of implant.

Connecting cortex to machines: recent advances in brain interfaces

Recent technological and scientific advances have generated wide interest in the possibility of creating a brain-machine interface (BMI), particularly as a means to aid paralyzed humans in communication. Advances have been made in detecting neural signals and translating them into command signals that can control devices. We now have systems that use externally derived neural signals as a command source, and faster and potentially more flexible systems that directly use intracortical recording are being tested. Studies in behaving monkeys show that neural output from the motor cortex can be used to control computer cursors almost as effectively as a natural hand would carry out the task. Additional research findings explore the possibility of using computers to return behaviorally useful feedback information to the cortex. Although significant scientific and technological challenges remain, progress in creating useful human BMIs is accelerating.

Ultra high-resolution fMRI in monkeys with implanted RF coils

Spatiotemporally resolved functional MRI (fMRI) in animals can reveal how wide-spread neural networks are organized and accompanying electrophysiological recordings can show how small neural assemblies contribute to this organization. Here we present a novel technique that yields high-resolution structural and functional images of the monkey brain with small, tissue-compatible, intraosteally implantable radiofrequency coils. Voxel sizes as small as 0.0113 microl with high signal-to-noise and contrast-to-noise ratios were obtained, revealing both structural and functional cortical architecture in great detail. Up to a certain point, contrast sensitivity increased with decreasing voxel size, probably because of the decreased partial volume effects. Spatial specificity was demonstrated by the lamina-specific activation in experiments comparing responses to moving and flickering stimuli. The implications of this technique for combined fMRI/electrophysiology experiments and its limitations in terms of spatial coverage are discussed.

Neuroprostheses for grasping

In recent years a number of neuroprostheses have been developed and used to assist stroke and spinal cord injured subjects to restore or improve grasping function. These neuroprostheses clearly demonstrated that the targeted group of subjects can significantly benefit from this technology and that functional electrical stimulation (FES) is a viable method for restoring or improving grasping function. In this article the FES technology is briefly explained and some of the better known neuroprostheses for grasping are discussed. Furthermore, a typical population of subjects that can benefit from this technology is indicated as well as the methodology to select and train these subjects to apply the neuroprosthesis in daily living activities. This article also provides a brief summary of the achieved results with the existing neuroprostheses for grasping and discusses some of the challenges this technology is currently facing.

Electrical stimulation for the treatment of bladder dysfunction: current status and future possibilities

Electrical stimulation of peripheral nerves can be used to cause muscle contraction, to activate reflexes, and to modulate some functions of the central nervous system (neuromodulation). If applied to the spinal cord or nerves controlling the lower urinary tract, electrical stimulation can produce bladder or sphincter contraction, produce micturition, and can be applied as a medical treatment in cases of incontinence and urinary retention. This article first reviews the history of electrical stimulation applied for treatment of bladder dysfunction and then focuses on the implantable Finetech-Brindley stimulator to produce bladder emptying, and on external and implantable neuromodulation systems for treatment of incontinence. We conclude by summarizing some recent research efforts including: (a) combined sacral posterior and anterior sacral root stimulator implant (SPARSI), (b) selective stimulation of nerve fibers for selective detrusor activation by sacral ventral root stimulation, (c) microstimulation of the spinal cord, and (d) a newly proposed closed-loop bladder neuroprosthesis to treat incontinence caused by bladder overactivity.