Deep brain stimulation for Parkinson's disease: disrupting the disruption

An effect of dopamine depletion on decision-making: the temporal coupling of deliberation and execution

When a decision between alternative actions has to be made, the primate brain is able to uncouple motor execution from mental deliberation, providing time for higher cognitive processes such as remembering and reasoning. The mental deliberation leading to the decision and the motor execution applying the decision are likely to involve different neuronal circuits linking the basal ganglia and the frontal cortex. Behavioral and physiological studies in monkeys indicate that dopamine depletion may result in a loss of functional segregation between these circuits, hence, in interference between the deliberation and execution processes. To test this hypothesis in humans, we analyzed the movements of parkinsonian patients in a go/no-go task, contrasting periods of uncertainty with periods of knowledge about the rule to be applied. Two groups of patients were compared to healthy subjects: one group was treated with dopaminergic medication and the other with deep brain stimulation; both groups were also tested without any treatment. In healthy subjects, the movement time was unaffected by uncertainty. In untreated patients, the movement time increased with uncertainty, reflecting interference between deliberation and execution processes. This interference was fully corrected with dopaminergic medication but was unchanged with deep brain stimulation. Moreover, decision-related hesitations were detectable in the movements of dopamine-depleted patients, revealing a temporal coupling of deliberation and execution. We suggest that such coupling may be related to the loss of dopamine-mediated functional segregation between basal ganglia circuits processing different stages of goal-directed behavior.

Subthalamic nucleus lesions enhance the psychomotor-activating, incentive motivational, and neurobiological effects of cocaine

The subthalamic nucleus (STN) is traditionally thought to be involved in motor control, and dysfunction of the STN is thought to contribute to movement disorders. Here, we show that the STN also plays an important role in motivational processes and the response to drugs of abuse. Specifically, bilateral STN lesions produced a dose-dependent increase in the psychomotor-activating effects of cocaine, the rate at which animals acquired cocaine self-administration, and the motivation for cocaine assessed using a progressive ratio schedule. Furthermore, bilateral STN lesions enhanced the ability of cocaine to induce gene expression in the nucleus accumbens and caudate-putamen, two structures known to be involved in mediating the psychomotor-activating and incentive motivational effects of drugs of abuse. These findings suggest that engagement of the STN serves to dampen the psychomotor-activating and incentive motivational effects of drugs of abuse. Thus, the STN may serve as a novel target for therapeutic interventions aimed at treating drug dependence.

Subthalamic oscillatory activities at beta or higher frequency do not change after high-frequency DBS in Parkinson's disease

This study aimed to assess whether changes in the patterns of local field potential (LFP) oscillations of the subthalamic nucleus (STN) underlie to the clinical improvement within 60 s after turning off subthalamic DBS. We studied by spectral analysis the STN LFPs recorded in 13 nuclei from 7 patients with Parkinson's disease before and immediately after unilateral high-frequency (130 Hz) stimulation of the same nucleus, when the clinical benefit of DBS was unchanged. The results were compared with LFP data previously reported [A. Priori, G. Foffani, A. Pesenti, F. Tamma, A.M. Bianchi, M. Pellegrini et al., Rhythm-specific pharmacological modulation of subthalamic activity in Parkinson's disease. Exp. Neurol. 189 (2004) 369-379]--namely 13 STN from 9 parkinsonian patients recorded before and after levodopa administration--which were used as a control. Before DBS, in the 'off' clinical state after overnight withdrawal of dopaminergic therapy, the STN spectrum did not significantly differ from the control nuclei, showing prominent activity at beta frequencies (13-20 and 20-35 Hz). After DBS (10-15 min) of the STN, the recorded nuclei significantly differed from the control, failing to show significant changes either in the beta bands or at higher frequencies (60-90 and 250-350 Hz). The patterns of subthalamic LFP oscillations after DBS therefore differ from those after dopaminergic medication. These results suggest (1) that subthalamic LFP modulations are not the epiphenomenon of peripheral motor improvement and (2) that the transitory clinical efficacy maintained after discontinuation of subthalamic DBS is not associated with local modulation of LFP activity at beta or higher frequencies within the STN.

A new approach to understand the pathophysiology of Parkinson's disease

Here I introduce a dynamic model of the basal ganglia functions for the control of voluntary movement: information through major pathways in the cortico-basal ganglia loop, i. e., the cortico-STN-GPi/SNr "hyperdirect", cortico-striato-GPi/SNr "direct" and cortico-striato-GPe-STN-GPi/SNr "indirect" pathways, dynamically controls the activity of the thalamus and cortex and releases only the selected motor program at the selected timing. Based on the dynamic model, the pathophysiology of Parkinson's disease and the mechanism for the effectiveness of stereotaxic surgery can better be explained by an increase or decrease of disinhibition and inhibition in the thalamus and cortex in the temporal and spatial domains.

Dopamine efflux in the rat striatum evoked by electrical stimulation of the subthalamic nucleus: potential mechanism of action in Parkinson's disease

The precise mechanism whereby continuous high-frequency electrical stimulation of the subthalamic nucleus ameliorates motor symptoms of Parkinson's disease is unknown. We examined the effects of high-frequency stimulation of regions dorsal to and within the subthalamic nucleus on dopamine efflux in the striatum of urethane-anaesthetized rats using constant potential amperometry. Complementary extracellular electrophysiological studies determined the activity of subthalamic nucleus neurons in response to similar electrical stimulation of the subthalamic nucleus. High-frequency stimulation of the subthalamic nucleus increased action potential firing in the subthalamic nucleus only during the initial stimulation period and was followed by a cessation of firing over the remainder of stimulation. Electrical stimulation of the subthalamic nucleus with 15 pulses elicited stimulus-time-locked increases in striatal dopamine efflux with maximal peak effects occurring at 50 Hz frequency and 300 microA intensity. Extended subthalamic nucleus stimulation (1000 pulses at 50 Hz; 300 microA) elicited a similar peak increase in striatal dopamine efflux that was followed by a relatively lower steady-state elevation in extracellular dopamine over the course of stimulation. In contrast, extended stimulation immediately adjacent and dorsal to the subthalamic nucleus resulted in an 11-fold greater increase in dopamine efflux that remained elevated over the course of the stimulation. Immunohistochemical staining for tyrosine hydroxylase revealed catecholaminergic fibers running immediately dorsal to and through the subthalamic nucleus. Taken together, these results suggest that enhanced dopamine release within the basal ganglia may be an important mechanism whereby high-frequency stimulation of the subthalamic nucleus improves motor symptoms of Parkinson's disease.

Induction of immediate early gene expression by high-frequency stimulation of the subthalamic nucleus in rats

Deep brain stimulation is associated with delayed improvement of parkinsonian symptoms, such as hypokinesia with subthalamic nucleus stimulation, or dystonia with globus pallidus internus stimulation. The latency observed is better explained by molecular alterations than immediate electrophysiological processes, and clinical improvement may involve adaptive gene expression. Here, we have studied immediate early gene expression as fast molecular response to subthalamic nucleus stimulation. Bipolar electrodes were implanted bilaterally into the subthalamic nucleus of anesthetized male Wistar rats. High-frequency stimulation (130 Hz or 80 Hz, 60 micros, 300 microA) or low-frequency stimulation (5 Hz, 60 micros, 300 microA) was performed with the right electrode for 15, 60, 120, and 240 min whereas the silent left electrode served as negative control. Brains were fixed by transcardial perfusion and frozen sections were stained with polyclonal antibodies directed against three immediate early gene-encoded proteins, c-Fos, c-Jun, and Krox-24 (NGFI-A, Egr-1, Zif268, Tis8, Zenk). After 120 and 240 h, c-Fos immunoreactivity was strongly upregulated in subthalamic nucleus neurons on the stimulated site. In contrast, no c-Fos immunoreactivity was detected on the non-stimulated site except for single positive cells located in close proximity to the electrode tracks. Furthermore, c-Fos immunoreactivity was induced in subthalamic nucleus projection areas, such as primary and secondary motor cortex, primary somatosensory and insular cortex, lateral and medial globus pallidus, suprageniculate thalamic nucleus, pontine nuclei, medial geniculate nucleus, and substantia nigra. Similarly, c-Jun and Krox-24 were induced at the site of stimulation and in projection areas following high-frequency subthalamic nucleus stimulation. Whereas high frequency stimulation with 80 Hz was similarly effective none of the three immediate early gene-encoded proteins was induced with low-frequency stimulation (5 Hz) for 4 h. This is in accordance with the therapeutic effects of deep brain stimulation which are only elicited with high frequency stimulation. Our data provide evidence that immediate early gene expression in the subthalamic nucleus is rapidly and substantially induced by high-frequency stimulation. The induction of immediate early genes in projection sites suggests ipsilateral transsynaptic modulation of neuronal activity.

Basal ganglia neural responses during behaviorally effective deep brain stimulation of the subthalamic nucleus in rats performing a treadmill locomotion test

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective treatment for Parkinson's disease (PD). In spite of proven therapeutic success, the mechanism underlying the benefits of DBS has not been resolved. A multiple-channel single-unit recording technique was used in the present study to investigate basal ganglia (BG) neural responses during behaviorally effective DBS of the STN in a rat model of PD. Rats underwent unilateral dopamine (DA) depletion by injection of 6-hydroxyDA (6-OHDA) into one side of the medial forebrain bundle and subsequently developed a partial akinesia, which was assessed during the treadmill locomotion task. High frequency stimulation (HFS) of the STN restored normal treadmill locomotion behavior. Simultaneous recording of single unit activity in the striatum (STR), globus pallidus (GP), substantia nigra pars reticulata (SNr), and STN revealed a variety of neural responses during behaviorally effective HFS of the STN. Predominant inhibitory responses appeared in the STN stimulation site. Nearly equal numbers of excitatory and inhibitory responses were found in the GP and SNr, whereas more rebound excitatory responses were found in the STR. Mean firing rate did not change significantly in the STR, GP, and SNr, but significantly decreased in both sides of STN during DBS. A decrease in firing rate in the contralateral side of STN provides neural substrate for the clinical observation that unilateral DBS produces bilateral benefits in patients with PD. In addition to the firing rate changes, a decrease in burst firing was observed in the GP and STN. The present study indicates that DBS induces complex modulations of the BG circuit and further suggests that BG network reorganization, rather than a simple excitation or inhibition, may underlie the therapeutic effects of DBS in patients with PD.

Impact of High-Frequency Stimulation Parameters on the Pattern of Discharge of Subthalamic Neurons

In clinical conditions, high-frequency stimulation (HFS) of subthalamic (STN) neurons in Parkinson's disease is empirically applied at ≥100 Hz (130–185 Hz), with pulses of short duration (60–100 μs) and 1- to 3-mA amplitude. Other parameter values produce no effect or aggravate the symptoms. To gain a better understanding of the mechanisms that underlie the therapeutic action of HFS, we have compared the effects of different combinations of parameter values delivered by clinical stimulators on the activity of STN neurons recorded in whole cell patch-clamp configuration in slices. We showed that none of tested combinations of parameters silenced the neurons. Non-therapeutic combinations i.e., low-frequency pulses (10–50 Hz), even at large amplitude or width, further excited the STN neurons with respect to their spontaneous activity. In contrast, combinations in the therapeutic range (80–185 Hz, 90–200 μs, 500–800 μA) replaced the preexisting activity by spikes, time-locked to the stimuli and thus presenting a striking regularity. When increasing pulse width or amplitude in this high-frequency range, the dual effect was still present but the activity generated became more irregular. We propose that during HFS at clinically relevant parameters, STN neurons behave as stable oscillators entirely driven by the stimulation, giving an average stable STN output that overrides spontaneous activity and introduces high-frequency regular spiking in the basal ganglia network.

Differential effects of subthalamic nucleus stimulation in advanced Parkinson disease on reaction time performance

The aim of the present study was to assess the effect of bilateral subthalamic nucleus (STN) stimulation and dopaminergic medication on speed of mental processing and motor function. Thirty-nine patients suffering from advanced Parkinson disease (PD) were operated on. Motor function and reaction time (RT) performance [simple RT (SRT) and complex RT (CRT)] were evaluated under four experimental conditions with stimulation (stim) and medication (med) on and off: stim-on/med-on, stim-on/med-off, stim-off/med-off and stim-off/med-on. In the last condition, the patients received either low medication (usual dose) or high medication (suprathreshold dose). STN stimulation improved the motor performance in the SRT and CRT tasks. Furthermore, STN deep brain stimulation (DBS) also improved response preparation as shown by the significant improvement of the RT performance in the SRT task. This effect of STN DBS on the RT performance in the SRT task was greater as compared with the CRT task. This is due to the more complex information processing that is required in the CRT task as compared to the SRT task. These data suggest that treatment of STN hyperactivity by DBS improves motor function, confirming earlier reports, but has a differential effect on cognitive functions. The STN seems to be an important modulator of cognitive processing and STN DBS can differentially affect motor and associative circuits.

The functional role of the subthalamic nucleus in cognitive and limbic circuits

Once it was believed that the subthalamic nucleus (STN) was no more than a relay station serving as a "gate" for ascending basal ganglia-thalamocortical circuits. Nowadays, the STN is considered to be one of the main regulators of motor function related to the basal ganglia. The role of the STN in the regulation of associative and limbic functions related to the basal ganglia has generally received little attention. In the present review, the functional role of the STN in the control of cortico-basal ganglia-thalamocortical associative and limbic circuits is discussed. In the past 20 years the concepts about the functional role of the STN have changed dramatically: from being an inhibitory nucleus to a potent excitatory nucleus, and from being involved in hyperkinesias to hypokinesias. However, it has been demonstrated only recently, mainly by reports on the behavioral (side-) effects of STN deep brain stimulation (DBS), which is a popular surgical technique in the treatment of patients suffering from advanced Parkinson Disease (PD), that the STN is clinically involved in associative and limbic functions. These findings were confirmed by results from animal studies. Experimental studies applying STN DBS or STN lesions to investigate the neuronal mechanisms involved in these procedures found profound effects on cognitive and motivational parameters. The anatomical, electrophysiological and behavioral data presented in this review point towards a potent regulatory function of the STN in the processing of associative and limbic information towards cortical and subcortical regions. In conclusion, it can be stated that the STN has anatomically a central position within the basal ganglia thalamocortical associative and limbic circuits and is functionally a potent regulator of these pathways.

Extradural Motor Cortex Stimulation in Advanced Parkinson's Disease: The Turin Experience: Technical Case Report

OBJECTIVE AND IMPORTANCE:

At our institution, extradural motor cortex stimulation (EMCS) has recently been applied for treating Parkinson's disease symptoms. We report our results and review the literature supporting this application of EMCS.

CLINICAL PRESENTATION:

Since 1998, six patients affected by advanced Parkinson's disease and not fulfilling inclusion criteria for deep brain stimulation underwent EMCS.

INTERVENTION:

A quadripolar electrode was introduced in the extradural space over the motor cortex, opposite to the side on which parkinsonian symptoms had begun. Bipolar chronic electrostimulation was delivered at 2.5 to 6 V, 150 to 180 microseconds, and 25 to 40 Hz. Preoperative and postoperative clinical status was assessed by the Unified Parkinson's Disease Rating Scale (UPDRS) and recorded on videotapes. The follow-up of this series varied from 4 months to 2.5 years. After EMCS, the overall UPDRS score decreased by 42 to 62%; Section III UPDRS score (motility evaluation) by 32 to 83%; and Section IV UPDRS score (therapy complications) by 100% in two patients, by 50 to 67% in four patients, and by 33% in one patient. l-Dopa therapy was reduced by 11 to 33% in three patients and by 70 to 73% in the other two patients. No postoperative complications or negative side effects of electrostimulation were recorded, except for a misplacement of the electrodes in one patient.

CONCLUSION:

Unilateral EMCS relieves, at least partially, but sometimes dramatically, the whole spectrum of symptoms in advanced Parkinson's disease. l-Dopa may be reduced up to 70%. The symptoms of long-term l-dopa syndrome are usually markedly improved. The neurophysiological mechanisms involved are still under debate. Our clinical experience adds favorable data to enlarge the series of parkinsonian patients treated by EMCS.

Abolition of spindle oscillations and 3-Hz absence seizurelike activity in the thalamus by using high-frequency stimulation: potential mechanism of action

OBJECT

The mechanism of action whereby high-frequency stimulation (HFS) in the thalamus ameliorates tremor and epilepsy is unknown. The authors studied the effects of HFS on thalamocortical relay neurons in a ferret in vitro slice preparation to test the hypothesis that HFS abolishes synchronized oscillations by neurotransmitter release.

METHODS

Intracellular and extracellular electrophysiological recordings were made in thalamic slices. The neurons in the thalamic slice spontaneously generated spindle oscillations, and treatment with picrotoxin, a gamma-aminobutyric acid A receptor antagonist, resulted in 3- to 4-Hz absence seizurelike activity. High-frequency stimulation (stimulation parameters: 10-1000-microA amplitude; l00-microsec pulse width; 100-Hz frequency; 1-60 seconds) was applied using a concentric bipolar stimulating electrode placed adjacent to the recording electrodes. High-frequency stimulation within the thalamus generated inhibitory and excitatory postsynaptic potentials, membrane depolarization, an increase in action potential firing during the stimulation period, and abolished the spindle oscillations in the thalamocortical relay neurons. High-frequency stimulation applied to 20-microM picrotoxin-treated slices eliminated the 3- to 4-Hz absence seizurelike activity.

CONCLUSIONS

High-frequency stimulation eliminates spontaneous spindle oscillations and picrotoxin-induced absence seizurelike activity in thalamic slices by synaptic neurotransmitter release; thus, HFS may abolish synchronous oscillatory activities such as those that generate tremor and seizures. Paradoxically, HFS, which is excitatory, and surgical lesions of the ventrointermedius thalamus, which are presumably inhibitory, both suppress tremors. This paradox is resolved by recognizing that HFS-mediated neurotransmitter release and thalamic surgery both disrupt the circuit generating tremor or seizure, albeit by different mechanisms.

Acute and separate modulation of motor and cognitive performance in parkinsonian rats by bilateral stimulation of the subthalamic nucleus

The subthalamic nucleus (STN) is involved in motor and cognitive performance through its key role in the basal ganglia-thalamocortical circuits, but how these different modalities (motor and cognition) are controlled (similar vs. dissimilar) has not yet been elucidated. In the present study, the effects of bilateral STN deep brain stimulation (DBS) on motor and cognitive performance were investigated in a rat model of Parkinson disease (PD). After being trained in a choice reaction time (CRT) task, rats received bilateral injections of 6-hydroxydopamine (6-OHDA) into the striatum. One group of 6-OHDA animals was implanted bilaterally with stimulation electrodes at the level of the STN. Stimulations were performed at 130 Hz (frequency), 60 micros (pulse width), and varying amplitudes of 1, 3, 30, and 150 microA during the CRT task. Finally, rats were sacrificed and the brains processed for staining to determine the dopaminergic lesion (TH immunohistochemistry) and localization of the electrode tip (HE histochemistry). Bilateral 6-OHDA infusion significantly decreased (70%) the number of dopaminergic cells in the substantia nigra pars compacta (SNc) and increased motor time (MT), proportion of premature responding (PR), and reaction time (RT). Bilateral STN stimulation with an amplitude of 3 microA normalized 6-OHDA-induced deficits in PR and RT. Simulation with an amplitude of 30 microA reversed the lesion-induced deficits in MT and RT. Our data show for the first time that bilateral STN stimulation differentially affected the 6-OHDA-induced motor and cognitive deficits. This means that basal ganglia-thalamocortical motor and associative circuits responsible for specific motor and cognitive performance, which are processed through the STN, have unique physiological properties that can acutely and separately be modulated by specific electrical stimuli.

Normal and pathological oscillatory communication in the brain

The huge number of neurons in the human brain are connected to form functionally specialized assemblies. The brain's amazing processing capabilities rest on local communication within and long-range communication between these assemblies. Even simple sensory, motor and cognitive tasks depend on the precise coordination of many brain areas. Recent improvements in the methods of studying long-range communication have allowed us to address several important questions. What are the common mechanisms that govern local and long-range communication and how do they relate to the structure of the brain? How does oscillatory synchronization subserve neural communication? And what are the consequences of abnormal synchronization?

Deep brain stimulation for treatment-resistant depression

Treatment-resistant depression is a severely disabling disorder with no proven treatment options once multiple medications, psychotherapy, and electroconvulsive therapy have failed. Based on our preliminary observation that the subgenual cingulate region (Brodmann area 25) is metabolically overactive in treatment-resistant depression, we studied whether the application of chronic deep brain stimulation to modulate BA25 could reduce this elevated activity and produce clinical benefit in six patients with refractory depression. Chronic stimulation of white matter tracts adjacent to the subgenual cingulate gyrus was associated with a striking and sustained remission of depression in four of six patients. Antidepressant effects were associated with a marked reduction in local cerebral blood flow as well as changes in downstream limbic and cortical sites, measured using positron emission tomography. These results suggest that disrupting focal pathological activity in limbic-cortical circuits using electrical stimulation of the subgenual cingulate white matter can effectively reverse symptoms in otherwise treatment-resistant depression.

High-frequency stimulation in Parkinson's disease: more or less?

Deep-brain stimulation at high frequency is now considered the most effective neurosurgical therapy for movement disorders. An electrode is chronically implanted in a particular area of the brain and, when continuously stimulated, it significantly alleviates motor symptoms. In Parkinson's disease, common target nuclei of high-frequency stimulation (HFS) are ventral thalamic nuclei and basal ganglia nuclei, such as the internal segment of the pallidum and the subthalamic nucleus (STN), with a preference for the STN in recent years. Two fundamental mechanisms have been proposed to underlie the beneficial effects of HFS: silencing or excitation of STN neurons. Relying on recent experimental data, we suggest that both are instrumental: HFS switches off a pathological disrupted activity in the STN (a 'less' mechanism) and imposes a new type of discharge in the upper gamma-band frequency that is endowed with beneficial effects (a 'more' mechanism). The intrinsic capacity of basal ganglia and particular STN neurons to generate oscillations and shift rapidly from a physiological to a pathogenic pattern is pivotal in the operation of these circuits in health and disease.

Electrical localization of neural activity in the dorsal horn of the spinal cord: a modeling study

Intraspinal microstimulation is a means of eliciting coordinated motor responses for restoration of function. However, detailed maps of the neuroanatomy of the human spinal cord are lacking, and it is not clear where electrodes should be implanted. We developed an electrical approach to localize active neurons in the spinal cord using potentials recorded from the surface of the spinal cord. We evaluated this localization method using an analytical model of the spinal cord and two previously developed inverse algorithms (standardized low resolution brain electromagnetic tomography (sLORETA) and a locally optimal source (LOS) method). The results support electrical source localization as a feasible imaging approach for localizing (within 300 microm) active neurons in the spinal cord. The LOS method could localize the source when 16 recording electrodes were placed on the dorsolateral aspect of the cord and the noise level was 2%. When recording electrodes were positioned around the entire circumference of the spinal cord, either localization method could localize the source, even at 15% noise. Finally, localization error was not sensitive to inaccuracies in the expected electrode positions or the electrical parameters of the forward model, but was sensitive to a geometrical modification of the forward model in one case.

Pallidal deep brain stimulation influences both reflexive and voluntary saccades in Huntington's disease

Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is being evaluated as a potential new therapy for patients with Huntington's disease (HD). In addition to skeletal movement disorders, HD patients have difficulty initiating voluntary saccades and have difficulty in suppressing rapid saccades toward newly appearing stimuli. We measured several saccade parameters in an HD patient who had marked improvement of clinical symptoms with bilateral GPi DBS to determine whether oculomotor performance improved in parallel with clinical scores. Oculomotor performance was assessed using three testing paradigms: pro-saccades, anti-saccades, and memory-guided saccades. The data from the HD patient was also compared to that of two healthy controls. Pallidal DBS decreased pro-saccade latency, total movement time, and the number of correctly executed trials, as well as increasing saccade gain. Memory-saccade performance was negatively affected with stimulation: saccade gain decreased, latency increased, and the patient's ability to suppress unwanted saccades decreased with stimulation. Our data demonstrate a task-specific improvement of oculomotor deficits in this HD patient with pallidal DBS, supporting a role of GPi in oculomotor control.

Extradural Motor Cortex Stimulation (EMCS) for Parkinson’s disease. History and first results by the study group of the Italian neurosurgical society

The preliminary results obtained by the Study Group for Treatment of Involuntary Movements by Extradural Motor Cortex Stimulation (EMCS) of the Italian Neurosurgical Society, are reported. The series includes 16 cases of very advanced Parkinson's Disease (PD), aged 46-81; 15 of them were not eligible for Deep Brain Stimulation. Ten cases have been evaluated at 3-30 months after implantation. Unilateral, sub-threshold extradural motor cortex stimulation (2 8 Volt, 100-400 microsec., 20-120 Hz) by chronically implanted electrodes, relieves, at least partially, but sometime dramatically, the whole spectrum of symptoms of advanced PD. Tremor and rigor bilaterally in all limbs and akinesia are reduced. Standing, gait, motor performance, speech and swallowing are improved. Benefit is marked as far as axial symptoms is concerned. Also the symptoms of Long Term Dopa Syndrome -dyskinesias, motor fluctuations - and other secondary effect of levodopa administration psychiatric symptoms - are improved. Levodopa dosage may be reduced by 50%. The effect seems persistent and does not fade away with time. Improvement ranged, on the basis of the UPDRS scale, from <25% to 75%. There was only one case of complete failure. Quality of life is markedly improved in patients who were absolutely incapable of walking and unable arise out of chair. After stimulation they could walk, even if assistance was necessary. Improvement was observed also in those with disabling motor fluctuation and dyskinesias which could be abolished.

Long-term deep brain stimulation in elderly patients with cardiac pacemakers

Object. Deep brain stimulation (DBS) has become an accepted therapy for movement disorders such as Parkinson disease (PD) and essential tremor (ET), when these conditions are refractory to medical treatment. The presence of a cardiac pacemaker is still considered a contraindication for DBS in functional neurosurgery. The goal of this study was to evaluate the technical and clinical management of DBS for the treatment of movement disorders in elderly patients with cardiac pacemakers.

Methods. Six patients with cardiac pacemakers underwent clinical and cardiac examinations to analyze the safety of DBS in the treatment of movement disorders. Four patients suffered from advanced PD and two patients had ET. The mean age of these patients at surgery was 69.5 years (range 63–79 years). The settings of the pacemakers were programmed in a manner considered to minimize the chance of interference between the two systems.

There were no adverse events during surgery. Four patients underwent stimulation of the thalamic ventralis intermedius nucleus (VIM), and two patients stimulation of the subthalamic nucleus. In general, bipolar sensing was chosen for the cardiac pacemakers. In all but one patient the quadripolar DBS electrodes were programmed for bipolar stimulation. Several control electrocardiography studies, including 24-hour monitoring, did not show any interference between the two systems. At the time this paper was written the patients had been followed up for a mean of 25.3 months (range 4–48 months).

Conclusions. In certain conditions it is safe for patients with cardiac pacemakers to receive DBS for treatment of concomitant movement disorders. Cardiac pacemakers should not be viewed as a general contraindication for DBS in patients with movement disorders.

Monopolar versus bipolar high frequency stimulation in the rat subthalamic nucleus: differences in histological damage

The aim of the present study was to determine the effects of monopolar and bipolar high frequency stimulation (HFS) on histological damage and current flow using a commonly applied stimulus amplitude (300 microA). Bipolar HFS resulted in a large amount of histological damage whereas with monopolar HFS no damage was observed except for the electrode trajectory. Oscilloscopic readings confirmed that this was due to the application of twice as much current to the target with bipolar HFS. Our results demonstrate that there are differences in tissue damage dependent of polarity. In order to create a better comparison to the clinical condition, we suggest that the present rodent models for studying the effect of chronic HFS require further adjustment. This can be achieved by decreasing the present current densities to a level comparable to the human situation.

Neurotransmitter release from high-frequency stimulation of the subthalamic nucleus

Object. High-frequency stimulation (HFS) delivered through implanted electrodes in the subthalamic nucleus (STN) has become an established treatment for Parkinson disease (PD). The precise mechanism of action of deep brain stimulation (DBS) in the STN is unknown, however. In the present study, the authors tested the hypothesis that HFS within the STN changes neuronal action potential firing rates during the stimulation period by modifying neurotransmitter release.

Methods. Intracellular electrophysiological recordings were obtained using sharp electrodes in rat STN neurons in an in vitro slice preparation. A concentric bipolar stimulating electrode was placed in the STN slice, and electrical stimulation (pulse width 50–100 µsec, duration 100–2000 µsec, amplitude 10–500 µA, and frequency 10–200 Hz) was delivered while simultaneously obtaining intracellular recordings from an STN neuron.

High-frequency stimulation of the STN either generated excitatory postsynaptic potentials (EPSPs) and increased the action potential frequency or it generated inhibitory postsynaptic potentials and decreased the action potential frequency of neurons within the STN. These effects were blocked after antagonists to glutamate and γ-aminobutyric acid were applied to the tissue slice, indicating that HFS resulted in the release of neurotransmitters. Intracellular recordings from substantia nigra pars compacta (SNc) dopaminergic neurons during HFS of the STN revealed increased generation of EPSPs and increased frequency of action potentials in SNc neurons.

Conclusions. During HFS of STN neurons the mechanism of DBS may involve the release of neurotransmitters rather than the primary electrogenic inhibition of neurons.

The pallidofugal motor fiber system in primates

The organization of the pallidofugal fiber system originating from the internal segment of the globus pallidus (GPi) in cynomolgus monkeys (Macaca fascicularis) was studied by means of a single-axon tracing method. The primate GPi is composed of a majority of neurons endowed with a highly collateralized axon that projects to the premotor neurons located in the ventral tier thalamic nuclei, the center-médian/parafascicular thalamic complex and the brainstem pedunculopontine nucleus. These axons often follow a long and tortuous course within the GPi and then emerge either through the ansa lenticularis (AL) or the lenticular fasciculus (LF), irrespective of the location of their parent cell body in the GPi. Other pallidofugal axons exit through the medial pole of the GPi, at various distances between the AL ventrally and the LF dorsally. Virtually all pallidofugal axons course through Forel's field H, on their way to the thalamus and brainstem. They emit numerous short collaterals and boutons en passant in this sector of the subthalamic region, which stands out as a major target of GPi axons. Our results indicate that AL and LF do not form separate anatomical entities, each carrying axons originating from distinct functional pallidal territories, as commonly believed. Instead, these two fascicles form the ventral and dorsal borders of a morphological continuum that harbors a multitude of pallidofugal axons arising from all sectors of the GPi. This type of information should be taken into account when interpreting data from deep brain stimulation applied to pallidal and subthalamic regions in Parkinson's disease.

Premature responding following bilateral stimulation of the rat subthalamic nucleus is amplitude and frequency dependent

The subthalamic nucleus (STN), a key component of the basal ganglia circuitry, functions as an internal clock that regulates the correct sequence of movements in a motor response. The importance of the STN in motor function is evidenced by its involvement in Parkinson disease (PD). This nucleus has also been associated with the attentional and emotional aspects of motor behavior through its connections with the limbic and prefrontal areas of the brain. As lesions of the STN have been shown to increase premature responding in a serial reaction time task in rats, indicative of its involvement in cognitive performance, the present study aimed to investigate whether bilateral deep brain stimulation (DBS) of the STN, in non-lesioned rats, affects cognitive functions and whether these are dependent on certain stimulation parameters. Rats were trained in a choice reaction time task and implanted bilaterally with electrodes. Stimulation parameters (amplitude, frequency and pulse width) were varied during the test procedure, after which rats were sacrificed and the brains processed for histochemical staining. Results show no change in reaction times or motor times during stimulation. However, a linear decrease in premature responses was observed with decreasing amplitudes and at high frequencies only. These results are the first to demonstrate that bilateral STN HFS has a positive effect on cognition in freely moving rats. This latter result is in contrast to findings following lesions of the STN, and suggests that current strength and frequency of stimulation are parameters that are integral to the mediation of stimulation effects. Furthermore, the overall effects of DBS on neuronal cells cannot be classified simply as being "inhibitory" and evidently mediates its effects by more complex mechanisms than lesions of the same brain area.

Deep brain stimulation surgery for Parkinson's disease: mechanisms and consequences

Despite the introduction of new medications, motor fluctuations and dyskinesias disable a significant proportion of Parkinson's disease patients. This has lead to renewed interest in stereotactic neurosurgery. A skilled team is needed to ensure that patient assessment and selection, operative technique, intraoperative monitoring, and post-operative management are optimised. High frequency stimulation has similar effects to ablative surgery, and is generally preferred. The clinical effects and possible mechanisms of action of deep brain stimulation of the subthalamic nucleus and globus pallidus are reviewed.

Engineering the brain

This chapter examines the ethical issues raised by new technologies that allow investigators to monitor and control the brain, and how they are distinctive from those raised by other medical technologies, such as genetic testing. It begins with a brief review of some new technologies that have emerged from neuroscience. These devices are intended to stimulate selected regions of the brain or peripheral nervous system for therapeutic purposes, or, more recently, as brain-computer interfaces to allow the brain to exchange information with the outsideworld through direct recording of potentials measured by means of electrodes implanted in the motor cortex, or placed on the surface of the head.

Chapter 78 How does DBS work?

Deep brain stimulation (DBS) produces striking effects in patients with various disorders including Parkinson's disease and dystonia, yet its precise mechanism of action is not clear. Because the clinical benefits of lesioning target structures such as the thalamus, globus pallidus and subthalamic nucleus appear to be similar to those achieved by chronic application of stimulation at these structures, it has been surmized that deep brain stimulation produces a functional inactivation or block of the target. This simplistic proposal has supporting and detracting evidence. In the present work we consider the mechanism of action of DBS and provide arguments for and against the stimulation or inhibition of target neural structures.