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Scerrati A, Gozzi A, Cavallo MA, Mantovani G, Antenucci P, Angelini C, Capone JG, De Bonis P, Morgante F, Rispoli V, Sensi M. Thalamic ventral-Oralis complex/rostral zona incerta deep brain stimulation for midline tremor. J Neurol 2024:10.1007/s00415-024-12619-3. [PMID: 39126514 DOI: 10.1007/s00415-024-12619-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 06/20/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024]
Abstract
BACKGROUND Midline Tremor is defined as an isolated or combined tremor that affects the neck, trunk, jaw, tongue, and/or voice and could be part of Essential Tremor (ET), or dystonic tremor. The clinical efficacy of deep brain stimulation for Midline Tremor has been rarely reported. The Ventral Intermediate Nucleus and Globus Pallidus Internus are the preferred targets, but with variable outcomes. Thalamic Ventral-Oralis (VO) complex and Zona Incerta (ZI) are emerging targets for tremor control in various etiologies. OBJECTIVE To report on neuroradiological, neurophysiological targeting and long-term efficacy of thalamic Ventral-Oralis complex and Zona Incerta deep brain stimulation in Midline Tremor. METHODS Three patients (two males and one female) with Midline Tremor in dystonic syndromes were recruited for this open-label study. Clinical, surgical, neurophysiological intraoperative testing and long-term follow-up data are reported. RESULTS Intraoperative testing and reconstruction of volume of tissue activated confirmed the position of the electrodes in the area stimulated between the thalamic Ventral-Oralis complex and Zona Incerta in all patients. All three patients showed optimal control of both tremor and dystonic features at short-term (6 months) and long-term follow-up (up to 6 years). No adverse events occurred. CONCLUSION In the syndromes of Midline Tremor of various origins, the best target for DBS might be difficult to identify. Our results showed that thalamic Ventral-Oralis complex/Zona Incerta may be a viable and safe option even in specific forms of tremor with axial distribution.
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Affiliation(s)
- Alba Scerrati
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Neurosurgery Department, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Andrea Gozzi
- Neurology Department, S. Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy.
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy, via Aldo Moro 8, 44124.
| | - Michele Alessandro Cavallo
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Neurosurgery Department, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Giorgio Mantovani
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Neurosurgery Department, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Pietro Antenucci
- Neurology Department, S. Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy, via Aldo Moro 8, 44124
| | - Chiara Angelini
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Neurosurgery Department, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Jay Guido Capone
- Neurology Department, S. Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
| | - Pasquale De Bonis
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
- Neurosurgery Department, S. Anna University Hospital of Ferrara, Ferrara, Italy
| | - Francesca Morgante
- Neurosciences and Cell Biology Institute, Neuromodulation and Motor Control Section, St George's University of London, London, UK
| | - Vittorio Rispoli
- Neurology, Neuroscience Head Neck Department, University of Modena and Reggio Emilia, Modena, Italy
| | - Mariachiara Sensi
- Neurology Department, S. Anna University Hospital of Ferrara, Via Aldo Moro 8, 44124, Ferrara, Italy
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Wong JK, Lopes JMLJ, Hu W, Wang A, Au KLK, Stiep T, Frey J, Toledo JB, Raike RS, Okun MS, Almeida L. Double blind, nonrandomized crossover study of active recharge biphasic deep brain stimulation for primary dystonia. Parkinsonism Relat Disord 2023; 109:105328. [PMID: 36827951 DOI: 10.1016/j.parkreldis.2023.105328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/19/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the globus pallidus interna (GPi) is an effective therapy for select patients with primary dystonia. DBS programming for dystonia is often challenging due to variable time to symptomatic improvement or stimulation induced side effects (SISE) such as capsular or optic tract activation which can prolong device optimization. OBJECTIVE To characterize the safety and tolerability of active recharge biphasic DBS (bDBS) in primary dystonia and to compare it to conventional clinical DBS (clinDBS). METHODS Ten subjects with primary dystonia and GPi DBS underwent a single center, double blind, nonrandomized crossover study comparing clinDBS versus bDBS. The testing occurred over two-days. bDBS and clinDBS were administered on separate days and each was activated for 6 h. Rating scales were collected by video recording and scored by four blinded movement disorders trained neurologists. RESULTS The bDBS paradigm was safe and well-tolerated in all ten subjects. There were no persistent SISE reported. The mean change in the Unified Dystonia Rating Scale after 4 h of stimulation was greater in bDBS when compared to clinDBS (-6.5 vs 0.3, p < 0.04). CONCLUSION In this pilot study, we demonstrated that biphasic DBS is a novel stimulation paradigm which can be administered safely. The biphasic waveform revealed a greater immediate improvement. Further studies are needed to determine whether this immediate improvement persists with chronic stimulation or if clinDBS will eventually achieve similar levels of improvement to bDBS over time.
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Affiliation(s)
- Joshua K Wong
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States.
| | - Janine Melo Lobo Jofili Lopes
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Wei Hu
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Anson Wang
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Ka Loong Kelvin Au
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Tamara Stiep
- Department of Neurology, UCSF Weill Institute for Neurosciences, Movement Disorder and Neuromodulation Center, University of California San Francisco, CA, United States
| | - Jessica Frey
- Department of Neurology, Rockefeller Neurosciences Institute, West Virginia University, Morgantown, WV, United States
| | - Jon B Toledo
- Nantz National Alzheimer Center, Stanley H. Appel Department of Neurology, Houston Methodist Hospital, Houston, TX, United States
| | - Robert S Raike
- Restorative Therapies Group Implantables, Research and Core Technology, Medtronic Inc., Minneapolis, MN, United States
| | - Michael S Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Leonardo Almeida
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
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Patel B, Chiu S, Wong JK, Patterson A, Deeb W, Burns M, Zeilman P, Wagle-Shukla A, Almeida L, Okun MS, Ramirez-Zamora A. Deep brain stimulation programming strategies: segmented leads, independent current sources, and future technology. Expert Rev Med Devices 2021; 18:875-891. [PMID: 34329566 DOI: 10.1080/17434440.2021.1962286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: Advances in neuromodulation and deep brain stimulation (DBS) technologies have facilitated opportunities for improved clinical benefit and side effect management. However, new technologies have added complexity to clinic-based DBS programming.Areas covered: In this article, we review basic basal ganglia physiology, proposed mechanisms of action and technical aspects of DBS. We discuss novel DBS technologies for movement disorders including the role of advanced imaging software, lead design, IPG design, novel programming techniques including directional stimulation and coordinated reset neuromodulation. Additional topics include the use of potential biomarkers, such as local field potentials, electrocorticography, and adaptive stimulation. We will also discuss future directions including optogenetically inspired DBS.Expert opinion: The introduction of DBS for the management of movement disorders has expanded treatment options. In parallel with our improved understanding of brain physiology and neuroanatomy, new technologies have emerged to address challenges associated with neuromodulation, including variable effectiveness, side-effects, and programming complexity. Advanced functional neuroanatomy, improved imaging, real-time neurophysiology, improved electrode designs, and novel programming techniques have collectively been driving improvements in DBS outcomes.
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Affiliation(s)
- Bhavana Patel
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Shannon Chiu
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Joshua K Wong
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Addie Patterson
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Wissam Deeb
- Department of Neurology, University of Massachusetts College of Medicine, Worcester, MA, USA
| | - Matthew Burns
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Pamela Zeilman
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Aparna Wagle-Shukla
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Leonardo Almeida
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Michael S Okun
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
| | - Adolfo Ramirez-Zamora
- Department of Neurology, University of Florida College of Medicine, Gainesville, FL, USA.,Norman Fixel Institute for Neurological Diseases, . Gainesville, FL, USA
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4
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Listik C, Listik E, Cury RG, Barbosa ER, Teixeira MJ, Andrade DCD. Deep brain stimulation treatment in dystonia: a bibliometric analysis. ARQUIVOS DE NEURO-PSIQUIATRIA 2020; 78:586-592. [PMID: 33053012 DOI: 10.1590/0004-282x20200016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/27/2020] [Indexed: 08/11/2023]
Abstract
BACKGROUND Dystonia is a heterogeneous disorder that, when refractory to medical treatment, may have a favorable response to deep brain stimulation (DBS). A practical way to have an overview of a research domain is through a bibliometric analysis, as it makes it more accessible for researchers and others outside the field to have an idea of its directions and needs. OBJECTIVE To analyze the 100 most cited articles in the use of DBS for dystonia treatment in the last 30 years. METHODS The research protocol was performed in June 2019 in Elsevier's Scopus database, by retrieving the most cited articles regarding DBS in dystonia. We analyzed authors, year of publication, country, affiliation, and targets of DBS. RESULTS Articles are mainly published in Movement Disorders (19%), Journal of Neurosurgery (9%), and Neurology (9%). European countries offer significant contributions (57% of our sample). France (192.5 citations/paper) and Germany (144.1 citations/paper) have the highest citation rates of all countries. The United States contributes with 31% of the articles, with 129.8 citations/paper. The publications are focused on General outcomes (46%), followed by Long-term outcomes (12.5%), and Complications (11%), and the leading type of dystonia researched is idiopathic or inherited, isolated, segmental or generalized dystonia, with 27% of articles and 204.3 citations/paper. CONCLUSIONS DBS in dystonia research is mainly published in a handful of scientific journals and focused on the outcomes of the surgery in idiopathic or inherited, isolated, segmental or generalized dystonia, and with globus pallidus internus as the main DBS target.
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Affiliation(s)
- Clarice Listik
- Universidade de São Paulo, Departamento de Neurologia, Centro de Distúrbios do Movimento, São Paulo SP, Brazil
| | - Eduardo Listik
- Universidade Federal de São Paulo, Departamento de Bioquímica, São Paulo SP, Brazil
| | - Rubens Gisbert Cury
- Universidade de São Paulo, Departamento de Neurologia, Centro de Distúrbios do Movimento, São Paulo SP, Brazil
| | - Egberto Reis Barbosa
- Universidade de São Paulo, Departamento de Neurologia, Centro de Distúrbios do Movimento, São Paulo SP, Brazil
| | | | - Daniel Ciampi de Andrade
- Universidade de São Paulo, Departamento de Neurologia, Centro de Distúrbios do Movimento, São Paulo SP, Brazil.,Instituto do Câncer do Estado de São Paulo, Centro de Dor, São Paulo SP, Brazil
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5
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Aubignat M, Lefranc M, Tir M, Krystkowiak P. Deep brain stimulation programming in Parkinson's disease: Introduction of current issues and perspectives. Rev Neurol (Paris) 2020; 176:770-779. [DOI: 10.1016/j.neurol.2020.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 01/28/2020] [Accepted: 02/12/2020] [Indexed: 12/11/2022]
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6
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Chiu SY, Tsuboi T, Hegland KW, Herndon NE, Shukla AW, Patterson A, Almeida L, Foote KD, Okun MS, Ramirez-Zamora A. Dysarthria and Speech Intelligibility Following Parkinson’s Disease Globus Pallidus Internus Deep Brain Stimulation. JOURNAL OF PARKINSONS DISEASE 2020; 10:1493-1502. [DOI: 10.3233/jpd-202246] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Although earlier studies reported variable speech changes following subthalamic nucleus (STN) deep brain stimulation (DBS) in Parkinson’s disease (PD) patients, the effects of globus pallidus internus (GPi) DBS on speech performance in PD remain largely unknown. Objective: We aimed to characterize speech changes following PD GPi-DBS. Methods: We retrospectively analyzed clinical and speech outcomes of 25 PD patients treated with bilateral GPi-DBS at a single center. Outcome measures included the Unified Parkinson’s Disease Rating Scale (UPDRS), speech subsystem domains (respiratory, laryngeal, resonance, orofacial, rate, prosody, rhythm, and naturalness), and overall speech intelligibility. Scores at baseline were compared with those at 6 months, 1 year, and the longest clinical follow-up available. Results: In the off-medication state, activities of daily living and motor function based on UPDRS II and III significantly improved postoperatively. We observed unique patterns of speech changes in patients with PD following GPi-DBS in the short- (n = 25) and longer-term (n = 8) follow-up periods. Velopharyngeal (resonance), laryngeal components, and prosody worsened after bilateral GPi-DBS (p < 0.015). Speech intelligibility did not worsen after GPi-DBS in the short-term, but there was a trend to deteriorate at long-term follow-up (e.g., one year and beyond). We observed worsening of hypokinetic dysarthria in individual patients. Also, a minority of patients developed stuttering, spastic dysarthria, or ataxic dysarthria. Conclusion: Bilateral GPi-DBS worsened several modalities of parkinsonian speech without compromising overall speech intelligibility. GPi-DBS can potentially worsen or induce hypokinetic dysarthria, stuttering, spastic dysarthria, or ataxic dysarthria. GPi-DBS may have different and variable effects on speech function when compared to STN-DBS.
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Affiliation(s)
- Shannon Y. Chiu
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Takashi Tsuboi
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Karen W. Hegland
- UF Health Rehab Center at the Norman Fixel Institute for Neurological Diseases, Gainesville, FL, USA
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
| | - Nicole E. Herndon
- UF Health Rehab Center at the Norman Fixel Institute for Neurological Diseases, Gainesville, FL, USA
- Department of Speech, Language, and Hearing Sciences, University of Florida, Gainesville, FL, USA
| | - Aparna Wagle Shukla
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Addie Patterson
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Leonardo Almeida
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Kelly D. Foote
- Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Michael S. Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
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7
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Maruyama S, Fukunaga M, Fautz HP, Heidemann R, Sadato N. Comparison of 3T and 7T MRI for the visualization of globus pallidus sub-segments. Sci Rep 2019; 9:18357. [PMID: 31797993 PMCID: PMC6892946 DOI: 10.1038/s41598-019-54880-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 11/20/2019] [Indexed: 12/17/2022] Open
Abstract
The success of deep brain stimulation (DBS) targeting the internal globus pallidus (GPi) depends on the accuracy of electrode localization inside the GPi. In this study, we sought to compare visualization of the medial medullary lamina (MML) and accessory medullary lamina (AML) between proton density-weighted (PDW) and T2-weighted (T2W) sequences on 3T and 7T MRI scanners. Eleven healthy participants (five men and six women; age, 19–28 years; mean, 21.5) and one 61-year-old man were scanned using two-dimensional turbo spin-echo PDW and T2W sequences on 3T and 7T MRI scanners with a 32-channel receiver head coil and a single-channel transmission coil. Profiles of signal intensity were obtained from the pixel values of straight lines over the GP regions crossing the MML and AML. Contrast ratios (CRs) for GPe/MML, GPie/MML, GPie/AML, and GPii/AML were calculated. Qualitatively, 7T visualized both the MML and AML, whereas 3T visualized the MML less clearly and hardly depicted the AML. The T2W sequence at 7T yielded significantly higher CRs for GPie/MML, GPie/AML, and GPii/AML than the PDW sequence at 7T or 3T. The T2W sequence at 7T allows visualization of the internal structures of GPi segments with high signal intensity and contrast.
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Affiliation(s)
- Shuki Maruyama
- Department of System Neuroscience, Division of Cerebral Integration, National Institute for Physiological Sciences (NIPS), 38 Nishigonaka, Myodaiji, Okazaki, Aichi, 444-8585, Japan.,Department of Physiological Sciences, School of Life Science, SOKENDAI (The Graduate University for Advanced Studies), Shonan Village, Hayama, Kanagawa, 240-0193, Japan
| | - Masaki Fukunaga
- Department of System Neuroscience, Division of Cerebral Integration, National Institute for Physiological Sciences (NIPS), 38 Nishigonaka, Myodaiji, Okazaki, Aichi, 444-8585, Japan.,Department of Physiological Sciences, School of Life Science, SOKENDAI (The Graduate University for Advanced Studies), Shonan Village, Hayama, Kanagawa, 240-0193, Japan
| | - Hans-Peter Fautz
- Siemens Healthineers, Allee am Roethelheimpark 2, 91052, Erlangen, Germany
| | - Robin Heidemann
- Siemens Healthineers, Allee am Roethelheimpark 2, 91052, Erlangen, Germany
| | - Norihiro Sadato
- Department of System Neuroscience, Division of Cerebral Integration, National Institute for Physiological Sciences (NIPS), 38 Nishigonaka, Myodaiji, Okazaki, Aichi, 444-8585, Japan. .,Department of Physiological Sciences, School of Life Science, SOKENDAI (The Graduate University for Advanced Studies), Shonan Village, Hayama, Kanagawa, 240-0193, Japan.
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8
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Koeglsperger T, Palleis C, Hell F, Mehrkens JH, Bötzel K. Deep Brain Stimulation Programming for Movement Disorders: Current Concepts and Evidence-Based Strategies. Front Neurol 2019; 10:410. [PMID: 31231293 PMCID: PMC6558426 DOI: 10.3389/fneur.2019.00410] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/04/2019] [Indexed: 11/16/2022] Open
Abstract
Deep brain stimulation (DBS) has become the treatment of choice for advanced stages of Parkinson's disease, medically intractable essential tremor, and complicated segmental and generalized dystonia. In addition to accurate electrode placement in the target area, effective programming of DBS devices is considered the most important factor for the individual outcome after DBS. Programming of the implanted pulse generator (IPG) is the only modifiable factor once DBS leads have been implanted and it becomes even more relevant in cases in which the electrodes are located at the border of the intended target structure and when side effects become challenging. At present, adjusting stimulation parameters depends to a large extent on personal experience. Based on a comprehensive literature search, we here summarize previous studies that examined the significance of distinct stimulation strategies for ameliorating disease signs and symptoms. We assess the effect of adjusting the stimulus amplitude (A), frequency (f), and pulse width (pw) on clinical symptoms and examine more recent techniques for modulating neuronal elements by electrical stimulation, such as interleaving (Medtronic®) or directional current steering (Boston Scientific®, Abbott®). We thus provide an evidence-based strategy for achieving the best clinical effect with different disorders and avoiding adverse effects in DBS of the subthalamic nucleus (STN), the ventro-intermedius nucleus (VIM), and the globus pallidus internus (GPi).
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Affiliation(s)
- Thomas Koeglsperger
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Carla Palleis
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Franz Hell
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität München, Martinsried, Germany
| | - Jan H Mehrkens
- Department of Neurosurgery, Ludwig Maximilians University, Munich, Germany
| | - Kai Bötzel
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
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9
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Magown P, Andrade RA, Soroceanu A, Kiss ZH. Deep brain stimulation parameters for dystonia: A systematic review. Parkinsonism Relat Disord 2018; 54:9-16. [DOI: 10.1016/j.parkreldis.2018.04.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 03/27/2018] [Accepted: 04/16/2018] [Indexed: 11/28/2022]
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10
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Shirvalkar P, Veuthey TL, Dawes HE, Chang EF. Closed-Loop Deep Brain Stimulation for Refractory Chronic Pain. Front Comput Neurosci 2018; 12:18. [PMID: 29632482 PMCID: PMC5879131 DOI: 10.3389/fncom.2018.00018] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/07/2018] [Indexed: 01/09/2023] Open
Abstract
Pain is a subjective experience that alerts an individual to actual or potential tissue damage. Through mechanisms that are still unclear, normal physiological pain can lose its adaptive value and evolve into pathological chronic neuropathic pain. Chronic pain is a multifaceted experience that can be understood in terms of somatosensory, affective, and cognitive dimensions, each with associated symptoms and neural signals. While there have been many attempts to treat chronic pain, in this article we will argue that feedback-controlled ‘closed-loop’ deep brain stimulation (DBS) offers an urgent and promising route for treatment. Contemporary DBS trials for chronic pain use “open-loop” approaches in which tonic stimulation is delivered with fixed parameters to a single brain region. The impact of key variables such as the target brain region and the stimulation waveform is unclear, and long-term efficacy has mixed results. We hypothesize that chronic pain is due to abnormal synchronization between brain networks encoding the somatosensory, affective and cognitive dimensions of pain, and that multisite, closed-loop DBS provides an intuitive mechanism for disrupting that synchrony. By (1) identifying biomarkers of the subjective pain experience and (2) integrating these signals into a state-space representation of pain, we can create a predictive model of each patient's pain experience. Then, by establishing how stimulation in different brain regions influences individual neural signals, we can design real-time, closed-loop therapies tailored to each patient. While chronic pain is a complex disorder that has eluded modern therapies, rich historical data and state-of-the-art technology can now be used to develop a promising treatment.
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Affiliation(s)
- Prasad Shirvalkar
- Pain Management Division, Departments of Neurology and Anesthesiology, University of California, San Francisco, San Francisco, CA, United States.,Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Tess L Veuthey
- Neuroscience Graduate Program, University of California, San Francisco, San Francisco, CA, United States
| | - Heather E Dawes
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Edward F Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
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11
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Xu SH, Yang C, Xian WB, Gu J, Liu JL, Jiang LL, Ye J, Liu YM, Guo QY, Zheng YF, Wu L, Chen WR, Pei Z, Chen L. Voltage adjustment improves rigidity and tremor in Parkinson's disease patients receiving deep brain stimulation. Neural Regen Res 2018; 13:347-352. [PMID: 29557387 PMCID: PMC5879909 DOI: 10.4103/1673-5374.226406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Deep brain stimulation of the subthalamic nucleus is recognized as the most effective treatment for moderate and advanced Parkinson's disease. Programming of the stimulation parameters is important for maintaining the efficacy of deep brain stimulation. Voltage is considered to be the most effective programming parameter. The present study is a retrospective analysis of six patients with Parkinson's disease (four men and two women, aged 37–65 years), who underwent bilateral deep brain stimulation of the subthalamic nucleus at the First Affiliated Hospital of Sun Yat-sen University, China, and who subsequently adjusted only the stimulation voltage. We evaluated motor symptom severity using the Unified Parkinson's Disease Rating Scale Part III, symptom progression using the Hoehn and Yahr scale, and the levodopa equivalent daily dose, before surgery and 1 and 2 years after surgery. The 2-year follow-up results show that rigidity and tremor improved, and clinical symptoms were reduced, while pulse width was maintained at 60 μs and frequency at 130 Hz. Voltage adjustment alone is particularly suitable for patients who cannot tolerate multiparameter program adjustment. Levodopa equivalent daily dose was markedly reduced 1 and 2 years after surgery compared with baseline. Our results confirm that rigidity, tremor and bradykinesia can be best alleviated by voltage adjustment. The trial was registered at ClinicalTrials.gov (identifier: NCT01934881).
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Affiliation(s)
- Shao-Hua Xu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Chao Yang
- Department of Neurosurgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Wen-Biao Xian
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jing Gu
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jin-Long Liu
- Department of Neurosurgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Lu-Lu Jiang
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jing Ye
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province; Department of Neurology, Tangshan Worker's Hospital, Tangshan, Hebei Province, China
| | - Yan-Mei Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Qi-Yu Guo
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Yi-Fan Zheng
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Lei Wu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Wan-Ru Chen
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Zhong Pei
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ling Chen
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
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Mogilner AY, Machado AG, Rezai AR. Deep Brain Stimulation. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00036-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ramasubbu R, Lang S, Kiss ZHT. Dosing of Electrical Parameters in Deep Brain Stimulation (DBS) for Intractable Depression: A Review of Clinical Studies. Front Psychiatry 2018; 9:302. [PMID: 30050474 PMCID: PMC6050377 DOI: 10.3389/fpsyt.2018.00302] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 06/18/2018] [Indexed: 01/16/2023] Open
Abstract
Background: The electrical parameters used for deep brain stimulation (DBS) in movement disorders have been relatively well studied, however for the newer indications of DBS for psychiatric indications these are less clear. Based on the movement disorder literature, use of the correct stimulation parameters should be crucial for clinical outcomes. This review examines the stimulation parameters used in DBS studies for treatment resistant depression (TRD) and their relevance to clinical outcome and brain targets. Methods: We examined the published studies on DBS for TRD archived in major databases. Data on stimulus parameters (frequency, pulse width, amplitude), stimulation mode, brain target, efficacy, safety, and duration of follow up were extracted from 29 observational studies including case reports of patients with treatment resistant unipolar, bipolar, and co-morbid depression. Results: The algorithms commonly used to optimize efficacy were increasing amplitude followed by changing the electric contacts or increasing pulse width. High frequency stimulation (>100 Hz) was applied in most cases across brain targets. Keeping the high frequency stimulation constant, three different combinations of parameters were mainly used: (i) short pulse width (60-90 us) and low amplitude (0-4 V), (ii) short pulse width and high amplitude (5-10 V), (iii) long pulse width (120-450 us) and low amplitude. There were individual variations in clinical response to electrical dosing and also in the time of clinical recovery. There was no significant difference in mean stimulation parameters between responders and non-responders suggesting a role for stimulation unrelated factors in response. Conclusions: Although limited by open trials and small sample size, three optimal stimulation parameter combinations emerged from this review. Studies are needed to assess the comparative efficacy and safety of these combinations, such as a registry of data from patients undergoing DBS for TRD with individual data on stimulation parameters.
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Affiliation(s)
- Rajamannar Ramasubbu
- Department of Psychiatry and Clinical Neurosciences, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Stefan Lang
- Department of Psychiatry and Clinical Neurosciences, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Zelma H T Kiss
- Department of Psychiatry and Clinical Neurosciences, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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DBS Programming: An Evolving Approach for Patients with Parkinson's Disease. PARKINSONS DISEASE 2017; 2017:8492619. [PMID: 29147598 PMCID: PMC5632902 DOI: 10.1155/2017/8492619] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 07/03/2017] [Accepted: 07/19/2017] [Indexed: 11/18/2022]
Abstract
Deep brain stimulation (DBS) surgery is a well-established therapy for control of motor symptoms in Parkinson's disease. Despite an appropriate targeting and an accurate placement of DBS lead, a thorough and efficient programming is critical for a successful clinical outcome. DBS programming is a time consuming and laborious manual process. The current approach involves use of general guidelines involving determination of the lead type, electrode configuration, impedance check, and battery check. However there are no validated and well-established programming protocols. In this review, we will discuss the current practice and the recent advances in DBS programming including the use of interleaving, fractionated current, directional steering of current, and the use of novel DBS pulses. These technological improvements are focused on achieving a more efficient control of clinical symptoms with the least possible side effects. Other promising advances include the introduction of computer guided programming which will likely impact the efficiency of programming for the clinicians and the possibility of remote Internet based programming which will improve access to DBS care for the patients.
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Sakas DE, Leonardos A, Boviatsis E, Gatzonis S, Panourias I, Stathis P, Stavrinou LC. Constant-Current Deep Brain Stimulation of the Globus Pallidus Internus in the Treatment of Primary Dystonia by a Novel 8-Contact (Octrode) Lead. World Neurosurg 2017; 103:45-56. [DOI: 10.1016/j.wneu.2017.03.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 03/19/2017] [Accepted: 03/20/2017] [Indexed: 12/31/2022]
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Wagle Shukla A, Okun MS. State of the Art for Deep Brain Stimulation Therapy in Movement Disorders: A Clinical and Technological Perspective. IEEE Rev Biomed Eng 2016; 9:219-33. [PMID: 27411228 DOI: 10.1109/rbme.2016.2588399] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Deep brain stimulation (DBS) therapy is a widely used brain surgery that can be applied for many neurological and psychiatric disorders. DBS is American Food and Drug Administration approved for medication refractory Parkinson's disease, essential tremor and dystonia. Although DBS has shown consistent success in many clinical trials, the therapy has limitations and there are well-recognized complications. Thus, only carefully selected patients are ideal candidates for this surgery. Over the last two decades, there have been significant advances in clinical knowledge on DBS. In addition, the surgical techniques and technology related to DBS has been rapidly evolving. The goal of this review is to describe the current status of DBS in the context of movement disorders, outline the mechanisms of action for DBS in brief, discuss the standard surgical and imaging techniques, discuss the patient selection and clinical outcomes in each of the movement disorders, and finally, introduce the recent advancements from a clinical and technological perspective.
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Picillo M, Lozano AM, Kou N, Puppi Munhoz R, Fasano A. Programming Deep Brain Stimulation for Parkinson's Disease: The Toronto Western Hospital Algorithms. Brain Stimul 2016; 9:425-437. [DOI: 10.1016/j.brs.2016.02.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/02/2016] [Accepted: 02/03/2016] [Indexed: 12/19/2022] Open
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Picillo M, Lozano AM, Kou N, Munhoz RP, Fasano A. Programming Deep Brain Stimulation for Tremor and Dystonia: The Toronto Western Hospital Algorithms. Brain Stimul 2016; 9:438-452. [DOI: 10.1016/j.brs.2016.02.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/02/2016] [Accepted: 02/03/2016] [Indexed: 10/22/2022] Open
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Heldman DA, Pulliam CL, Urrea Mendoza E, Gartner M, Giuffrida JP, Montgomery EB, Espay AJ, Revilla FJ. Computer-Guided Deep Brain Stimulation Programming for Parkinson's Disease. Neuromodulation 2015; 19:127-32. [PMID: 26621764 DOI: 10.1111/ner.12372] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/22/2015] [Accepted: 10/12/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Pilot study to evaluate computer-guided deep brain stimulation (DBS) programming designed to optimize stimulation settings using objective motion sensor-based motor assessments. MATERIALS AND METHODS Seven subjects (five males; 54-71 years) with Parkinson's disease (PD) and recently implanted DBS systems participated in this pilot study. Within two months of lead implantation, the subject returned to the clinic to undergo computer-guided programming and parameter selection. A motion sensor was placed on the index finger of the more affected hand. Software guided a monopolar survey during which monopolar stimulation on each contact was iteratively increased followed by an automated assessment of tremor and bradykinesia. After completing assessments at each setting, a software algorithm determined stimulation settings designed to minimize symptom severities, side effects, and battery usage. RESULTS Optimal DBS settings were chosen based on average severity of motor symptoms measured by the motion sensor. Settings chosen by the software algorithm identified a therapeutic window and improved tremor and bradykinesia by an average of 35.7% compared with baseline in the "off" state (p < 0.01). CONCLUSIONS Motion sensor-based computer-guided DBS programming identified stimulation parameters that significantly improved tremor and bradykinesia with minimal clinician involvement. Automated motion sensor-based mapping is worthy of further investigation and may one day serve to extend programming to populations without access to specialized DBS centers.
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Affiliation(s)
| | | | | | | | | | | | | | - Fredy J Revilla
- University of Cincinnati, Cincinnati, OH, USA.,Greenville Health System, University of South Carolina School of Medicine-Greenville, Greenville, SC, USA
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Noor MS, Murari K, McCracken CB, Kiss ZHT. Spatiotemporal dynamics of cortical perfusion in response to thalamic deep brain stimulation. Neuroimage 2015; 126:131-9. [PMID: 26578359 DOI: 10.1016/j.neuroimage.2015.11.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Revised: 11/04/2015] [Accepted: 11/08/2015] [Indexed: 12/12/2022] Open
Abstract
Deep brain stimulation (DBS) has revolutionized the treatment of movement disorders. The parameters of electrical stimulation are important to its therapeutic effect and remain a source of clinical controversy. DBS exerts its actions not only locally at the site of stimulation but also remotely through afferent and efferent connections, which are vital to its clinical effects. Yet, only a few studies have examined how cortical activity changes in response to various electrical parameters. Here, we investigated how the parameters of thalamic DBS alter cortical perfusion in rats using intrinsic optical imaging. We hypothesized that thalamic DBS will increase perfusion in primary motor cortex (M1), proportional to amplitude, pulse width, or frequency of the stimulation applied. We applied 45 different combinations of amplitude, pulse width and frequency in the ventro-lateral (VL) nucleus of the thalamus in anesthetized rats while measuring perfusion in M1. VL thalamic DBS reduced cortical reflectance, which corresponds to an increase in cortical perfusion. We computed the maximum change in reflectance (MCR) as well as the spatial spread of MCR in each trial. Both MCR and spatial spread increased linearly with increases in current amplitude or pulse width of stimulation; however, the effect of frequency was non-linear. Stimulation at 20 Hz was significantly different from that at higher frequencies while stimulation at higher frequencies did not differ significantly from each other. Moreover, the effect of pulse width on MCR was larger than the effect of amplitude. The proportional increase in M1 perfusion due to increase in amplitude or pulse width suggests that both activate more neural elements and increase the volume of tissue activated. These results should help clinicians set parameters of DBS. The use of optical imaging to monitor effects of DBS on M1 may not only help understand DBS mechanisms, but may also provide feedback for closed loop DBS devices.
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Affiliation(s)
- M Sohail Noor
- Hotchkiss Brain Institute, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Electrical and Computer Engineering, Schulich School of Engineering, University of Calgary, Calgary, AB, Canada
| | - Kartikeya Murari
- Electrical and Computer Engineering, Schulich School of Engineering, University of Calgary, Calgary, AB, Canada
| | - Clinton B McCracken
- Hotchkiss Brain Institute, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zelma H T Kiss
- Hotchkiss Brain Institute, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Xiao Y, Peña E, Johnson MD. Theoretical Optimization of Stimulation Strategies for a Directionally Segmented Deep Brain Stimulation Electrode Array. IEEE Trans Biomed Eng 2015. [PMID: 26208259 DOI: 10.1109/tbme.2015.2457873] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Programming deep brain stimulation (DBS) systems currently involves a clinician manually sweeping through a range of stimulus parameter settings to identify the setting that delivers the most robust therapy for a patient. With the advent of DBS arrays with a higher number and density of electrodes, this trial and error process becomes unmanageable in a clinical setting. This study developed a computationally efficient, model-based algorithm to estimate an electrode configuration that will most strongly activate tissue within a volume of interest. The cerebellar-receiving area of motor thalamus, the target for treating essential tremor with DBS, was rendered from imaging data and discretized into grid points aligned in approximate afferent and efferent axonal pathway orientations. A finite-element model (FEM) was constructed to simulate the volumetric tissue voltage during DBS. We leveraged the principle of voltage superposition to formulate a convex optimization-based approach to maximize activating function (AF) values at each grid point (via three different criteria), hence increasing the overall probability of action potential initiation and neuronal entrainment within the target volume. For both efferent and afferent pathways, this approach achieved global optima within several seconds. The optimal electrode configuration and resulting AF values differed across each optimization criteria and between axonal orientations. This approach only required a set of FEM simulations equal to the number of DBS array electrodes, and could readily accommodate anisotropic-inhomogeneous tissue conductances or other axonal orientations. The algorithm provides an efficient, flexible determination of optimal electrode configurations for programming DBS arrays.
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22
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Li J, Zhang Y, Li Y. Long-term follow-up of bilateral subthalamic nucleus stimulation in Chinese Parkinson's disease patients. Br J Neurosurg 2015; 29:329-33. [DOI: 10.3109/02688697.2014.997665] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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23
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Motion sensor strategies for automated optimization of deep brain stimulation in Parkinson's disease. Parkinsonism Relat Disord 2015; 21:378-82. [PMID: 25703990 DOI: 10.1016/j.parkreldis.2015.01.018] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/23/2015] [Accepted: 01/30/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) is a well-established treatment for Parkinson's disease (PD). Optimization of DBS settings can be a challenge due to the number of variables that must be considered, including presence of multiple motor signs, side effects, and battery life. METHODS Nine PD subjects visited the clinic for programming at approximately 1, 2, and 4 months post-surgery. During each session, various stimulation settings were assessed and subjects performed motor tasks while wearing a motion sensor to quantify tremor and bradykinesia. At the end of each session, a clinician determined final stimulation settings using standard practices. Sensor-based ratings of motor symptom severities collected during programming were then used to develop two automated programming algorithms--one to optimize symptom benefit and another to optimize battery life. Therapeutic benefit was compared between the final clinician-determined DBS settings and those calculated by the automated algorithm. RESULTS Settings determined using the symptom optimization algorithm would have reduced motor symptoms by an additional 13 percentage points when compared to clinician settings, typically at the expense of increased stimulation amplitude. By adding a battery life constraint, the algorithm would have been able to decrease stimulation amplitude by an average of 50% while maintaining the level of therapeutic benefit observed using clinician settings for a subset of programming sessions. CONCLUSIONS Objective assessment in DBS programming can identify settings that improve symptoms or obtain similar benefit as clinicians with improvement in battery life. Both options have the potential to improve post-operative patient outcomes.
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Munhoz RP, Cerasa A, Okun MS. Surgical treatment of dyskinesia in Parkinson's disease. Front Neurol 2014; 5:65. [PMID: 24808889 PMCID: PMC4010755 DOI: 10.3389/fneur.2014.00065] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/16/2014] [Indexed: 11/13/2022] Open
Abstract
One of the main indications for stereotactic surgery in Parkinson's disease (PD) is the control of levodopa-induced dyskinesia. This can be achieved by pallidotomy and globus pallidus internus (GPi) deep brain stimulation (DBS) or by subthalamotomy and subthalamic nucleus (STN) DBS, which usually allow for a cut down in the dosage of levodopa. DBS has assumed a pivotal role in stereotactic surgical treatment of PD and, in fact, ablative procedures are currently considered surrogates, particularly when bilateral procedures are required, as DBS does not produce a brain lesion and the stimulator can be programed to induce better therapeutic effects while minimizing adverse effects. Interventions in either the STN and the GPi seem to be similar in controlling most of the other motor aspects of PD, nonetheless, GPi surgery seems to induce a more particular and direct effect on dyskinesia, while the anti-dyskinetic effect of STN interventions is mostly dependent on a reduction of dopaminergic drug dosages. Hence, the si ne qua non-condition for a reduction of dyskinesia when STN interventions are intended is their ability to allow for a reduction of levodopa dosage. Pallidal surgery is indicated when dyskinesia is a dose-limiting factor for maintaining or introducing higher adequate levels of dopaminergic therapy. Also medications used for the treatment of PD may be useful for the improvement of several non-motor aspects of the disease, including sleep, psychiatric, and cognitive domains, therefore, dose reduction of medication withdrawal are not always a fruitful objective.
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Affiliation(s)
- Renato P Munhoz
- Division of Neurology, Department of Medicine, University of Toronto, Toronto Western Hospital , Toronto, ON , Canada
| | - Antonio Cerasa
- Neuroimaging Unit, Institute of Molecular Bioimaging and Physiology, National Research Council (IBFM-CNR) , Germaneto , Italy ; Magna Græcia University of Catanzaro , Germaneto , Italy
| | - Michael S Okun
- Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine , Gainesville, FL , USA
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Williams NR, Foote KD, Okun MS. STN vs. GPi Deep Brain Stimulation: Translating the Rematch into Clinical Practice. Mov Disord Clin Pract 2014; 1:24-35. [PMID: 24779023 DOI: 10.1002/mdc3.12004] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
When formulating a deep brain stimulation (DBS) treatment plan for a patient with Parkinson's disease (PD), two critical questions should be addressed: 1- Which brain target should be chosen to optimize this patient's outcome? and 2- Should this patient's DBS operation be unilateral or bilateral? Over the past two decades, two targets have emerged as leading contenders for PD DBS; the subthalamic nucleus (STN) and the globus pallidus internus (GPi). While the GPi target does have a following, most centers have uniformly employed bilateral STN DBS for all Parkinson's disease cases (Figure 1). This bilateral STN "one-size-fits-all" approach was challenged by an editorial entitled "STN vs. GPi: The Rematch," which appeared in the Archives of Neurology in 2005. Since 2005, a series of well designed clinical trials and follow-up studies have addressed the question as to whether a more tailored approach to DBS therapy might improve overall outcomes. Such a tailored approach would include the options of targeting the GPi, or choosing a unilateral operation. The results of the STN vs. GPi 'rematch' studies support the conclusion that bilateral STN DBS may not be the best option for every Parkinson's disease surgical patient. Off period motor symptoms and tremor improve in both targets, and with either unilateral or bilateral stimulation. Advantages of the STN target include more medication reduction, less frequent battery changes, and a more favorable economic profile. Advantages of GPi include more robust dyskinesia suppression, easier programming, and greater flexibility in adjusting medications. In cases where unilateral stimulation is anticipated, the data favor GPi DBS. This review summarizes the accumulated evidence regarding the use of bilateral vs. unilateral DBS and the selection of STN vs. GPi DBS, including definite and possible advantages of different targets and approaches. Based on this evidence, a more patient-tailored, symptom specific approach will be proposed to optimize outcomes of PD DBS therapy. Finally, the importance of an interdisciplinary care team for screening and effective management of DBS patients will be reaffirmed. Interdisciplinary teams can facilitate the proposed patient-specific DBS treatment planning and provide a more thorough analysis of the risk-benefit ratio for each patient.
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Affiliation(s)
- Nolan R Williams
- Department of Psychiatry, Medical University of South Carolina, Charleston SC ; Department of Neurosciences, Medical University of South Carolina, Charleston SC
| | - Kelly D Foote
- Departments of Neurology and Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration and the McKnight Brain Institute, UF Health College of Medicine, Gainesville FL
| | - Michael S Okun
- Departments of Neurology and Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration and the McKnight Brain Institute, UF Health College of Medicine, Gainesville FL
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Panov F, Gologorsky Y, Connors G, Tagliati M, Miravite J, Alterman RL. Deep brain stimulation in DYT1 dystonia: a 10-year experience. Neurosurgery 2014; 73:86-93; discussion 93. [PMID: 23615098 DOI: 10.1227/01.neu.0000429841.84083.c8] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Globus Pallidus Interna (GPi) deep brain stimulation (DBS) is an effective treatment for DYT1-associated dystonia, but long-term results are lacking. OBJECTIVE To evaluate the long-term effects of GPi DBS in patients with DYT1 dystonia. METHODS A retrospective chart review (cohort study) of 47 consecutive DYT1+ patients treated by a single surgical team over a 10-year period and followed for up to 96 months (mean, 46 months) was performed. Symptom severity was quantified with the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) motor (M) and disability (D) sub-scores. RESULTS As measured with the BFMDRS (M), symptom severity was reduced to less than 20% of baseline after 2 years of DBS therapy (P = .001). The disability scores were reduced to <30% of baseline (P = .001). Symptomatic improvement was durable throughout available follow-up. Sixty-one percent of patients had discontinued all dystonia-related medications at their last follow-up. Ninety-one percent had discontinued at least 1 class of medication. Infections requiring removal and later reimplantation of hardware occurred in 4 of 47 patients (8.5%). Hardware malfunction including lead fractures occurred in 4 of 47 cases (8.5%). Lead revision to address poor clinical response was performed in 2 of 92 implanted leads (2.2%). CONCLUSION GPi DBS is an effective therapy for DYT1-associated torsion dystonia. Statistically significant efficacy is maintained for up to 7 years. Neurologic complications are rare, but long-term hardware-related complications can be significant.
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Affiliation(s)
- Fedor Panov
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, New York, USA
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27
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Moro E, Lang AE. Criteria for deep-brain stimulation in Parkinson’s disease: review and analysis. Expert Rev Neurother 2014; 6:1695-705. [PMID: 17144783 DOI: 10.1586/14737175.6.11.1695] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Deep-brain stimulation is currently the most effective surgical treatment for advanced Parkinson's disease. The relevant targets to date are the subthalamic nucleus and the globus pallidus internus, although the thalamus (ventralis intermedius nucleus) is preferred in tremor-dominant, aged Parkinson's disease patients. Long-term benefit in cardinal parkinsonian signs, motor fluctuations and dyskinesia has been reported in 5-year follow-up studies of subthalamic nucleus deep-brain stimulation. However, some psychiatric consequences have raised important issues and emphasized the need for an experienced deep-brain stimulation surgical team. This team should be multidisciplinary and involve movement disorder neurologists, neurosurgeons, neuropsychologists and psychiatrists. The recent observation that deep-brain stimulation of the pedunculopontine nucleus improves axial signs, possibly even in those less responsive to levodopa, brings new hope to the management of advanced Parkinson's disease.
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Affiliation(s)
- Elena Moro
- University of Toronto, Department of Medicine, Movement Disorders Center, 399 Bathurst Street, McL7 402, Canada.
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Abstract
Dystonia is a movement disorder characterized by involuntary muscular contractions that generate twisting and repetitive movements and/or abnormal postures. It can affect a few muscle groups (focal dystonia) or spread to most muscles in the body (generalized dystonia). While botulinum toxin injections can be successfully used to treat focal dystonias, medical options for generalized dystonia are very limited. Surgical therapies--and in particular deep brain stimulation (DBS)--are becoming the standard of care for medically intractable, disabling dystonias. Advantages of DBS include reversibility, adjustability and continued access to the therapeutic target. Initial reports describing the use of DBS in generalized dystonia have been very encouraging and experience in the use of DBS to treat various forms of dystonia is continuously growing. This article reviews the issues related to DBS treatment of dystonia, including proper patient selection, surgical approaches to target choice and device implant, a description of the stimulating device and its programming principles, clinical results - with a focus on different outcomes for primary versus secondary and generalized versus cervical dystonia - and complications.
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Affiliation(s)
- Michele Tagliati
- Beth Israel Medical Center, 10 Union Square East, Suite 2R, New York, NY 1003, USA.
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Wagle Shukla A, Okun MS. Surgical treatment of Parkinson's disease: patients, targets, devices, and approaches. Neurotherapeutics 2014; 11:47-59. [PMID: 24198187 PMCID: PMC3899492 DOI: 10.1007/s13311-013-0235-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Surgical treatment for Parkinson's disease (PD) has evolved from ablative procedures, within a variety of brain regions, to implantation of electrodes into specific targets of the basal ganglia. Electrode implantation surgery, referred to as deep brain stimulation (DBS), is preferred to ablative procedures by many experts owing to its reversibility, programmability, and the ability to be safely performed bilaterally. Several randomized clinical studies have demonstrated the effectiveness of DBS surgery for control of PD symptoms. Many brain targets, including the subthalamic nucleus and the globus pallidus internus, have emerged as potentially effective, with each target being closely associated with important pros and cons. Selection of appropriate PD candidates through a methodical interdisciplinary screening is considered a prerequisite for a successful surgical outcome. Despite recent growth in DBS knowledge, there is currently no consensus on the ideal surgical technique, the best surgical approach, and the most appropriate surgical target. DBS is now targeted towards treating specific PD-related symptoms in a given individual, and not simply addressing the disease with one pre-defined approach. In this review we will discuss the historical aspects of surgical treatments, the selection of an appropriate DBS candidate, the current surgical techniques, and recently introduced DBS-related technologies. We will address important pre- and postoperative issues related to DBS. We will also discuss the lessons learned from the randomized clinical studies for DBS and the shifting paradigm to tailor to a more patient-centered and symptom-specific approach.
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Affiliation(s)
- Aparna Wagle Shukla
- Center for Movement Disorders and Neurorestoration, Department of Neurology, University of Florida, 3450 Hull Road, Gainesville, FL, 32607, USA,
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Hariz GM, Hamberg K. Perceptions of living with a device-based treatment: an account of patients treated with deep brain stimulation for Parkinson's disease. Neuromodulation 2013; 17:272-7; discussion 277-8. [PMID: 24033886 DOI: 10.1111/ner.12073] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Revised: 03/30/2013] [Accepted: 04/02/2013] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Deep brain stimulation (DBS) is an established treatment for Parkinson's disease. Little is known about patients' own perceptions of living with the implanted hardware. We aimed to explore patients' own perceptions of living with an implanted device. MATERIALS AND METHODS Semistructured interviews with open-ended questions were conducted with 42 patients (11 women) who had been on DBS for a mean of three years. The questions focused on patients' experiences of living with and managing the DBS device. The interviews were transcribed verbatim and analyzed according to the difference and similarity technique in grounded theory. RESULTS From the patients' narratives concerning living with and managing the DBS device, the following four categories emerged: 1) The device-not a big issue: although the hardware was felt inside the body and also visible from outside, the device as such was not a big issue. 2) Necessary carefulness: Patients expressed the need to be careful when performing certain daily activities in order not to dislocate or harm the device. 3) Continuous need for professional support: Most patients relied solely on professionals for fine-tuning the stimulation rather than using their handheld controller, even if this entailed numerous visits to a remote hospital. 4) Balancing symptom relief and side-effects: Patients expressed difficulties in finding the optimal match between decrease of symptoms and stimulation-induced side-effects. CONCLUSIONS The in-depth interviews of patients on chronic DBS about their perceptions of living with an implanted device provided useful insights that would be difficult to capture by quantitative evaluations.
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Affiliation(s)
- Gun-Marie Hariz
- Department of Community Medicine and Rehabilitation, Occupational Therapy, Umeå University, Umeå, Sweden; Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
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Abstract
Dystonia has generally been considered a basal ganglia (BG) disorder. Early models hypothesized that dystonia occurred as the result of reduced mean discharge rates in the internal segment of the globus pallidus (GPi). Increasing evidence suggests a more systemwide disruption of the basal ganglia thalamic circuit (BGTC) resulting in altered firing patterns, synchronized oscillations, and widened receptive fields. A model of dystonia incorporating these changes within the BGTC is presented in which we postulate that this pathophysiology arises from disruptions within the striatum. Alterations in the cerebellothalamocortical (CBTC) pathway to the development of dystonia may also play a role. However, the contribution of CBTC abnormalities to dystonia remains unclear and may vary with different etiologies of dystonia. Finally, the relevance of established and emerging theories related to the pathophysiology of dystonia is addressed within the context of improving conventional approaches for deep brain stimulation (DBS) treatment strategies.
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Kupsch A, Tagliati M, Vidailhet M, Aziz T, Krack P, Moro E, Krauss JK. Early postoperative management of DBS in dystonia: programming, response to stimulation, adverse events, medication changes, evaluations, and troubleshooting. Mov Disord 2011; 26 Suppl 1:S37-53. [PMID: 21692111 DOI: 10.1002/mds.23624] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Early postoperative management in deep brain stimulation-treated patients with dystonia differs from that of patients with essential tremor and Parkinson's disease, mainly due to the usually delayed effects of deep brain stimulation and the heterogenous clinical manifestation and etiologies of dystonia. The present chapter summarizes the available data about and concentrates on practical clinical aspects of early postoperative management in deep brain stimulation-treated patients with dystonia.
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Affiliation(s)
- Andreas Kupsch
- Division of Neurology, Charité, Campus Virchow, Berlin, Germany.
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Mandat T, Tykocki T, Koziara H, Koziorowski D, Brodacki B, Rola R, Bonicki W, Nauman P. Subthalamic deep brain stimulation for the treatment of Parkinson disease. Neurol Neurochir Pol 2011; 45:32-6. [PMID: 21384291 DOI: 10.1016/s0028-3843(14)60057-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE The role of subthalamic nucleus deep brain stimulation (STN DBS) in the treatment of Parkinson disease (PD) is well established. The authors present a group of patients diagnosed with PD who were treated with STN DBS. MATERIAL AND METHODS Between 2008 and 2009, 32 female and 34 male patients with PD were treated with STN DBS. Mean age at implantation was 57 ± 12 years. PD lasted from 6 to 21 years (mean 10 years). Patients were qualified for the surgery according to the CAPSIT-PD criteria. The STN was identified with direct and indirect methods. Macrostimulation and microrecording for STN identification were used in all cases. A unilateral STN DBS system was implanted in two cases and bilateral implantation was performed among rest of the group. Outcome was assessed six months after implantation. Results : The mean reduction of UPDRS III score among 51 patients who underwent follow-up was 45% (5-89%). Reduction of levodopa consumption varied from 15 to 100%. Infection forced the authors to remove the DBS system in one case four months after implantation. Skin erosion above the internal pulse generator was noted in four cases. CONCLUSIONS Cardinal symptoms of Parkinson's disease can be safely and effectively treated with STN DBS in selected group of patients.
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Affiliation(s)
- Tomasz Mandat
- Centrum Onkologii - Instytut, Klinika Nowotworów Układu Nerwowego, ul. Roentgena 5, 02-781 Warszawa.
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Moro E, Albanese A, Krauss JK, Metman LV, Vidailhet M, Hariz MI. Guest Editors' introduction. Mov Disord 2011; 26 Suppl 1:S1-2. [DOI: 10.1002/mds.23560] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Bhatia R, Dalton A, Richards M, Hopkins C, Aziz T, Nandi D. The incidence of deep brain stimulator hardware infection: the effect of change in antibiotic prophylaxis regimen and review of the literature. Br J Neurosurg 2011; 25:625-31. [DOI: 10.3109/02688697.2011.566384] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mera T, Vitek JL, Alberts JL, Giuffrida JP. Kinematic optimization of deep brain stimulation across multiple motor symptoms in Parkinson's disease. J Neurosci Methods 2011; 198:280-6. [PMID: 21459111 DOI: 10.1016/j.jneumeth.2011.03.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 03/23/2011] [Accepted: 03/24/2011] [Indexed: 11/25/2022]
Abstract
Parkinson's disease (PD) is a neurodegenerative disorder characterized by motor symptoms including tremor and bradykinesia (slowness of movement). Drug treatment, although capable of controlling these symptoms over a number of years, becomes less effective as the disease progresses and leads to motor complications such as drug-induced dyskinesia (involuntary abnormal movements). Deep brain stimulation (DBS) provides an alternative means of controlling motor symptoms in these patients, and while DBS has been effective in improving motor symptoms, these improvements are largely based on accurate placement of the lead and the ability of medical personnel to adequately program the DBS device following implantation. While guidelines exist for DBS programming, selection of stimulation parameters and patient outcome is greatly dependent on subjective clinical assessments and the experience of the medical personnel performing the programming. The aim of this project was to assess the feasibility of using a quantitative and objective approach to programming. Two subjects underwent standard procedures for DBS programming while wearing a small, compact motion sensor. Kinematic data were collected from subjects as they completed motor tasks to evaluate DBS efficacy. Quantitative variables characterizing tremor and bradykinesia were related to stimulation parameters. Results indicated different stimulation settings might be required for optimal improvement of different motor symptoms. A standardized method of programming DBS parameters utilizing motion analysis may provide an objective method of assessment that the programmer can use to better identify stimulation parameters to achieve optimal improvement across multiple motor symptoms.
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Affiliation(s)
- Thomas Mera
- Division of Movement Disorders, Cleveland Medical Devices, Inc., 4415 Euclid Ave Suite 400, Cleveland, OH 44103, USA.
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Isaias IU, Volkmann J, Kupsch A, Burgunder JM, Ostrem JL, Alterman RL, Mehdorn HM, Schönecker T, Krauss JK, Starr P, Reese R, Kühn AA, Schüpbach WMM, Tagliati M. Factors predicting protracted improvement after pallidal DBS for primary dystonia: the role of age and disease duration. J Neurol 2011; 258:1469-76. [DOI: 10.1007/s00415-011-5961-9] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Revised: 02/10/2011] [Accepted: 02/11/2011] [Indexed: 11/30/2022]
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Sankar T, Lozano AM. Surgical approach to l-dopa-induced dyskinesias. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2011; 98:151-71. [PMID: 21907086 DOI: 10.1016/b978-0-12-381328-2.00006-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Many patients treated chronically with l-dopa for Parkinson disease (PD) become functionally disabled by l-dopa-induced dyskinesias (LID). Evolved from early empirical procedures, modern stereotactic surgical lesioning techniques and deep brain stimulation (DBS) can effectively treat LID while simultaneously improving the cardinal motor symptoms of PD. Here we review the common surgical targets used to treat LID, and compare their relative efficacy. We explain the anti-dyskinetic action of surgery at each of these targets based on evolving models of basal ganglia function. Finally, we discuss the appropriate selection of patients with LID for surgery and address relevant technical and management issues in these patients.
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Affiliation(s)
- Tejas Sankar
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Collins KL, Lehmann EM, Patil PG. Deep brain stimulation for movement disorders. Neurobiol Dis 2010; 38:338-45. [DOI: 10.1016/j.nbd.2009.11.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2009] [Revised: 11/20/2009] [Accepted: 11/26/2009] [Indexed: 10/20/2022] Open
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Moro E, Piboolnurak P, Arenovich T, Hung SW, Poon YY, Lozano AM. Pallidal stimulation in cervical dystonia: clinical implications of acute changes in stimulation parameters. Eur J Neurol 2009; 16:506-12. [PMID: 19207733 DOI: 10.1111/j.1468-1331.2008.02520.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is successful in dystonia, but the role of each electrical parameters of stimulation is unclear. We studied the clinical effects of acute changes of different parameters of GPi-DBS in cervical dystonia (CD). METHODS Eight CD patients with bilateral GPi-DBS at 28.6 +/- 19.2 (mean +/- SD) months after surgery were recruited. Mean improvement in the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) severity score was 54.5% compared to before surgery. Ten settings, including a combination of a wide range of pulse widths (PWs), low and high frequencies and voltage, were administered in a randomized double blinded fashion. Clinical benefit was assessed by two raters using the TWSTRS and by the patients using an analogue rating scale. RESULTS The TWSTRS severity scores were reduced by 56.7% with stimulation at the best settings. Improvement was significantly associated with high frequency (> or = 60 Hz) and high voltage. Stimulation at 130 Hz showed the best clinical improvement. Increasing PWs (from 60 to 450 micros) did not result in a significant improvement. CONCLUSION Frequency and amplitude appear to be the most important factors in the acute anti-dystonic effects in GPi-DBS patients with CD.
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Affiliation(s)
- E Moro
- Movement Disorders Center, Toronto Western Hospital, University of Toronto, University Health Network, Toronto, ON, Canada.
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42
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Deep Brain Stimulation. Neuromodulation 2009. [DOI: 10.1016/b978-0-12-374248-3.00086-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Johnson MD, McIntyre CC. Quantifying the neural elements activated and inhibited by globus pallidus deep brain stimulation. J Neurophysiol 2008; 100:2549-63. [PMID: 18768645 DOI: 10.1152/jn.90372.2008] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Deep brain stimulation (DBS) of the globus pallidus pars interna (GPi) is an effective therapy option for controlling the motor symptoms of medication-refractory Parkinson's disease and dystonia. Despite the clinical successes of GPi DBS, the precise therapeutic mechanisms are unclear and questions remain on the optimal electrode placement and stimulation parameter selection strategies. In this study, we developed a three-dimensional computational model of GPi-DBS in nonhuman primates to investigate how membrane channel dynamics, synaptic inputs, and axonal collateralization contribute to the neural responses generated during stimulation. We focused our analysis on three general neural elements that surround GPi-DBS electrodes: GPi somatodendritic segments, GPi efferent axons, and globus pallidus pars externa (GPe) fibers of passage. During high-frequency electrical stimulation (136 Hz), somatic activity in the GPi showed interpulse excitatory phases at 1-3 and 4-5.5 ms. When including stimulation-induced GABA(A) and AMPA receptor dynamics into the model, the somatic firing patterns continued to be entrained to the stimulation, but the overall firing rate was reduced (78.7 to 25.0 Hz, P < 0.001). In contrast, axonal output from GPi neurons remained largely time-locked to each pulse of the stimulation train. Similar entrainment was also observed in GPe efferents, a majority of which have been shown to project through GPi en route to the subthalamic nucleus. The models suggest that pallidal DBS may have broader network effects than previously realized and the modes of therapy may depend on the relative proportion of GPi and/or GPe efferents that are directly affected by the stimulation.
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Affiliation(s)
- Matthew D Johnson
- Department of Biomedical Engineering, Cleveland Clinic Foundation, 9500 Euclid Avenue, ND20, Cleveland, OH, 44195, USA
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Isaias IU, Alterman RL, Tagliati M. Outcome predictors of pallidal stimulation in patients with primary dystonia: the role of disease duration. ACTA ACUST UNITED AC 2008; 131:1895-902. [PMID: 18567622 DOI: 10.1093/brain/awn120] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Pallidal deep brain stimulation (DBS) is currently the most effective treatment for advanced, medically refractory dystonia. However, factors predicting clinical outcome are not well defined. We reviewed the clinical records of 39 consecutive patients with medically refractory primary dystonia who underwent pallidal DBS implants. Thirty-five patients were implanted bilaterally and four unilaterally. Seven patients had fixed skeletal deformities (FSD). The Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) scores at baseline, 3 and 12 months after DBS were used to evaluate clinical outcome. We investigated the outcome predictive role of several demographic and clinical factors. FSD patients had a significantly inferior outcome at 12 months, mostly affected by axial scores. All other patients (n = 32) showed a remarkable improvement (median BFMDRS percentage improvement = 87.8). Only disease duration showed a significant correlation with DBS outcome at 3 and 12 months. No other demographic and baseline clinical features predicted DBS outcome. This study confirms that patients with primary, medically refractory dystonia are generally outstanding candidates for pallidal DBS, with the possible exception of axial FSD. Patients with shorter duration of disease may expect a better general outcome. No particular predictive value should be assigned to age at onset, age at surgery, severity of disease, DYT1 status and the presence of phasic or tonic involuntary movements.
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Affiliation(s)
- Ioannis U Isaias
- Department of Neurology, Mount Sinai School of Medicine, 5 East 98th Street, Box 1139, New York, NY 10029, USA
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Liu X, Wang S, Yianni J, Nandi D, Bain PG, Gregory R, Stein JF, Aziz TZ. The sensory and motor representation of synchronized oscillations in the globus pallidus in patients with primary dystonia. Brain 2008; 131:1562-73. [PMID: 18487278 DOI: 10.1093/brain/awn083] [Citation(s) in RCA: 101] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In 15 patients with primary dystonia (six cervical and nine generalized dystonias) who were treated with bilateral chronic pallidal stimulation, we investigated the sensorimotor modulation of the oscillatory local field potentials (LFPs) recorded from the pallidal electrodes. We correlated these with the surface electromyograms in the affected muscles. The effects of involuntary, passive and voluntary movement and muscle-tendon vibration on frequency ranges of 0-3 Hz, theta (3-8 Hz), alpha (8-12 Hz), low (12-20 Hz) and high beta (20-30 Hz), and low (30-60 Hz) and high gamma (60-90 Hz) power were recorded and compared between cervical and generalized dystonia groups. Significant decreases in LFP synchronization at 8-20 Hz occurred during the sensory modulation produced by voluntary or passive movement or vibration. Voluntary movement also caused increased gamma band activity (30-90 Hz). Dystonic involuntary muscle spasms were specifically associated with increased theta, alpha and low beta (3-18 Hz). Furthermore, the increase in the frequency range of 3-20 Hz correlated with the strength of the muscle spasms and preceded them by approximately 320 ms. Differences in modulation of pallidal oscillation between cervical and generalized dystonias were also revealed. This study yields new insights into the pathophysiological mechanisms of primary dystonias and their treatment using pallidal deep brain stimulation.
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Affiliation(s)
- Xuguang Liu
- Department of Physiology, Anatomy, and Genetics,University of Oxford, UK.
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Cohen DB, Oh MY, Baser SM, Angle C, Whiting A, Birk C, Whiting DM. Fast-track programming and rehabilitation model: a novel approach to postoperative deep brain stimulation patient care. Arch Phys Med Rehabil 2007; 88:1320-4. [PMID: 17908576 DOI: 10.1016/j.apmr.2007.06.770] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2007] [Revised: 06/12/2007] [Accepted: 06/13/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To propose a new model of integrated, multidisciplinary postoperative care of the patients with deep brain stimulation (DBS). DESIGN Observational cohort study with follow-up at 3 months and 1 year. SETTING Academic medical center movement disorder clinic. PARTICIPANTS Seventy-three consecutive patients with medically refractory Parkinson's disease underwent bilateral DBS. Patients were then transferred directly to an inpatient rehabilitation facility. INTERVENTION DBS and inpatient programming and rehabilitation. Simultaneous programming and rehabilitation was carried out by a multidisciplinary team. MAIN OUTCOME MEASURES The FIM instrument, Unified Parkinson Disease Rating Scale (UPDRS), and levodopa dosage. RESULTS The average rehabilitation stay was 17.3 days, with a mean of 6.2 stimulator adjustments during that time. FIM scores improved from 62.1 (admission) to 98.5 (discharge), an average improvement of 36.4 (58.6%). Average UPDRS scores improved from 52.5 (preoperative off) and 30.1 (preoperative on) to 20.4 (3mo postoperative on-medication, on-stimulation), a 32.2% improvement from the preoperative on score. Levodopa dosages decreased by an average of 48.3% (all P<.001). CONCLUSIONS We describe our fast-track protocol, which allows for rapid DBS programming and tapering of Parkinson's medications. It also provides for treatment of concomitant medical and psychologic problems and optimized physical performance.
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Affiliation(s)
- David B Cohen
- Department of Neurosurgery, Division of Neuromodulation, Allegheny General Hospital, Pittsburgh, PA 15212, USA
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Kiss ZHT, Doig-Beyaert K, Eliasziw M, Tsui J, Haffenden A, Suchowersky O. The Canadian multicentre study of deep brain stimulation for cervical dystonia. Brain 2007; 130:2879-86. [PMID: 17905796 DOI: 10.1093/brain/awm229] [Citation(s) in RCA: 203] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Deep brain stimulation (DBS) of the globus pallidus pars interna (GPi) is an effective treatment for generalized dystonia. Its role in the management of other types of dystonia is uncertain. Therefore we performed a prospective, single-blind, multicentre study assessing the efficacy and safety of bilateral GPi-DBS in 10 patients with severe, chronic, medication-resistant cervical dystonia. Two blinded neurologists assessed patients before surgery and at 6 and 12 months post-operatively using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS). The primary outcome measure was the severity subscore (range 0-30, higher scores indicating greater impairment). Secondary outcomes included disability (0 to 30), pain (0 to 40) subscores and total scores of the TWSTRS, Short Form-36 and Beck depression inventory. Swallowing and neuropsychological assessment were also performed at baseline and 12 months. One-way repeated measures analysis of variance was used to analyse the data. The TWSTRS severity score improved from a mean (SD) of 14.7 (4.2) before surgery to 8.4 (4.4) at 12 months post-operatively (P = 0.003). The disability and pain scores improved from 14.9 (3.8) and 26.6 (3.6) before surgery, to 5.4 (7.0) and 9.2 (13.1) at 12 months, respectively (both P < 0.001). General health and physical functioning as well as depression scores improved significantly. Complications were mild and reversible in four patients. Some changes in neuropsychological tests were observed, although these did not impact daily life or employment. Our results support the efficacy and safety of GPi-DBS for the treatment of patients with severe and prolonged cervical dystonia who have failed medical management.
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Affiliation(s)
- Zelma H T Kiss
- Department of Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada.
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Abstract
BACKGROUND Deep brain stimulation (DBS) for the treatment of neurologic diseases has markedly increased in popularity over the past 15 years. This review primarily focuses on movement disorder applications and efficacy of DBS, but also briefly reviews other promising new and old uses of DBS. REVIEW SUMMARY A multidisciplinary team consisting of a movement disorders neurologist, a functional neurosurgeon, and a neuropsychologist optimally selects patients for DBS. Patients must be significantly disabled despite optimal medical therapy and be cognitively healthy without significant psychiatric disorders. Although this surgery is elective, it should not be withheld until the patient suffers marked loss of quality of life. Patients must have support from caregivers and postoperatively multiple DBS programming visits may be required. DBS of the subthalamic nucleus (STN) and the globus pallidus pars interna (GPi) significantly improves motor performance, activities of daily living, and quality of life in advanced Parkinson disease. In addition, STN DBS allows for marked reductions of antiparkinson medication. Stimulation of the ventralis intermedius nucleus of the thalamus is an effective treatment for essential tremor with sustained long-term effects. The GPi may be the preferred site of stimulation for dystonia with movement scores typically improved by 75% in patients with primary dystonia. CONCLUSIONS DBS is an effective surgical treatment for movement disorders with sustained long-term benefits. Further research is ongoing to better understand the mechanism of DBS, refine the hardware to improve efficacy and reduce adverse effects, and identify additional applications and new anatomic targets.
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Affiliation(s)
- Drew S Kern
- College of Medicine, University of Vermont, Burlington, Vermont, USA
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Kopell BH, Greenberg BD. Anatomy and physiology of the basal ganglia: implications for DBS in psychiatry. Neurosci Biobehav Rev 2007; 32:408-22. [PMID: 17854894 DOI: 10.1016/j.neubiorev.2007.07.004] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2005] [Revised: 06/08/2007] [Accepted: 06/08/2007] [Indexed: 11/21/2022]
Abstract
The basal ganglia have been a target for neuromodulation surgery since Russell Meyers' pioneering works in the late 1930s. Contemporary movement disorder surgery on the brain has evolved from empiric observations on movement behavior after neurological lesions. So too has the development of psychiatric surgical procedures followed the observation of lesions in the brain on cognitive and affective behavior. Just as deep brain stimulation (DBS) has revolutionized the practice of movement disorder surgery, its application to psychiatric illness has become the cutting edge of functional and restorative neurosurgery. The fundamental concept of the cortico-striatal-pallido-thalamocortical loop will be explored in the context of psychiatric disorders. DBS targeting this circuitry appears from initial evidence in obsessive-compulsive disorder (OCD) to be a promising option for patients with neuropsychiatric illness resistant to conventional therapies. Further exploring the anatomic interconnectivity of the physiologically relevant cortical and subcortical areas will inevitably lead to better applications of DBS for the treatment of OCD, major depression (MD) and potentially for other psychiatric disorders. Implementing such therapies optimally will require the creation of treatment centers with specialized expertise in the psychiatric, neurosurgical, and ethical issues that arise with these populations.
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Affiliation(s)
- Brian Harris Kopell
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Sudhyadhom A, Bova FJ, Foote KD, Rosado CA, Kirsch-Darrow L, Okun MS. Limbic, associative, and motor territories within the targets for deep brain stimulation: Potential clinical implications. Curr Neurol Neurosci Rep 2007; 7:278-89. [PMID: 17618533 DOI: 10.1007/s11910-007-0043-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The use of deep brain stimulation (DBS) has recently been expanding for the treatment of many neurologic disorders such as Parkinson disease, dystonia, essential tremor, Tourette's syndrome, cluster headache, epilepsy, depression, and obsessive compulsive disorder. The target structures for DBS include specific segregated territories within limbic, associative, or motor regions of very small subnuclei. In this review, we summarize current clinical techniques for DBS, the cognitive/mood/motor outcomes, and the relevant neuroanatomy with respect to functional territories within specific brain targets. Future development of new techniques and technology that may include a more direct visualization of "motor" territories within target structures may prove useful for avoiding side effects that may result from stimulation of associative and limbic regions. Alternatively, newer procedures may choose and specifically target non-motor territories for chronic electrical stimulation.
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Affiliation(s)
- Atchar Sudhyadhom
- Department of Neurology, McKnight Brain Institute, 100 South Newell Drive, Gainesville, FL 32610, USA.
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