Neuropsychiatric complications and neuroimaging characteristics after deep brain stimulation surgery for Parkinson’s disease

Pathological pain: Non-motor manifestations in Parkinson disease and its treatment

In addition to motor symptoms, non-motor manifestations of Parkinson's disease (PD), i.e. pain, depression, sleep disturbance, and autonomic disorders, have received increasing attention. As one of the non-motor symptoms, pain has a high prevalence and is considered an early pre-motor symptom in the development of PD. In relation to pathological pain and its management in PD, particularly in the early stages, it is hypothesized that the loss of dopaminergic neurons causes a functional deficit in supraspinal structures, leading to an imbalance in endogenous descending modulation. Deficits in dopaminergic-dependent pathways also affect non-dopaminergic neurotransmitter systems that contribute to the pathological processing of nociceptive input, the integration, and modulation of pain in PD. This review examines the onset and progression of pain in PD, with a particular focus on alterations in the central modulation of nociception. The discussion highlights the importance of abnormal endogenous descending facilitation and inhibition in PD pain, which may provide potential clues to a better understanding of the nature of pathological pain and its effective clinical management.

Risk Factors for Postoperative Delirium Severity After Deep Brain Stimulation Surgery in Parkinson's Disease

Background

Postoperative delirium (POD) is a serious complication following deep brain stimulation (DBS) but only received little attention. Its main risk factors are higher age and preoperative cognitive deficits. These are also main risk factors for long-term cognitive decline after DBS in Parkinson's disease (PD).

Objective

To identify risk factors for POD severity after DBS surgery in PD.

Methods

57 patients underwent DBS (21 female; age 60.2±8.2; disease duration 10.5±5.9 years). Preoperatively, general, PD- and surgery-specific predictors were recorded. Montreal Cognitive Assessment and the neuropsychological test battery CANTAB ConnectTM were used to test domain-specific cognition. Volumes of the cholinergic basal forebrain were calculated with voxel-based morphometry. POD severity was recorded with the delirium scales Confusion Assessment Method for Intensive Care Unit (CAM-ICU) and Nursing Delirium Scale (NU-DESC). Spearman correlations were calculated for univariate analysis of predictors and POD severity and linear regression with elastic net regularization and leave-one-out cross-validation was performed to fit a multivariable model.

Results

21 patients (36.8%) showed mainly mild courses of POD following DBS. Correlation between predicted and true POD severity was significant (spearman rho = 0.365, p = 0.001). Influential predictors were age (p < 0.001), deficits in attention and motor speed (p = 0.002), visual learning (p = 0.036) as well as working memory (p < 0.001), Nucleus basalis of Meynert volumes (p = 0.003) and burst suppression (p = 0.005).

Conclusions

General but also PD- and surgery-specific factors were predictive of POD severity. These findings underline the multifaceted etiology of POD after DBS in PD. Valid predictive models must therefore consider general, PD- and surgery-specific factors.

Postoperative delirium after intracranial neurosurgery: A prospective cohort study from a developing nation

INTRODUCTION

Post-operative delirium (POD) is a major complication after anesthesia and surgery with an incidence varying from 5 to 50%. The incidence of POD after intracranial surgery is likely to be higher due to the pre-existing brain pathology and direct handling of the brain during neurosurgery. The primary objective of this study was to assess the incidence of POD after intracranial neurosurgery and our secondary objective was to identify the potential risk factors for its occurrence.

MATERIALS AND METHODS

This prospective observational study was conducted after the institutional ethics committee approval between october 2020 and march 2021. We included patients of either gender aged ≥ 18 years and undergoing elective intracranial neurosurgery. Exclusion criteria included patients aged below 18 years, undergoing emergency neurosurgery, patients with impaired consciousness and patients with psychiatric comorbidities or those taking psychotropic medications. We planned to exclude patients from analysis who were transferred to intensive care unit (ICU) or if they were not extubated after surgery. Our study outcome was development of POD as assessed by confusion assessment method (CAM).

RESULTS

The overall incidence of POD during the three postoperative days was 19.2% (n=60/313). The incidence of POD on days 1, 2, and 3 were 19.2% (n=60/313), 17.2% (n=50/291), and 16.3% (n=39/239). Preoperative delirium and hyperactive Emergence Delirium were found to be the significant predictors of POD.

CONCLUSION

Every one in five patients undergoing intracranial neurosurgery is vulnerable for the development of POD within first three days after surgery. The incidence of occurrence of POD is time-sensitive and is decremental.

Evidence for upregulation of excitatory synaptic transmission in the substantia nigra in Schizophrenia: a postmortem ultrastructural study

The dopamine hypothesis of schizophrenia suggests that psychotic symptoms originate from dysregulation of dopaminergic activity, which may be controlled by upstream innervation. We hypothesized that we would find anatomical evidence for the hyperexcitability seen in the SN. We examined and quantified synaptic morphology, which correlates with function, in the postmortem substantia nigra (SN) from 15 schizophrenia and 12 normal subjects. Synapses were counted using stereological techniques and classified based on the morphology of the post-synaptic density (PSD) and the presence or absence of a presynaptic density. The density and proportion of excitatory synapses was higher in the schizophrenia group than in controls, while the proportion (but not density) of inhibitory synapses was lower. We also detected in the schizophrenia group an increase in density of synapses with a PSD of intermediate thickness, which may represent excitatory synapses. The density of synapses with presynaptic densities was similar in both groups. The density of synapses with mixed morphologies was higher in the schizophrenia group than in controls. The human SN contains atypical synaptic morphology. We found an excess amount and proportion of excitatory synapses in the SN in schizophrenia that could result in hyperactivity and drive the psychotic symptoms of schizophrenia. The sources of afferent excitatory inputs to the SN arise from the subthalamic nucleus, the pedunculopontine nucleus, and the ventral tegmental area (VTA), areas that could be the source of excess excitation. Synapses with mixed morphologies may represent inputs from the VTA, which release multiple transmitters.

A systematic review of brain morphometry related to deep brain stimulation outcome in Parkinson's disease

While the efficacy of deep brain stimulation (DBS) is well-established in Parkinson’s Disease (PD), the benefit of DBS varies across patients. Using imaging features for outcome prediction offers potential in improving effectiveness, whereas the value of presurgical brain morphometry, derived from the routinely used imaging modality in surgical planning, remains under-explored. This review provides a comprehensive investigation of links between DBS outcomes and brain morphometry features in PD. We systematically searched PubMed and Embase databases and retrieved 793 articles, of which 25 met inclusion criteria and were reviewed in detail. A majority of studies (24/25), including 1253 of 1316 patients, focused on the outcome of DBS targeting the subthalamic nucleus (STN), while five studies included 57 patients receiving globus pallidus internus (GPi) DBS. Accumulated evidence showed that the atrophy of motor cortex and thalamus were associated with poor motor improvement, other structures such as the lateral-occipital cortex and anterior cingulate were also reported to correlated with motor outcome. Regarding non-motor outcomes, decreased volume of the hippocampus was reported to correlate with poor cognitive outcomes. Structures such as the thalamus, nucleus accumbens, and nucleus of basalis of Meynert were also reported to correlate with cognitive functions. Caudal middle frontal cortex was reported to have an impact on postsurgical psychiatric changes. Collectively, the findings of this review emphasize the utility of brain morphometry in outcome prediction of DBS for PD. Future efforts are needed to validate the findings and demonstrate the feasibility of brain morphometry in larger cohorts.

Neuropsychiatric Symptoms in Clinically Defined Parkinson’s Disease: An Updated Review of Literature

Background

Neuropsychiatric symptoms (NPS) are a common and potentially serious manifestation of Parkinson's disease (PD) but are frequently overlooked in favor of a focus on motor symptomatology. Here, we conducted a literature review of the prevalence and type of NPS experienced by PD patients with a clinically defined course of their illness.

Methods

We identified reports of NPS in patients with PD and mean disease duration over 3 years. Three databases—PubMed, Scopus, and Dialnet—were searched for relevant literature published between 2010 and 2020. Predefined exclusion criteria were applied prior to a descriptive analysis of the literature base.

Results

In all, 87 unique reports were identified and 30 met inclusion and exclusion criteria. These included 7142 patients with PD (male: 67.3%; mean age: 66.2 years; mean disease duration: 6.7 years). The most frequent NPS were mood disorders (apathy, depression, and anxiety), psychosis, and impulse control disorders (ICD). Treatment with dopamine agonists was identified as an important risk factor for ICD. Co-occurrence of NPS and cognitive dysfunction was also evidenced in a number of studies. Patients with more significant cognitive deficits and higher levels of NPS appeared to be of older age with a longer disease duration and to have more severe motor symptoms.

Conclusions

NPS, most commonly mood disorders (apathy, depression, and anxiety), psychosis, and ICDs are frequent manifestations of PD. The results of this review reflect the need to develop unified validated assessment protocols for NPS in PD, as well as to improve their management in clinical practice.

Parkinson's Disease and Deep Brain Stimulation Have an Impact on My Life: A Multimodal Study on the Experiences of Patients and Family Caregivers

Parkinson’s disease (PD) has a large impact on patients’ physical and mental health, which also greatly affects their family caregivers. Deep brain stimulation (DBS) has emerged as an effective treatment for PD, but different authors have expressed their concerns about the potential impact of DBS on personality and identity. Our study aims at better understanding how patients and family caregivers experience life with PD and DBS, the impact of both on their personal and social lives, and their perception of the changes that have occurred as a result of the disease and the treatment. Our study applies a multimodal approach by means of narrative semi-structured interviews and drawings. Seven principal themes have been identified: “everyone’s Parkinson’s is different”, “changing as a person during the disease”, “going through Parkinson’s together”, “DBS improved my life”, “I am treated with DBS but I have Parkinson’s still”, “DBS is not perfect”, and “being different after DBS”. PD is perceived as an unpredictable and heterogeneous disease that changes from person to person, as does the effect of DBS. While DBS side-effects may have an impact on patients’ personality, behavior, and self-perception, PD symptoms and drug side-effects also have a great impact on these aspects.

Estimating the Risk of Deep Brain Stimulation in the Modern Era: 2008 to 2020

BACKGROUND

Deep brain stimulation (DBS) was first approved by the United States Food and Drug Administration in 1997. Although the fundamentals of DBS remain the same, hardware, software, and imaging have evolved significantly.

OBJECTIVE

To test our hypothesis that the aggregate complication rate in the medical literature in the past 12 years would be lower than what is often cited based on early experience with DBS surgery.

METHODS

PubMed, PsycINFO, and EMBASE were queried for studies from 2008 to 2020 that included patients treated with DBS from 2007 to 2019. This yielded 34 articles that evaluated all complications of DBS surgery, totaling 2249 patients.

RESULTS

The overall complication rate in this study was 16.7% per patient. There was found to be a systemic complication rate of 0.89%, intracranial complication rate of 2.7%, neurological complication rate of 4.6%, hardware complication rate of 2.2%, and surgical site complication rate of 3.4%. The infection and erosion rate was 3.0%.

CONCLUSION

This review suggests that surgical complication rates have decreased since the first decade after DBS was first FDA approved. Understanding how to minimize complications from the inception of a technique should receive more attention.

How neuropsychiatric comorbidity, modulatory indication, demographics, and other factors impact deep brain stimulation inpatient outcomes in the United States: A population-based study of 27,956 patients

OBJECTIVE

To determine how neuropsychiatric comorbidity, modulatory indication, demographics, and other characteristics affect inpatient deep brain stimulation (DBS) outcomes.

METHODS

This is a retrospective study of 45 months' worth of data from the National Inpatient Sample. Patients were aged ≥ 18 years old and underwent DBS for Parkinson Disease (PD), essential tremor (ET), general dystonia and related disorders, other movement disorder (non-PD/ET), or obsessive-compulsive disorder (OCD) at a US hospital. Primary endpoints were prolonged length of stay (PLOS), high-end hospital charges (HEHCs), unfavorable disposition, and inpatient complications. Logistic models were constructed with odds ratios under 95% confidence intervals. A p-value of 0.05 determined significance.

RESULTS

Of 214,098 records, there were 27,956 eligible patients. Average age was 63.9 ± 11.2 years, 17,769 (63.6%) were male, and 10,182 (36.4%) patients were female. Most of the cohort was White (51.1%), Medicare payer (64.3%), and treated at a large-bed size (80.7%), private non-profit (76.9%), and metro-teaching (94.0%) hospital. Neuropsychiatric comorbidity prevalence ranged from 29.9% to 47.7% depending on indication. Compared with PD, odds of complications and unfavorable disposition were significantly higher with other movement disorders and dystonia, whereas OCD conferred greater risk for HEHCs (p < 0.05). Patients with ET had favorable outcomes. Neuropsychiatric comorbidity, Black race, and Charlson Comorbidity Index > 0 were significantly associated with unfavorable outcomes (p < 0.05).

CONCLUSION

The risk of adverse inpatient outcomes for DBS in the United States is independently correlated with non-PD/ET disorders, neuropsychiatric comorbidity, and non-White race, reflecting the heterogeneity and infancy of widespread DBS for these patients.

The Impacts of Subthalamic Nucleus-Deep Brain Stimulation (STN-DBS) on the Neuropsychiatric Function of Patients with Parkinson's Disease Using Image Features of Magnetic Resonance Imaging under the Artificial Intelligence Algorithms

This study was to explore the effect of subthalamic nucleus- (STN-) deep brain stimulation (DBS) on the neuropsychiatric function of Parkinson's disease (PD) patients using the magnetic resonance imaging (MRI) image analysis technology and the artificial intelligence (AI) algorithm. In this study, 40 PD patients admitted to our hospital from August 2018 to March 2020 were selected as the research objects, and they were divided into a control group and an observation group according to the random number table method, with 20 cases in each group. The patients in the control group were given oral treatment with levodopa tablets; and patients in the observation group were treated with STN-DBS + levodopa tablets. In patients, MRI examinations were performed before and after the treatment, and the image optimization processing algorithm under AI was adopted to process the images. The MRI imaging results of the two groups of patients were observed, analyzed, and compared before and after treatment; and the sports, cognition, and mental states of the two groups of patients were analyzed. It was believed that the MRI image before using the AI algorithm was blurry, and the image was clear after the noise reduction optimization process, which was convenient for observation. The data analysis revealed that the signal-to-noise ratio (SNR) after denoising (32.41) and structural similarity (SSIM) (0.79) had been improved. The results of the study suggested that the space occupation and bleeding symptoms of the two groups of patients were reduced after treatment, and those in the observation group were better than those of the control group; the incidences of dyskinesia and motor symptom fluctuations in the observation group were 5% and 0%, respectively, which were lower than those in the control group (35% and 25%, respectively). After treatment, the Unified Parkinson's Disease Rating Scale (UPDRS) score of the two groups of patients decreased, and it was lower in the observation group than in the control group; and the Montreal Cognitive Assessment (MoCA) and Mini-Mental State Scale (MMSE) scores increased, and those in the observation group were higher in contrast to those in the control group (all P < 0.05). STN-DBS was beneficial to improve the clinical symptoms of patients and delay the progress of the disease, and MRI based on AI algorithms can effectively observe the changes in the neuropsychiatric function of patients, which was conducive to further clinical diagnosis and treatment.

Characterizing Complications of Deep Brain Stimulation Devices for the Treatment of Parkinsonian Symptoms Without Tremor: A Federal MAUDE Database Analysis

Introduction Deep brain stimulation (DBS) is a modality of treatment for medication refractory Parkinson's disease (PD) in patients with debilitating motor symptoms. While potentially life-changing for individuals with Parkinson's disease, characterization of adverse events for these DBS devices have not yet been systematically organized. Therefore, the goal of this study was to characterize reported complications of DBS devices reported to the Food & Drug Administration over the last 10 years. Methods The Manufacturer and User Facility Device Experience (MAUDE) database was utilized to retrieve entries reported under "Stimulator, Electrical, Implanted, For Parkinsonian Symptoms" between July 31, 2010 and August 1, 2020. After removing duplicate entries, each unique adverse event reported was sorted into complication categories based on the entries' provided narrative description. A final tabulation of complications was generated. Results The search query revealed 221 unique adverse events. The most common DBS devices were the Vercise Gevia, Vercise Cartesia and Vercise PC produced by Boston Scientific (Brian Walker, Boston Scientific, Marlborough, MA, USA). The most commonly reported complications were infection (16.2%) follow by lead migrations (8.6%). Other common causes of complications were circuit-related impedance (6.5%), cerebral bleeds (6.3%), device failure (6.3%) and device-related trauma (4.5%). Over a third (40%) of all devices reported with adverse events required returning to the operating room for explant or revision. Conclusion The most common complications of DBS systems are infections followed by lead migrations. Further research is needed to minimize infection rates associated with DBS systems and to reduce intrinsic device malfunctions for patients in the future.

Delirium after Deep Brain Stimulation in Parkinson's Disease

Deep brain stimulation is a primary treatment method that improves motor and motor complications in patients with advanced Parkinson's disease. Delirium is a common and serious complication following deep brain stimulation. However, the clinical attention toward this complication remains insufficient. Advanced age, cognitive decline, and the severity of the disease may all be risk factors for delirium. The presence of delirium may also affect cognitive function and disease prognosis. Neurotransmitters such as acetylcholine and dopamine may be involved in the occurrence of delirium. Furthermore, inflammation, the effects of microlesioning of local nuclei, and brain atrophy may also play roles in the onset of delirium. Nonpharmacological therapy appears to be the primary treatment for postoperative delirium in Parkinson's disease. The current article reviews the pathogenesis, epidemiology, prognosis, and treatment of delirium following deep brain stimulation in Parkinson's disease to help clinicians better understand this common complication and to prevent, identify, and treat it as soon as possible, as well as to provide more accurate treatment for patients.