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Chudy D, Deletis V, Paradžik V, Dubroja I, Marčinković P, Orešković D, Chudy H, Raguž M. Deep brain stimulation in disorders of consciousness: 10 years of a single center experience. Sci Rep 2023; 13:19491. [PMID: 37945710 PMCID: PMC10636144 DOI: 10.1038/s41598-023-46300-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Accepted: 10/30/2023] [Indexed: 11/12/2023] Open
Abstract
Disorders of consciousness (DoC), namely unresponsive wakefulness syndrome (UWS) and minimally conscious state (MCS), represent severe conditions with significant consequences for patients and their families. Several studies have reported the regaining of consciousness in such patients using deep brain stimulation (DBS) of subcortical structures or brainstem nuclei. Our study aims to present the 10 years' experience of a single center using DBS as a therapy on a cohort of patients with DoC. Eighty Three consecutive patients were evaluated between 2011 and 2022; entry criteria consisted of neurophysiological and neurological evaluations and neuroimaging examinations. Out of 83, 36 patients were considered candidates for DBS implantation, and 32 patients were implanted: 27 patients had UWS, and five had MCS. The stimulation target was the centromedian-parafascicular complex in the left hemisphere in hypoxic brain lesion or the one better preserved in patients with traumatic brain injury. The level of consciousness was improved in seven patients. Three out of five MCS patients emerged to full awareness, with the ability to interact and communicate. Two of them can live largely independently. Four out of 27 UWS patients showed consciousness improvement with two patients emerging to full awareness, and the other two reaching MCS. In patients with DoC lasting longer than 12 months following traumatic brain injury or 6 months following anoxic-ischemic brain lesion, spontaneous recovery is rare. Thus, DBS of certain thalamic nuclei could be recommended as a treatment option for patients who meet neurological, neurophysiological and neuroimaging criteria, especially in earlier phases, before occurrence of irreversible musculoskeletal changes. Furthermore, we emphasize the importance of cooperation between centers worldwide in studies on the potentials of DBS in treating patients with DoC.
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Affiliation(s)
- Darko Chudy
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia.
- Department of Surgery, School of Medicine, University of Zagreb, Zagreb, Croatia.
| | - Vedran Deletis
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
- Albert Einstein College of Medicine, New York, USA
| | - Veronika Paradžik
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
| | - Ivan Dubroja
- Brain Trauma Unit, Specialty Hospital for Medical Rehabilitation, Krapinske Toplice, Croatia
| | - Petar Marčinković
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
| | - Darko Orešković
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
| | - Hana Chudy
- Department of Neurology, Dubrava University Hospital, Zagreb, Croatia
| | - Marina Raguž
- Department of Neurosurgery, Dubrava University Hospital, Zagreb, Croatia
- School of Medicine, Catholic University of Croatia, Zagreb, Croatia
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Meier LJ. Memories without Survival: Personal Identity and the Ascending Reticular Activating System. THE JOURNAL OF MEDICINE AND PHILOSOPHY 2023; 48:478-491. [PMID: 37314862 PMCID: PMC10501180 DOI: 10.1093/jmp/jhad028] [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] [Indexed: 06/16/2023] Open
Abstract
Lockean views of personal identity maintain that we are essentially persons who persist diachronically by virtue of being psychologically continuous with our former selves. In this article, I present a novel objection to this variant of psychological accounts, which is based on neurophysiological characteristics of the brain. While the mental states that constitute said psychological continuity reside in the cerebral hemispheres, so that for the former to persist only the upper brain must remain intact, being conscious additionally requires that a structure originating in the brainstem-the ascending reticular activating system-be functional. Hence, there can be situations in which even small brainstem lesions render individuals irreversibly comatose and thus forever preclude access to their mental states, while the neural correlates of the states themselves are retained. In these situations, Lockeans are forced to regard as fulfilled their criterion of diachronic persistence since psychological continuity, as they construe it, is not disrupted. Deeming an entity that is never again going to have any mental experiences to be a person, however, is an untenable position for a psychological account to adopt. In their current form, Lockean views of personal identity are therefore incompatible with human neurophysiology.
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Lemaire JJ, Pontier B, Chaix R, El Ouadih Y, Khalil T, Sinardet D, Achim V, Postelnicu A, Coste J, Germain V, Sarret C, Sontheimer A. Neural correlates of consciousness and related disorders: From phenotypic descriptors of behavioral and relative consciousness to cortico-subcortical circuitry. Neurochirurgie 2021; 68:212-222. [PMID: 34051246 DOI: 10.1016/j.neuchi.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/13/2021] [Accepted: 05/09/2021] [Indexed: 01/01/2023]
Abstract
We report a review of medical aspects of the consciousness. The behavioral dimension, phenotypic descriptors, relative consciousness and neural correlates of consciousness and related disorders were addressed successively in a holistic and chronological approach. Consciousness is relative, specific to each individual across time and space. Historically defined as the perception of the self and the environment, it cannot be separated from behaviors, entailing an idea of conscious behavior with metapractic and metagnostic aspects. Observation of spontaneous and evoked overt behavior distinguishes three main types of disorder of consciousness (DoC): coma, vegetative state or unresponsive wakefulness, and minimally conscious or relationally impoverished state. Modern functional exploration techniques, such as imaging, increase the understanding of DoCs and consciousness. Whether consciousness is a superior function and/or an instrumental function is discussed. Neural correlates can be subdivided into two wakefulness pathways (superior thalamic cholinergic and inferior extra-thalamic), and cortico-subcortical circuitry. The deep brain structures are those described in the well-known sensorimotor, associative and limbic loops, as illustrated in the mesolimbic model of DoC. The cortices can be segregated into several overlapping networks: (1) a global workspace including thalamo-cortical loops; (2) the default mode network (DMN) and related intrinsic connectivity networks (i.e., central executive, medial DMN and salience networks); (3) a 3-fold network comprising the fronto-parietal control system and its dorsal and ventral attentional sub-networks, the fronto-parietal executive control network, and the cingulo-opercular salience network; (4) the internal and external cortices, respectively medial, turned toward the self, and lateral, turned toward the environment. The network dynamics is the reflection of consciousness, notably anticorrelations such as the decrease in activity of the posterior cingulate-precuneus regions during attentional tasks. Thanks to recent advances in DoC pathophysiology, further significative therapeutic progress is expected, taking into account the societal context. This depends notably on the dissemination of medical knowledge and its transfer to a wider public.
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Affiliation(s)
- J-J Lemaire
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France.
| | - B Pontier
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - R Chaix
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Y El Ouadih
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - T Khalil
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - D Sinardet
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - V Achim
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - A Postelnicu
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - J Coste
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - V Germain
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - C Sarret
- Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
| | - A Sontheimer
- Service de neurochirurgie, CHU Clermont-Ferrand, Clermont-Ferrand, France; Institut Pascal, université Clermont Auvergne CNRS SIGMA, Clermont-Ferrand, France
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Disrupted Pallido-Thalamo-Cortical Functional Connectivity in Chronic Disorders of Consciousness. Brain Sci 2021; 11:brainsci11030356. [PMID: 33799582 PMCID: PMC7999530 DOI: 10.3390/brainsci11030356] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 03/08/2021] [Accepted: 03/09/2021] [Indexed: 12/04/2022] Open
Abstract
Chronic disorders of consciousness (DOC) encompass unresponsive wakefulness syndrome and minimally conscious state. Their anatomo-functional correlates are not clearly defined yet, although impairments of functional cortical networks have been reported, as well as the implication of the thalamus and deep brain structures. However, the pallidal functional connectivity with the thalamus and the cortical networks has not been studied so far. Using resting-state functional MRI, we conducted a functional connectivity study between the pallidum, the thalamus and the cortical networks in 13 patients with chronic DOC and 19 healthy subjects. We observed in chronic DOC patients that the thalami were no longer connected to the cortical networks, nor to the pallidums. Concerning the functional connectivity of pallidums, we reported an abolition of the negative correlation with the default mode network, and of the positive correlation with the salience network. The disrupted functional connectivity observed in chronic DOC patients between subcortical structures and cortical networks could be related to the mesocircuit model. A better understanding of the DOC underlying physiopathology could provide food for thought for future therapeutic proposals.
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Affiliation(s)
- Daniel Kondziella
- From the Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital; Department of Clinical Medicine (D.K.), Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; and Department of Neurology (J.A.F.), NYU Grossman School of Medicine, New York.
| | - Jennifer A Frontera
- From the Department of Neurology (D.K.), Rigshospitalet, Copenhagen University Hospital; Department of Clinical Medicine (D.K.), Faculty of Health and Medical Sciences, University of Copenhagen, Denmark; and Department of Neurology (J.A.F.), NYU Grossman School of Medicine, New York
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Gruenbaum BF. Comparison of anaesthetic- and seizure-induced states of unconsciousness: a narrative review. Br J Anaesth 2021; 126:219-229. [PMID: 32951841 PMCID: PMC7844374 DOI: 10.1016/j.bja.2020.07.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/23/2020] [Accepted: 07/20/2020] [Indexed: 10/23/2022] Open
Abstract
In order to understand general anaesthesia and certain seizures, a fundamental understanding of the neurobiology of unconsciousness is needed. This review article explores similarities in neuronal and network changes during general anaesthesia and seizure-induced unconsciousness. Both seizures and anaesthetics cause disruption in similar anatomical structures that presumably lead to impaired consciousness. Despite differences in behaviour and mechanisms, both of these conditions are associated with disruption of the functionality of subcortical structures that mediate neuronal activity in the frontoparietal cortex. These areas are all likely to be involved in maintaining normal consciousness. An assessment of the similarities in the brain network disruptions with certain seizures and general anaesthesia might provide fresh insights into the mechanisms of the alterations of consciousness seen in these particular unconscious states, allowing for innovative therapies for seizures and the development of anaesthetic approaches targeting specific networks.
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Decreased level of consciousness due to a depleted deep brain stimulator battery: Paving the way to wake up the brain? Rev Neurol (Paris) 2019; 175:274-275. [PMID: 30879605 DOI: 10.1016/j.neurol.2018.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 06/13/2018] [Accepted: 06/18/2018] [Indexed: 11/23/2022]
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Cabessa J, Villa AEP. Attractor dynamics of a Boolean model of a brain circuit controlled by multiple parameters. CHAOS (WOODBURY, N.Y.) 2018; 28:106318. [PMID: 30384642 DOI: 10.1063/1.5042312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/29/2018] [Indexed: 06/08/2023]
Abstract
Studies of Boolean recurrent neural networks are briefly introduced with an emphasis on the attractor dynamics determined by the sequence of distinct attractors observed in the limit cycles. We apply this framework to a simplified model of the basal ganglia-thalamocortical circuit where each brain area is represented by a "neuronal" node in a directed graph. Control parameters ranging from neuronal excitability that affects all cells to targeted local connections modified by a new adaptive plasticity rule, and the regulation of the interactive feedback affecting the external input stream of information, allow the network dynamics to switch between stable domains delimited by highly discontinuous boundaries and reach very high levels of complexity with specific configurations. The significance of this approach with regard to brain circuit studies is briefly discussed.
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Affiliation(s)
- Jérémie Cabessa
- Laboratory of Mathematical Economics (LEMMA), Université Paris 2-Panthéon-Assas, 75005 Paris, France
| | - Alessandro E P Villa
- Neuroheuristic Research Group, University of Lausanne, CH-1015 Lausanne, Switzerland
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Lio G, Thobois S, Ballanger B, Lau B, Boulinguez P. Removing deep brain stimulation artifacts from the electroencephalogram: Issues, recommendations and an open-source toolbox. Clin Neurophysiol 2018; 129:2170-2185. [PMID: 30144660 DOI: 10.1016/j.clinph.2018.07.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 07/23/2018] [Accepted: 07/28/2018] [Indexed: 12/30/2022]
Abstract
A major question for deep brain stimulation (DBS) research is understanding how DBS of one target area modulates activity in different parts of the brain. EEG gives privileged access to brain dynamics, but its use with implanted patients is limited since DBS adds significant high-amplitude electrical artifacts that can completely obscure neural activity measured using EEG. Here, we systematically review and discuss the methods available for removing DBS artifacts. These include simple techniques such as oversampling, antialiasing analog filtering and digital low-pass filtering, which are necessary but typically not sufficient to fully remove DBS artifacts when each is used in isolation. We also cover more advanced methods, including techniques tracking outliers in the frequency-domain, which can be effective, but are rarely used. The reason for that is twofold: First, it requires advanced skills in signal processing since no user friendly tool for removing DBS artifacts is currently available. Second, it involves fine-tuning to avoid over-aggressive filtering. We highlight an open-source toolbox incorporating most artifact removal methods, allowing users to combine different strategies.
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Affiliation(s)
- Guillaume Lio
- Université de Lyon, F-69622 Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS, Centre de Neuroscience Cognitive, Bron, France
| | - Stéphane Thobois
- Université de Lyon, F-69622 Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS, Centre de Neuroscience Cognitive, Bron, France; Hospices civils de Lyon, hôpital neurologique Pierre Wertheimer, Bron, France
| | - Bénédicte Ballanger
- Université de Lyon, F-69622 Lyon, France; Université Lyon 1, Villeurbanne, France; INSERM U1028, CNRS UMR5292, Centre de Recherche en Neurosciences de Lyon, Lyon, France
| | - Brian Lau
- Sorbonne Universités, UPMC Univ Paris 06, UMR S 1127, CNRS UMR 7225, Institut du Cerveau et de la Moelle épinière, F-75013 Paris, France
| | - Philippe Boulinguez
- Université de Lyon, F-69622 Lyon, France; Université Lyon 1, Villeurbanne, France; INSERM U1028, CNRS UMR5292, Centre de Recherche en Neurosciences de Lyon, Lyon, France.
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Towards unambiguous reporting of complications related to deep brain stimulation surgery: A retrospective single-center analysis and systematic review of the literature. PLoS One 2018; 13:e0198529. [PMID: 30071021 PMCID: PMC6071984 DOI: 10.1371/journal.pone.0198529] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 05/21/2018] [Indexed: 02/04/2023] Open
Abstract
Background and objective To determine rates of adverse events (AEs) related to deep brain stimulation (DBS) surgery or implanted devices from a large series from a single institution. Sound comparisons with the literature require the definition of unambiguous categories, since there is no consensus on the reporting of such AEs. Patients and methods 123 consecutive patients (median age 63 yrs; female 45.5%) treated with DBS in the subthalamic nucleus (78 patients), ventrolateral thalamus (24), internal pallidum (20), and centre médian-parafascicular nucleus (1) were analyzed retrospectively. Both mean and median follow-up time was 4.7 years (578 patient-years). AEs were assessed according to three unambiguous categories: (i) hemorrhages including other intracranial complications because these might lead to neurological deficits or death, (ii) infections and similar AEs necessitating the explantation of hardware components as this results in the interruption of DBS therapy, and (iii) lead revisions for various reasons since this involves an additional intracranial procedure. For a systematic review of the literature AE rates were calculated based on primary data presented in 103 publications. Heterogeneity between studies was assessed with the I2 statistic and analyzed further by a random effects meta-regression. Publication bias was analyzed with funnel plots. Results Surgery- or hardware-related AEs (23) affected 18 of 123 patients (14.6%) and resolved without permanent sequelae in all instances. In 2 patients (1.6%), small hemorrhages in the striatum were associated with transient neurological deficits. In 4 patients (3.3%; 0.7% per patient-year) impulse generators were removed due to infection. In 2 patients electrodes were revised (1.6%; 0.3% per patient-year). There was no lead migration or surgical revision because of lead misplacement. Age was not statistically significant different (p>0.05) between patients affected by AEs or not. AE rates did not decline over time and similar incidences were found among all patients (423) implanted with DBS systems at our institution until December 2016. A systematic literature review revealed that exact AE rates could not be determined from many studies, which could not be attributed to study designs. Average rates for intracranial complications were 3.8% among studies (per-study analysis) and 3.4% for pooled analysis of patients from different studies (per-patient analysis). Annual hardware removal rates were 3.6 and 2.4% for per-study and per-patient analysis, respectively, and lead revision rates were 4.1 and 2.6%, respectively. There was significant heterogeneity between studies (I2 ranged between 77% and 91% for the three categories; p< 0.0001). For hardware removal heterogeneity (I2 = 87.4%) was reduced by taking study size (p< 0.0001) and publication year (p< 0.01) into account, although a significant degree of heterogeneity remained (I2 = 80.0%; p< 0.0001). Based on comparisons with health care-related databases there appears to be publication bias with lower rates for hardware-related AEs in published patient cohorts. Conclusions The proposed categories are suited for an unequivocal assessment of AEs even in a retrospective manner and useful for benchmarking. AE rates in the present cohorts from our institution compare favorable with the literature.
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Chudy D, Deletis V, Almahariq F, Marčinković P, Škrlin J, Paradžik V. Deep brain stimulation for the early treatment of the minimally conscious state and vegetative state: experience in 14 patients. J Neurosurg 2017. [PMID: 28621620 DOI: 10.3171/2016.10.jns161071] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE An effective treatment of patients in a minimally conscious state (MCS) or vegetative state (VS) caused by hypoxic encephalopathy or traumatic brain injury (TBI) is not yet available. Deep brain stimulation (DBS) of the thalamic reticular nuclei has been attempted as a therapeutic procedure mainly in patients with TBI. The purpose of this study was to investigate the therapeutic use of DBS for patients in VS or MCS. METHODS Fourteen of 49 patients in VS or MCS qualified for inclusion in this study and underwent DBS. Of these 14 patients, 4 were in MCS and 10 were in VS. The etiology of VS or MCS was TBI in 4 cases and hypoxic encephalopathy due to cardiac arrest in 10. The selection criteria for DBS, evaluating the status of the cerebral cortex and thalamocortical reticular formation, included: neurological evaluation, electrophysiological evaluation, and the results of positron emission tomography (PET) and MRI examinations. The target for DBS was the centromedian-parafascicular (CM-pf) complex. The duration of follow-up ranged from 38 to 60 months. RESULTS Two MCS patients regained consciousness and regained their ability to walk, speak fluently, and live independently. One MCS patient reached the level of consciousness, but was still in a wheelchair at the time the article was written. One VS patient (who had suffered a cerebral ischemic lesion) improved to the level of consciousness and currently responds to simple commands. Three VS patients died of respiratory infection, sepsis, or cerebrovascular insult (1 of each). The other 7 patients remained without substantial improvement of consciousness. CONCLUSIONS Spontaneous recovery from MCS/VS to the level of consciousness with no or minimal need for assistance in everyday life is very rare. Therefore, if a patient in VS or MCS fulfills the selection criteria (presence of somatosensory evoked potentials from upper extremities, motor and brainstem auditory evoked potentials, with cerebral glucose metabolism affected not more than the level of hypometabolism, which is judged using PET), DBS could be a treatment option.
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Affiliation(s)
- Darko Chudy
- 1Department of Neurosurgery.,2Croatian Institute for Brain Research, University of Zagreb, School of Medicine, Zagreb
| | - Vedran Deletis
- 3University of Split, School of Medicine, Split, Croatia; and.,4Albert Einstein College of Medicine, New York, New York
| | | | | | - Jasenka Škrlin
- 5Center for Clinical Microbiology and Hospital Infections, and
| | - Veronika Paradžik
- 6Center for Physical Medicine and Rehabilitation, University Hospital Dubrava, Zagreb
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Cortical Arousal With Deep Brain Stimulation After General Anesthesia for Laparoscopic Cholecystectomy. J Neurosurg Anesthesiol 2016; 30:77-78. [PMID: 27851692 DOI: 10.1097/ana.0000000000000389] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gummadavelli A, Kundishora AJ, Willie JT, Andrews JP, Gerrard JL, Spencer DD, Blumenfeld H. Neurostimulation to improve level of consciousness in patients with epilepsy. Neurosurg Focus 2016; 38:E10. [PMID: 26030698 DOI: 10.3171/2015.3.focus1535] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
When drug-resistant epilepsy is poorly localized or surgical resection is contraindicated, current neurostimulation strategies such as deep brain stimulation and vagal nerve stimulation can palliate the frequency or severity of seizures. However, despite medical and neuromodulatory therapy, a significant proportion of patients continue to experience disabling seizures that impair awareness, causing disability and risking injury or sudden unexplained death. We propose a novel strategy in which neuromodulation is used not only to reduce seizures but also to ameliorate impaired consciousness when the patient is in the ictal and postictal states. Improving or preventing alterations in level of consciousness may have an effect on morbidity (e.g., accidents, drownings, falls), risk for death, and quality of life. Recent studies may have elucidated underlying networks and mechanisms of impaired consciousness and yield potential novel targets for neuromodulation. The feasibility, benefits, and pitfalls of potential deep brain stimulation targets are illustrated in human and animal studies involving minimally conscious/vegetative states, movement disorders, depth of anesthesia, sleep-wake regulation, and epilepsy. We review evidence that viable therapeutic targets for impaired consciousness associated with seizures may be provided by key nodes of the consciousness system in the brainstem reticular activating system, hypothalamus, basal ganglia, thalamus, and basal forebrain.
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Affiliation(s)
| | | | - Jon T Willie
- 2Departments of Neurosurgery and Neurology, Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | - Hal Blumenfeld
- Departments of 1Neurosurgery.,3Neurology, and.,4Neurobiology, Yale University School of Medicine, New Haven, Connecticut; and
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Nwaneshiudu IC, Nwaneshiudu CA, Schwartz DT. Separation and enhanced detection of anesthetic compounds using solid phase micro-extraction (SPME)-Raman spectroscopy. APPLIED SPECTROSCOPY 2014; 68:1254-1259. [PMID: 25285420 DOI: 10.1366/13-07362] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Polydimethylsiloxane (PDMS)-based solid-phase micro-extraction (SPME) was used along with Raman spectroscopy (RS) to separate and enhance the detection of five anesthetic compounds (halothane, propofol, isoflurane, enflurane, and etomidate) from aqueous and serum phases. Raman signals in the spectral ranges 250-450 cm(-1) and 950-1050 cm(-1) allowed the unique characterization of all five compounds when extracted into the PDMS phase. The SPME-RS detection of clinically relevant concentrations of aqueous propofol (6.5 μM) and halothane (200 μM) is shown. We quantify the partition coefficient for aqueous halothane in PDMS as log K = 1.9 ± 0.2. Solid-phase micro-extraction of the anesthetics makes their detection possible without the strong autofluorescent interference of serum proteins. Because of low solubility and/or weak Raman scattering, we found it challenging to detect enflurane, isoflurane, and etomidate directly from the aqueous phase, but could we do so with SPME enhancement. These studies show the potential of SPME-RS as a method for the direct detection of anesthetics in blood.
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Affiliation(s)
- Ikechukwu C Nwaneshiudu
- University of Washington, Department of Chemical Engineering, Box 351750, Seattle, WA 98195, USA
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Leung LS, Luo T, Ma J, Herrick I. Brain areas that influence general anesthesia. Prog Neurobiol 2014; 122:24-44. [PMID: 25172271 DOI: 10.1016/j.pneurobio.2014.08.001] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 08/03/2014] [Accepted: 08/19/2014] [Indexed: 10/24/2022]
Abstract
This document reviews the literature on local brain manipulation of general anesthesia in animals, focusing on behavioral and electrographic effects related to hypnosis or loss of consciousness. Local inactivation or lesion of wake-active areas, such as locus coeruleus, dorsal raphe, pedunculopontine tegmental nucleus, perifornical area, tuberomammillary nucleus, ventral tegmental area and basal forebrain, enhanced general anesthesia. Anesthesia enhancement was shown as a delayed emergence (recovery of righting reflex) from anesthesia or a decrease in the minimal alveolar concentration that induced loss of righting. Local activation of various wake-active areas, including pontis oralis and centromedial thalamus, promoted behavioral or electrographic arousal during maintained anesthesia and facilitated emergence. Lesion of the sleep-active ventrolateral preoptic area resulted in increased wakefulness and decreased isoflurane sensitivity, but only for 6 days after lesion. Inactivation of any structure within limbic circuits involving the medial septum, hippocampus, nucleus accumbens, ventral pallidum, and ventral tegmental area, amygdala, entorhinal and piriform cortex delayed emergence from anesthesia, and often reduced anesthetic-induced behavioral excitation. In summary, the concept that anesthesia works on the sleep-wake system has received strong support from studies that inactivated/lesioned or activated wake-active areas, and weak support from studies that lesioned sleep-active areas. In addition to the conventional wake-sleep areas, limbic structures such as the medial septum, hippocampus and prefrontal cortex are also involved in the behavioral response to general anesthesia. We suggest that hypnosis during general anesthesia may result from disrupting the wake-active neuronal activities in multiple areas and suppressing an atropine-resistant cortical activation associated with movements.
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Affiliation(s)
- L Stan Leung
- Department of Physiology and Pharmacology, The University of Western Ontario, London, Ontario, Canada N6A 5C1.
| | - Tao Luo
- Department of Anesthesiology, Peking University, Shenzhen Hospital, China
| | - Jingyi Ma
- Department of Physiology and Pharmacology, The University of Western Ontario, London, Ontario, Canada N6A 5C1
| | - Ian Herrick
- Department of Anaesthesiology and Perioperative Medicine, The University of Western Ontario, London, Ontario, Canada N6A 5C1
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Regional cerebral metabolic patterns demonstrate the role of anterior forebrain mesocircuit dysfunction in the severely injured brain. Proc Natl Acad Sci U S A 2014; 111:6473-8. [PMID: 24733913 DOI: 10.1073/pnas.1320969111] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Although disorders of consciousness (DOCs) demonstrate widely varying clinical presentations and patterns of structural injury, global down-regulation and bilateral reductions in metabolism of the thalamus and frontoparietal network are consistent findings. We test the hypothesis that global reductions of background synaptic activity in DOCs will associate with changes in the pattern of metabolic activity in the central thalamus and globus pallidus. We compared 32 [(18)F]fluorodeoxyglucose PETs obtained from severely brain-injured patients (BIs) and 10 normal volunteers (NVs). We defined components of the anterior forebrain mesocircuit on high-resolution T1-MRI (ventral, associative, and sensorimotor striatum; globus pallidus; central thalamus and noncentral thalamus). Metabolic profiles for BI and NV demonstrated distinct changes in the pattern of uptake: ventral and association striatum (but not sensorimotor) were significantly reduced relative to global mean uptake after BI; a relative increase in globus pallidus metabolism was evident in BI subjects who also showed a relative reduction of metabolism in the central thalamus. The reversal of globus pallidus and central thalamus profiles across BIs and NVs supports the mesocircuit hypothesis that broad functional (or anatomic) deafferentation may combine to reduce central thalamus activity and release globus pallidus activity in DOCs. In addition, BI subjects showed broad frontoparietal metabolic down-regulation consistent with prior studies supporting the link between central thalamic/pallidal metabolism and down-regulation of the frontoparietal network. Recovery of left hemisphere frontoparietal metabolic activity was further associated with command following.
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Moll CKE, Galindo-Leon E, Sharott A, Gulberti A, Buhmann C, Koeppen JA, Biermann M, Bäumer T, Zittel S, Westphal M, Gerloff C, Hamel W, Münchau A, Engel AK. Asymmetric pallidal neuronal activity in patients with cervical dystonia. Front Syst Neurosci 2014; 8:15. [PMID: 24574981 PMCID: PMC3920073 DOI: 10.3389/fnsys.2014.00015] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/23/2014] [Indexed: 11/24/2022] Open
Abstract
The origin of asymmetric clinical manifestation of symptoms in patients suffering from cervical dystonia (CD) is hitherto poorly understood. Dysregulated neuronal activity in the basal ganglia has been suggested to have a role in the pathophysiology of CD. Here, we re-assessed the question to what extent relative changes occur in the direct vs. indirect basal ganglia pathway in CD, whether these circuit changes are lateralized, and how these alterations relate to CD symptoms. To this end, we recorded ongoing single cell and local field potential (LFP) activity from the external (GPe) and internal pallidal segment (GPi) of 13 CD patients undergoing microelectrode-guided stereotactic surgery for deep brain stimulation in the GPi. We compared pallidal recordings from CD patients operated under local anaesthesia (LA) with those obtained in CD patients operated under general anaesthesia (GA). In awake patients, mean GPe discharge rate (52 Hz) was lower than that of GPi (72 Hz). Mean GPi discharge ipsilateral to the side of head turning was higher than contralateral and correlated with torticollis symptom severity. Lateralized differences were absent at the level of the GPe and in recordings from patients operated under GA. Furthermore, in the GPi of CD patients there was a subpopulation of theta-oscillatory cells with unique bursting characteristics. Power and coherence of GPe– and GPi–LFPs were dominated by a theta peak and also exhibited band-specific interhemispheric differences. Strong cross-frequency coupling of low-gamma amplitude to theta phase was a feature of pallidal LFPs recorded under LA, but not GA. These results indicate that CD is associated with an asymmetric pallidal outflow. Based on the finding of symmetric neuronal discharges in the GPe, we propose that an imbalanced interhemispheric direct pathway gain may be involved in CD pathophysiology.
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Affiliation(s)
- Christian K E Moll
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Edgar Galindo-Leon
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Andrew Sharott
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany ; Medical Research Council Anatomical Neuropharmacology Unit, Department of Pharmacology, University of Oxford Oxford, UK
| | - Alessandro Gulberti
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Johannes A Koeppen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Maxine Biermann
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Tobias Bäumer
- Department of Paediatric and Adult Movement Disorders and Neuropsychiatry, Institute of Neurology, University Medical Center Schleswig-Holstein Lübeck, Germany
| | - Simone Zittel
- Department of Paediatric and Adult Movement Disorders and Neuropsychiatry, Institute of Neurology, University Medical Center Schleswig-Holstein Lübeck, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Alexander Münchau
- Department of Paediatric and Adult Movement Disorders and Neuropsychiatry, Institute of Neurology, University Medical Center Schleswig-Holstein Lübeck, Germany
| | - Andreas K Engel
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
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Abstract
Awake surgery is regarded mandatory for optimal electrode implantation into the subthalamic nucleus (STN) for deep brain stimulation (DBS) in Parkinson's disease (PD). However, this is questionable since general anaesthesia (GA) does not preclude intraoperative microrecordings and clinical evaluation of, for example, current spread to the corticospinal tract. In addition, even in the awake state, clinical testing is not without limitations. We report on intra- and postoperative findings in 11 patients suffering from advanced PD who were operated under GA (propofol/remifentanil). The activity of STN neurons under GA was characterized by excessive burst discharges that differed fundamentally from the irregular tonic patterns observed in the STN of awake patients. In all patients, we obtained improved motor symptoms and reduced levodopa-induced dyskinesias and motor fluctuations, which was associated with a reduction in the levodopa equivalent daily dose. Therapeutic DBS was not limited by current spread to the corticospinal tract in any of the patients. The trajectories chosen for electrode implantation in GA compared well to awake surgery. Our results indicate that STN surgery in GA can be performed in a safe manner. It can be offered to anxious patients, and represents a viable option when awake surgery bears a risk for the patient.
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Abstract
Traumatic coma is associated with disruption of axonal pathways throughout the brain, but the specific pathways involved in humans are incompletely understood. In this study, we used high angular resolution diffusion imaging to map the connectivity of axonal pathways that mediate the 2 critical components of consciousness-arousal and awareness-in the postmortem brain of a 62-year-old woman with acute traumatic coma and in 2 control brains. High angular resolution diffusion imaging tractography guided tissue sampling in the neuropathologic analysis. High angular resolution diffusion imaging tractography demonstrated complete disruption of white matter pathways connecting brainstem arousal nuclei to the basal forebrain and thalamic intralaminar and reticular nuclei. In contrast, hemispheric arousal pathways connecting the thalamus and basal forebrain to the cerebral cortex were only partially disrupted, as were the cortical "awareness pathways." Neuropathologic examination, which used β-amyloid precursor protein and fractin immunomarkers, revealed axonal injury in the white matter of the brainstem and cerebral hemispheres that corresponded to sites of high angular resolution diffusion imaging tract disruption. Axonal injury was also present within the gray matter of the hypothalamus, thalamus, basal forebrain, and cerebral cortex. We propose that traumatic coma may be a subcortical disconnection syndrome related to the disconnection of specific brainstem arousal nuclei from the thalamus and basal forebrain.
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Buhmann C, Moll CKE, Zittel S, Münchau A, Engel AK, Hamel W. Deep brain stimulation of the ventrolateral thalamic base and posterior subthalamic area in dystonic head tremor. ACTA NEUROCHIRURGICA. SUPPLEMENT 2013; 117:67-72. [PMID: 23652659 DOI: 10.1007/978-3-7091-1482-7_11] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Dystonic head tremor (DHT) is characterized by head tremor associated with cervical dystonia (CD). Deep brain stimulation (DBS) can be considered when local treatment with botulinum toxin or oral medication has failed. However, there is lack of data regarding the optimal target structure for surgery in DHT.DBS of the ventrolateral (VL) thalamus is an established treatment option for medically refractory tremor. Tremor suppression is described as being most effective when stimulating at the inferior thalamic base and within the posterior subthalamic area (PSA). Moreover, there is surgical evidence from the pre-DBS era that both lesions and high-frequency stimulation of the PSA improve CD. Based on these observations, we performed DBS in three patients with DHT, placing the proximal contacts of the electrodes into the inferior base of VL thalamic nuclei and the distal contacts into the adjacent PSA. Chronic stimulation improved not only head tremor but also CD. These findings suggest that DBS at the base of VL thalamus and the adjacent PSA should undergo further investigation as a potential target for patients with DHT.
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Affiliation(s)
- Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany,
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Zittel S, Moll CKE, Brüggemann N, Tadic V, Hamel W, Kasten M, Lohmann K, Lohnau T, Winkler S, Gerloff C, Schönweiler R, Hagenah J, Klein C, Münchau A, Schneider SA. Clinical neuroimaging and electrophysiological assessment of three DYT6 dystonia families. Mov Disord 2011; 25:2405-12. [PMID: 20687193 DOI: 10.1002/mds.23279] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
The purpose of the study was to delineate clinical and electrophysiological characteristics as well as laryngoscopical and transcranial ultrasound (TCS) findings in THAP1 mutation carriers (MutC). According to recent genetic studies, DYT6 (THAP1) gene mutations are an important cause of primary early-onset dystonia. In contrast to DYT1 mutations, THAP1 mutations are associated with primary early-onset segmental or generalised dystonia frequently involving the craniocervical region and the larynx. Blood samples from twelve individuals of three German families with DYT6 positive index cases were obtained to test for THAP1 mutations. Eight THAP1 MutC were identified. Of these, six (three symptomatic and three asymptomatic) THAP1 MutC could be clinically evaluated. Laryngoscopy was performed to evaluate laryngeal dysfunction in patients. Brainstem echogenicity was investigated in all MutC using TCS. Two of the patients had undergone bilateral pallidal DBS. In all three symptomatic MutC, early-onset laryngeal dystonia was a prominent feature. Laryngeal assessment demonstrated adductor-type dystonia in all of them. On clinical examination, the three asymptomatic MutC also showed subtle signs of focal or segmental dystonia. TCS revealed increased substantia nigra (SN) hyperechogenicity in all MutC. Intraoperative microelectrode recordings under general anesthesia in two of the patients showed no difference between THAP1 and previously operated DYT1 MutC. The presence of spasmodic dysphonia in patients with young-onset segmental or generalised dystonia is a hallmark of DYT6 dystonia. SN hyperechogenicity on TCS may represent an endophenotype in these patients. Pallidal DBS in two patients was unsatisfactory.
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Affiliation(s)
- Simone Zittel
- Department of Neurology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
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