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Brinke TRT, Jergas H, Sisodia V, Barbe MT, Odekerken VJJ, Verbaan D, Dijk JM, Bot M, Beudel M, van den Munckhof P, Schuurman PR, de Bie RMA. Directional versus ring-mode deep brain stimulation for Parkinson's disease: protocol of a multi-centre double-blind randomised crossover trial. BMC Neurol 2023; 23:372. [PMID: 37853327 PMCID: PMC10583384 DOI: 10.1186/s12883-023-03387-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/12/2023] [Indexed: 10/20/2023] Open
Abstract
BACKGROUND The effectiveness of Deep Brain Stimulation (DBS) therapy for Parkinson's disease can be limited by side-effects caused by electrical current spillover into structures adjacent to the target area. The objective of the STEEred versus RING-mode DBS for Parkinson's disease (STEERING) study is to investigate if directional DBS for Parkinson's disease results in a better clinical outcome when compared to ring-mode DBS. METHODS The STEERING study is a prospective multi-centre double-blind randomised crossover trial. Inclusion criteria are Parkinson's disease, subthalamic nucleus DBS in a 'classic' ring-mode setting for a minimum of six months, and optimal ring-mode settings have been established. Participants are categorised into one of two subgroups according to their clinical response to the ring-mode settings as 'responders' (i.e., patient with a satisfactory effect of ring-mode DBS) or 'non-responder' (i.e., patient with a non-satisfactory effect of ring-mode DBS). A total of 64 responders and 38 non-responders will be included (total 102 patients). After an optimisation period in which an optimal directional setting is found, participants are randomised to first receive ring-mode DBS for 56 days (range 28-66) followed by directional DBS for 56 days (28-66) or vice-versa. The primary outcome is the difference between ring-mode DBS and directional DBS settings on the Movement Disorders Society Unified Parkinson's Disease Rating Scale - Motor Evaluation (MDS-UPDRS-ME) in the off-medication state. Secondary outcome measures consist of MDS-UPDRS-ME in the on-medication state, MDS-UPDRS Activities of Daily Living, MDS-UPDRS Motor Complications-Dyskinesia, disease related quality of life measured with the Parkinson's Disease Questionnaire 39, stimulation-induced side-effects, antiparkinsonian medication use, and DBS-parameters. Participants' therapy preference is measured at the end of the study. Outcomes will be analysed for both responder and non-responder groups, as well as for both groups pooled together. DISCUSSION The STEERING trial will provide insights into whether or not directional DBS should be standardly used in all Parkinson's disease DBS patients or if directional DBS should only be used in a case-based approach. TRIAL REGISTRATION This trial was registered on the Netherlands Trial Register, as trial NL6508 ( NTR6696 ) on June 23, 2017.
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Affiliation(s)
- Timo R Ten Brinke
- Amsterdam UMC, University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, Netherlands
| | - Hannah Jergas
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Vibuthi Sisodia
- Amsterdam UMC, University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, Netherlands
| | - Michael T Barbe
- Department of Neurology, University of Cologne, Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Vincent J J Odekerken
- Amsterdam UMC, University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, Netherlands
| | - Dagmar Verbaan
- Amsterdam UMC, University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, Netherlands
| | - Joke M Dijk
- Amsterdam UMC, University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, Netherlands
| | - Maarten Bot
- Amsterdam UMC, University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, Netherlands
| | - Martijn Beudel
- Amsterdam UMC, University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, Netherlands
| | - Pepijn van den Munckhof
- Amsterdam UMC, University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, Netherlands
| | - P Rick Schuurman
- Amsterdam UMC, University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, Netherlands
| | - Rob M A de Bie
- Amsterdam UMC, University of Amsterdam, Neurology, Meibergdreef 9, Amsterdam, Netherlands.
- Amsterdam Neuroscience, Neurodegeneration, Amsterdam, Netherlands.
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Zitman FMP, Janssen A, van der Gaag NA, Hoffmann CFE, Zutt R, Contarino MF. The actual use of directional steering and shorter pulse width in selected patients undergoing deep brain stimulation. Parkinsonism Relat Disord 2021; 93:58-61. [PMID: 34800852 DOI: 10.1016/j.parkreldis.2021.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Directional deep brain stimulation (DBS) and pulse with <60μs increase side-effects threshold, enlarging the therapeutic window. However, new systems allowing these advanced features are more expensive and often available only for a limited number of patients in some centers. It is unknown how many and which DBS patients actually need the advanced features because of an insufficient improvement with standard parameters. METHODS We included in the analysis all patients with Parkinson's disease, dystonia and tremor who were selected to receive implantation of advanced DBS systems based on specific preoperative or intraoperative clinical features. RESULTS After a median follow-up of 15 months, 54.9% of the 51 patients implanted with directional leads were using the advanced features in one or both leads (n = 42 leads, 42%), meaning these leads were programmed either with directional stimulation (n = 9, 9%), a shorter pw (n = 20, 20%) or both (n = 13, 13%). This included 92% of patients implanted in the Vim, 44% of those implanted in the STN, and 40% of those implanted in the GPi. CONCLUSIONS DBS systems with advanced features may be particularly indicated for selected patients based on some clinical characteristics and the chosen target. This data may help clinicians allocate resources in a more informed way.
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Affiliation(s)
- Femke M P Zitman
- Department of Neurology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Alexander Janssen
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands; Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Carel F E Hoffmann
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - Rodi Zutt
- Department of Neurology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Maria Fiorella Contarino
- Department of Neurology, Haga Teaching Hospital, The Hague, the Netherlands; Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.
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Iorio-Morin C, Fomenko A, Kalia SK. Deep-Brain Stimulation for Essential Tremor and Other Tremor Syndromes: A Narrative Review of Current Targets and Clinical Outcomes. Brain Sci 2020; 10:E925. [PMID: 33271848 PMCID: PMC7761254 DOI: 10.3390/brainsci10120925] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 02/06/2023] Open
Abstract
Tremor is a prevalent symptom associated with multiple conditions, including essential tremor (ET), Parkinson's disease (PD), multiple sclerosis (MS), stroke and trauma. The surgical management of tremor evolved from stereotactic lesions to deep-brain stimulation (DBS), which allowed safe and reversible interference with specific neural networks. This paper reviews the current literature on DBS for tremor, starting with a detailed discussion of current tremor targets (ventral intermediate nucleus of the thalamus (Vim), prelemniscal radiations (Raprl), caudal zona incerta (Zi), thalamus (Vo) and subthalamic nucleus (STN)) and continuing with a discussion of results obtained when performing DBS in the various aforementioned tremor syndromes. Future directions for DBS research are then briefly discussed.
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Affiliation(s)
- Christian Iorio-Morin
- Christian Iorio-Morin, Division of Neurosurgery, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
| | - Anton Fomenko
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
| | - Suneil K. Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
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Borton DA, Dawes HE, Worrell GA, Starr PA, Denison TJ. Developing Collaborative Platforms to Advance Neurotechnology and Its Translation. Neuron 2020; 108:286-301. [PMID: 33120024 PMCID: PMC7610607 DOI: 10.1016/j.neuron.2020.10.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/02/2020] [Accepted: 10/02/2020] [Indexed: 12/19/2022]
Abstract
Neurotechnological devices are failing to deliver on their therapeutic promise because of the time it takes to translate them from bench to clinic. In this Perspective, we reflect on lessons learned from medical device successes and failures and consider how such lessons might shape a strategic vision for translating neurotechnologies in the future. We articulate how the intentional design and deployment of "scientific platforms," from the technology stack of hardware and software through the supporting ecosystem, could catalyze a new wave of innovation, discovery, and therapy. We also identify specific actions that could promote future neurotechnology roadmaps and industrial-academic-government collaborative activities. We believe that community-supported neurotechnology platforms will prove to be transformational in accelerating ideas from bench to bedside, maximizing scientific discovery and improving patient care.
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Affiliation(s)
- David A Borton
- School of Engineering and the Carney Institute for Brain Science, Brown University, Providence, RI 02906, USA; VA RR&D Center for Neurorestoration and Neurotechnology, Providence VA Medical Center, Providence, RI, USA
| | - Heather E Dawes
- Department of Neurological Surgery, UCSF, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, UCSF, San Francisco, CA 94143, USA
| | - Gregory A Worrell
- Department of Neurology, Mayo Clinic, Rochester, MN 55902, USA; Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, MN 55902, USA
| | - Philip A Starr
- Department of Neurological Surgery, UCSF, San Francisco, CA 94143, USA; Weill Institute for Neurosciences, UCSF, San Francisco, CA 94143, USA
| | - Timothy J Denison
- Department of Engineering Science, University of Oxford, Oxford OX3 7DQ, UK; MRC Brain Network Dynamics Unit, University of Oxford, Oxford OX3 7DQ, UK.
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Directional Deep Brain Stimulation: First experiences in centers across the globe. Brain Stimul 2018; 11:949-950. [DOI: 10.1016/j.brs.2018.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/05/2018] [Indexed: 11/19/2022] Open
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Cossu G, Sensi M. Deep Brain Stimulation Emergencies: How the New Technologies Could Modify the Current Scenario. Curr Neurol Neurosci Rep 2017; 17:51. [PMID: 28497305 DOI: 10.1007/s11910-017-0761-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
After 25 years of deep brain stimulation (DBS) for the treatment of Parkinson's disease, it has become increasingly recognized that a range of postoperative urgent situations and emergencies may occur. In this review we describe the possible scenarios of DBS-related emergencies: perioperative (intraoperative and early postoperative) and postoperative settings and issues from suboptimal control of motor and nonmotor symptoms in the early programming phase and during long-term follow-up. We also outline potential advantages in the management of these emergencies offered by the newest devices, emerging technologies, and new possibilities in programming.
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Affiliation(s)
- Giovanni Cossu
- Movement Disorders Unit, Department of Neurology, Brotzu General Hospital, Piazzale Ricchi 1, 09134, Cagliari, Italy.
| | - Mariachiara Sensi
- Department of Neurology, Azienda Ospedaliera Universitaria Arcispedale Sant'Anna, Ferrara, Italy
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Abstract
Important advances are afoot in the field of neurosurgery-particularly in the realms of deep brain stimulation (DBS), deep brain manipulation (DBM), and the newly introduced refinement "closed-loop" deep brain stimulation (CLDBS). Use of closed-loop technology will make both DBS and DBM more precise as procedures and will broaden their indications. CLDBS utilizes as feedback a variety of sources of electrophysiological and neurochemical afferent information about the function of the brain structures to be treated or studied. The efferent actions will be either electric, i.e. the classic excitatory or inhibitory ones, or micro-injection of such things as neural proteins and transmitters, neural grafts, implants of pluripotent stem cells or mesenchymal stem cells, and some variants of gene therapy. The pathologies to be treated, beside Parkinson's disease and movement disorders, include repair of neural tissues, neurodegenerative pathologies, psychiatric and behavioral dysfunctions, i.e. schizophrenia in its various guises, bipolar disorders, obesity, anorexia, drug addiction, and alcoholism. The possibility of using these new modalities to treat a number of cognitive dysfunctions is also under consideration. Because the DBS-CLDBS technology brings about a cross-fertilization between scientific investigation and surgical practice, it will also contribute to an enhanced understanding of brain function.
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Affiliation(s)
- Stylianos Nicolaidis
- Retired from Collège de France and CNRS, 84 Boulevard du Maréchal Joffre, 92340 Bourg-la-Reine, France.
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Almeida L, Deeb W, Spears C, Opri E, Molina R, Martinez-Ramirez D, Gunduz A, Hess CW, Okun MS. Current Practice and the Future of Deep Brain Stimulation Therapy in Parkinson's Disease. Semin Neurol 2017; 37:205-214. [PMID: 28511261 PMCID: PMC6195220 DOI: 10.1055/s-0037-1601893] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Deep brain stimulation (DBS) is an effective therapy for Parkinson's disease patients experiencing motor fluctuations, medication-resistant tremor, and/or dyskinesia. Currently, the subthalamic nucleus and the globus pallidus internus are the two most widely used targets, with individual advantages and disadvantages influencing patient selection. Potential DBS patients are selected using the few existing guidelines and the available DBS literature, and many centers employ an interdisciplinary team review of the individual's risk-benefit profile. Programmed settings vary based on institution- or physician-specific protocols designed to maximize benefits and limit adverse effects. Expectations should be realistic and clearly defined during the evaluation process, and each bothersome symptom should be addressed in the context of building the risk-benefit profile. Current DBS research is focused on improved symptom control, the development of newer technologies, and the improved efficiency of stimulation delivery. Techniques deliver stimulation in a more personalized way, and methods of adaptive DBS such as closed-loop approaches are already on the horizon.
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Affiliation(s)
- Leonardo Almeida
- Department of Neurology, University of Florida, Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Wissam Deeb
- Department of Neurology, University of Florida, Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Chauncey Spears
- Department of Neurology, University of Florida, Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Enrico Opri
- Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Rene Molina
- Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Daniel Martinez-Ramirez
- Department of Neurology, University of Florida, Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Aysegul Gunduz
- Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Christopher W. Hess
- Department of Neurology, University of Florida, Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Michael S. Okun
- Department of Neurology, University of Florida, Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
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Rowland NC, Sammartino F, Lozano AM. Advances in surgery for movement disorders. Mov Disord 2016; 32:5-10. [PMID: 27125681 DOI: 10.1002/mds.26636] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Revised: 03/03/2016] [Accepted: 03/06/2016] [Indexed: 12/27/2022] Open
Abstract
Movement disorder surgery has evolved throughout history as our knowledge of motor circuits and ways in which to manipulate them have expanded. Today, the positive impact on patient quality of life for a growing number of movement disorders such as Parkinson's disease is now well accepted and confirmed through several decades of randomized, controlled trials. Nevertheless, residual motor symptoms after movement disorder surgery such as deep brain stimulation and lack of a definitive cure for these conditions demand that advances continue to push the boundaries of the field and maximize its therapeutic potential. Similarly, advances in related fields - wireless technology, artificial intelligence, stem cell and gene therapy, neuroimaging, nanoscience, and minimally invasive surgery - mean that movement disorder surgery stands at a crossroads to benefit from unique combinations of all these developments. In this minireview, we outline some of these developments as well as evidence supporting topics of recent discussion and controversy in our field. Moving forward, expectations remain high that these improvements will come to encompass an even broader range of patients who might benefit from this therapy and decrease the burden of disease associated with these conditions. © 2016 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Nathan C Rowland
- Toronto Western Hospital, Division of Neurosurgery, Toronto, Ontario, Canada
| | | | - Andres M Lozano
- Toronto Western Hospital, Division of Neurosurgery, Toronto, Ontario, Canada
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