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Leplus A, Isan P, Balossier A, Mouffok S, Donnet A, Papadopoulo T, Lanteri‐Minet M, Regis J, Fontaine D. Somatotopy of the sensory thalamus: inputs from directional deep brain stimulation in pain patients. Ann Clin Transl Neurol 2024; 11:1502-1513. [PMID: 38668642 PMCID: PMC11187955 DOI: 10.1002/acn3.52067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/05/2024] [Accepted: 02/27/2024] [Indexed: 06/20/2024] Open
Abstract
OBJECTIVE The sensory ventroposterior (VP) thalamic nuclei display a mediolateral somatotopic organization (respectively head, arm, and leg). We studied this somatotopy using directional VP deep brain stimulation (DBS) in patients treated for chronic neuropathic pain. METHODS Six patients with central (four) or peripheral (two) neuropathic pain were treated by VP DBS using directional leads in a prospective study (clinicaltrials.gov NCT03399942). Lead-DBS toolbox was used for leads localization, visualization, and modeling of the volume of tissue activated (VTA). Stimulation was delivered in each direction, 1 month after surgery and correlated to the location of stimulation-induced paresthesias. The somatotopy was modeled by correlating the respective locations of paresthesias and VTAs. We recorded 48 distinct paresthesia maps corresponding to 48 VTAs (including 36 related to directional stimulation). RESULTS We observed that, in each patient, respective body representations of the trunk, upper limb, lower limb, and head were closely located around the lead. These representations differed across patients, did not follow a common organization and were not concordant with the previously described somatotopic organization of the sensory thalamus. INTERPRETATION Thalamic reorganization has been reported in chronic pain patients compared to non-pain patients operated for movement disorders in previous studies using intraoperative recordings and micro-stimulation. Using a different methodology, namely 3D representation of the VTA by the directional postoperative stimulation through a stationary electrode, our study brings additional arguments in favor of a reorganization of the VP thalamic somatotopy in patients suffering from chronic neuropathic pain of central or peripheral origin.
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Affiliation(s)
- Aurelie Leplus
- Department of Neurosurgery, FHU INOVPAIN, CHU de NiceUniversité Côte d'AzurNiceFrance
- UR2CAUniversité Côte d'AzurNiceFrance
| | - Petru Isan
- Department of Neurosurgery, FHU INOVPAIN, CHU de NiceUniversité Côte d'AzurNiceFrance
- UR2CAUniversité Côte d'AzurNiceFrance
| | - Anne Balossier
- Department of NeurosurgeryHopital La Timone, APHM, FHU INOVPAINMarseilleFrance
| | - Sarah Mouffok
- INRIA CenterUniversité Cote d'AzurSophia AntipolisFrance
| | - Anne Donnet
- Pain ClinicHopital La Timone, APHMMarseilleFrance
- Neuro‐Dol, Trigeminal PainINSERM/UCA, U1107Clermont‐FerrandFrance
| | | | - Michel Lanteri‐Minet
- UR2CAUniversité Côte d'AzurNiceFrance
- Neuro‐Dol, Trigeminal PainINSERM/UCA, U1107Clermont‐FerrandFrance
- Pain Clinic, FHU INOVPAIN, CHU de NiceUniversité Côte d'AzurNiceFrance
| | - Jean Regis
- Department of NeurosurgeryHopital La Timone, APHM, FHU INOVPAINMarseilleFrance
| | - Denys Fontaine
- Department of Neurosurgery, FHU INOVPAIN, CHU de NiceUniversité Côte d'AzurNiceFrance
- UR2CAUniversité Côte d'AzurNiceFrance
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Cavalloni F, Brugger F, Kägi G, Naseri Y, Brogle D, Bozinov O, Bauer R, Hägele-Link S, Krüger MT. Evaluation of the Rotational Stability of Directional Deep Brain Stimulation Leads: A Case Series and Systematic Review. J Neurol Surg A Cent Eur Neurosurg 2024; 85:288-293. [PMID: 37832590 DOI: 10.1055/s-0043-1775759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
BACKGROUND The rotational stability of directional deep brain stimulation leads is a major prerequisite for sustained clinical effects. Data on directional lead stability are limited and controversial. METHODS We aimed to evaluate the long-term rotational stability of directional leads and define confounding factors in our own population and the current literature. We retrospectively evaluated the orientation of directional leads in patients with available postoperative computed tomography (CT; T1; day of surgery) and an additional postoperative image (T2; CT or rotational fluoroscopy) performed more than 7 days after the initial scan. The potential impact of intracranial air was assessed. We also reviewed the literature to define factors impacting stability. RESULTS Thirty-six leads were evaluated. The mean follow-up between T1 and T2 was 413.3 (7-1,171) days. The difference in rotation between T1 and T2 was 2.444 ± 2.554 degrees (range: 0-9.0 degrees). The volume of intracranial air did not impact the rotation. The literature search identified one factor impacting the stability of directional leads, which is the amount of twist applied at implantation. CONCLUSION Directional leads for deep brain stimulation show stable long-term orientation after implantation. Based on our literature review, large amounts of twist during implantation can lead to delayed rotation and should thus be avoided.
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Affiliation(s)
- Fabian Cavalloni
- Department of Neurosurgery, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
- Department of Neurosurgery, Inselspital, University Hospital of Berne, Berne, Switzerland
| | - Florian Brugger
- Department of Neurology, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
| | - Yashar Naseri
- Department of Neurosurgery, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
- Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany
| | - Deborah Brogle
- Department of Neurology, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
| | - Ronald Bauer
- Department of Neurosurgery, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Stefan Hägele-Link
- Department of Neurology, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
| | - Marie Therese Krüger
- Department of Neurosurgery, Kantonsspital Sankt Gallen, Sankt Gallen, Switzerland
- Department of Neurosurgery, Freiburg University Medical Center, Freiburg, Germany
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Brown G, De Jesus S. Bridging the Gap: Local Field Potentials Offer a Peek Into the Brain of a Person With Parkinson Disease. Neurology 2024; 102:e209283. [PMID: 38513164 DOI: 10.1212/wnl.0000000000209283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 01/20/2024] [Indexed: 03/23/2024] Open
Abstract
Clinically available deep brain recordings in patients with Parkinson disease (PD) offer insights into disease mechanisms and create a pathway for personalized treatment strategies. This case illustrates the transformative potential of recordings of neuronal firing in the form of local field potentials (LFPs) by detailing a patient's clinical trajectory for 6 months after deep brain stimulation (DBS) surgery to treat their PD symptoms. LFPs, obtained easily in clinic with a tablet interface to measure and track brain rhythms across the disease course, enriched the patient's clinical picture. Specifically, strong beta peaks were captured at initial programming, and, as the beta peaks diminished over the course of optimizing settings, symptoms improved. These signals may also reveal insights into the neural dynamics of PD such as hypersynchrony in basal ganglia circuitry. Furthermore, the ability to record chronically may unlock new understanding of neuronal dysfunction in PD, possibly enabling future adaptive DBS. In conclusion, identification, tracking, and modulation of LFPs correlated with subjective and objective clinical improvement in the case presented. The use of neurophysiologic signals in the future may lead to therapeutic innovations for our patients with PD.
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Affiliation(s)
- Gregory Brown
- From the Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA
| | - Sol De Jesus
- From the Department of Neurology, Pennsylvania State University-Milton S. Hershey Medical Center, Hershey, PA
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Moscovich M, Aquino CHD, Marinho MM, Barcelos LB, Felício AC, Halverson M, Hamani C, Ferraz HB, Munhoz RP. Fundamentals of deep brain stimulation for Parkinson's disease in clinical practice: part 2. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-9. [PMID: 38653486 PMCID: PMC11039109 DOI: 10.1055/s-0044-1786037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 10/30/2023] [Indexed: 04/25/2024]
Abstract
The field of neuromodulation has evolved significantly over the past decade. Developments include novel indications and innovations of hardware, software, and stimulation techniques leading to an expansion in scope and role of these techniques as powerful therapeutic interventions. In this review, which is the second part of an effort to document and integrate the basic fundamentals and recent successful developments in the field, we will focus on classic paradigms for electrode placement as well as new exploratory targets, mechanisms of neuromodulation using this technique and new developments, including focused ultrasound driven ablative procedures.
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Affiliation(s)
- Mariana Moscovich
- Christian-Albrechts University, Department of Neurology, Kiel, Germany.
| | - Camila Henriques de Aquino
- University of Calgary, Cumming School of Medicine, Department of Clinical Neurosciences, Calgary, AB, Canada.
- University of Calgary, Hotchkiss Brain Institute, Calgary, AB, Canada.
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
| | - Murilo Martinez Marinho
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
| | - Lorena Broseghini Barcelos
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
| | | | - Matthew Halverson
- University of Utah, Department of Neurology, Salt Lake City, Utah, United States.
| | - Clement Hamani
- University of Toronto, Sunnybrook Hospital, Toronto, ON, Canada.
| | - Henrique Ballalai Ferraz
- Universidade Federal de São Paulo, Escola Paulista de Medicina, Departamento de Neurologia e Neurocirurgia, São Paulo SP, Brazil.
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Calvano A, Kleinholdermann U, Heun AS, Bopp MHA, Nimsky C, Timmermann L, Pedrosa DJ. Structural connectivity of low-frequency subthalamic stimulation for improving stride length in Parkinson's disease. Neuroimage Clin 2024; 42:103591. [PMID: 38507954 PMCID: PMC10965492 DOI: 10.1016/j.nicl.2024.103591] [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: 01/19/2024] [Revised: 03/07/2024] [Accepted: 03/13/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND A reduction in stride length is considered a key characteristic of gait kinematics in Parkinson's disease (PD) and has been identified as a predictor of falls. Although low-frequency stimulation (LFS) has been suggested as a method to improve gait characteristics, the underlying structural network is not well understood. OBJECTIVE This study aims to investigate the structural correlates of changes in stride length during LFS (85 Hz). METHODS Objective gait performance was retrospectively evaluated in 19 PD patients who underwent deep brain stimulation (DBS) at 85 Hz and 130 Hz. Individual DBS contacts and volumes of activated tissue (VAT) were computed using preoperative magnetic resonance imaging (MRI) and postoperative computed tomography (CT) scans. Structural connectivity profiles to predetermined cortical and mesencephalic areas were estimated using a normative connectome. RESULTS LFS led to a significant improvement in stride length compared to 130 Hz stimulation. The intersection between VAT and the associative subregion of the subthalamic nucleus (STN) was associated with an improvement in stride length and had structural connections to the supplementary motor area, prefrontal cortex, and pedunculopontine nucleus. Conversely, we found that a lack of improvement was linked to stimulation volumes connected to cortico-diencephalic fibers bypassing the STN dorsolaterally. The robustness of the connectivity model was verified through leave-one-patient-out, 5-, and 10-fold cross cross-validation paradigms. CONCLUSION These findings offer new insights into the structural connectivity that underlies gait changes following LFS. Targeting the non-motor subregion of the STN with LFS on an individual level may present a potential therapeutic approach for PD patients with gait disorders.
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Affiliation(s)
- Alexander Calvano
- Department of Neurology, Philipps-University Marburg, Marburg, Germany
| | - Urs Kleinholdermann
- Department of Neurology, Philipps-University Marburg, Marburg, Germany; Center of Mind, Brain and Behaviour, Philipps-University Marburg, Marburg, Germany
| | | | - Miriam H A Bopp
- Center of Mind, Brain and Behaviour, Philipps-University Marburg, Marburg, Germany; Department of Neurosurgery, Philipps-University Marburg, Marburg, Germany
| | - Christopher Nimsky
- Center of Mind, Brain and Behaviour, Philipps-University Marburg, Marburg, Germany; Department of Neurosurgery, Philipps-University Marburg, Marburg, Germany
| | - Lars Timmermann
- Department of Neurology, Philipps-University Marburg, Marburg, Germany; Center of Mind, Brain and Behaviour, Philipps-University Marburg, Marburg, Germany
| | - David J Pedrosa
- Department of Neurology, Philipps-University Marburg, Marburg, Germany; Center of Mind, Brain and Behaviour, Philipps-University Marburg, Marburg, Germany.
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Bočková M, Lamoš M, Chrastina J, Daniel P, Kupcová S, Říha I, Šmahovská L, Baláž M, Rektor I. Coupling between beta band and high frequency oscillations as a clinically useful biomarker for DBS. NPJ Parkinsons Dis 2024; 10:40. [PMID: 38383550 PMCID: PMC10882016 DOI: 10.1038/s41531-024-00656-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/07/2024] [Indexed: 02/23/2024] Open
Abstract
Beta hypersynchrony was recently introduced into clinical practice in Parkinson's disease (PD) to identify the best stimulation contacts and for adaptive deep brain stimulation (aDBS) sensing. However, many other oscillopathies accompany the disease, and beta power sensing may not be optimal for all patients. The aim of this work was to study the potential clinical usefulness of beta power phase-amplitude coupling (PAC) with high frequency oscillations (HFOs). Subthalamic nucleus (STN) local field potentials (LFPs) from externalized DBS electrodes were recorded and analyzed in PD patients (n = 19). Beta power and HFOs were evaluated in a resting-state condition; PAC was then studied and compared with the electrode contact positions, structural connectivity, and medication state. Beta-HFO PAC (mainly in the 200-500 Hz range) was observed in all subjects. PAC was detectable more specifically in the motor part of the STN compared to beta power and HFOs. Moreover, the presence of PAC better corresponds to the stimulation setup based on the clinical effect. PAC is also sensitive to the laterality of symptoms and dopaminergic therapy, where the greater PAC cluster reflects the more affected side and medication "off" state. Coupling between beta power and HFOs is known to be a correlate of the PD "off" state. Beta-HFO PAC seems to be more sensitive than beta power itself and could be more helpful in the selection of the best clinical stimulation contact and probably also as a potential future input signal for aDBS.
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Affiliation(s)
- Martina Bočková
- Brain and Mind Research Program, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
- First Department of Neurology, Masaryk University School of Medicine, St. Anne's Hospital, Brno, Czech Republic
| | - Martin Lamoš
- Brain and Mind Research Program, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
| | - Jan Chrastina
- Department of Neurosurgery, Masaryk University School of Medicine, St. Anne's Hospital, Brno, Czech Republic
| | - Pavel Daniel
- Brain and Mind Research Program, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
- First Department of Neurology, Masaryk University School of Medicine, St. Anne's Hospital, Brno, Czech Republic
| | - Silvia Kupcová
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ivo Říha
- Department of Neurosurgery, Masaryk University School of Medicine, St. Anne's Hospital, Brno, Czech Republic
| | - Lucia Šmahovská
- First Department of Neurology, Masaryk University School of Medicine, St. Anne's Hospital, Brno, Czech Republic
- Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Marek Baláž
- Brain and Mind Research Program, Central European Institute of Technology, Masaryk University, Brno, Czech Republic
- First Department of Neurology, Masaryk University School of Medicine, St. Anne's Hospital, Brno, Czech Republic
| | - Ivan Rektor
- Brain and Mind Research Program, Central European Institute of Technology, Masaryk University, Brno, Czech Republic.
- First Department of Neurology, Masaryk University School of Medicine, St. Anne's Hospital, Brno, Czech Republic.
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Krauss P, Duarte-Batista P, Hart M, Avecillas-Chasin J, Bercu M, Hvingelby V, Massey F, Ackermans L, Kubben P, van der Gaag N, Krüger M. Directional electrodes in deep brain stimulation: Results of a survey by the European Association of Neurosurgical Societies (EANS). BRAIN & SPINE 2024; 4:102756. [PMID: 38510592 PMCID: PMC10951785 DOI: 10.1016/j.bas.2024.102756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 01/05/2024] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Introduction Directional Leads (dLeads) represent a new technical tool in Deep Brain Stimulation (DBS), and a rapidly growing population of patients receive dLeads. Research question The European Association of Neurosurgical Societies(EANS) functional neurosurgery Task Force on dLeads conducted a survey of DBS specialists in Europe to evaluate their use, applications, advantages, and disadvantages. Material and methods EANS functional neurosurgery and European Society for Stereotactic and Functional Neurosurgery (ESSFN) members were asked to complete an online survey with 50 multiple-choice and open questions on their use of dLeads in clinical practice. Results Forty-nine respondents from 16 countries participated in the survey (n = 38 neurosurgeons, n = 8 neurologists, n = 3 DBS nurses). Five had not used dLeads. All users reported that dLeads provided an advantage (n = 23 minor, n = 21 major). Most surgeons (n = 35) stated that trajectory planning does not differ when implanting dLeads or conventional leads. Most respondents selected dLeads for the ability to optimize stimulation parameters (n = 41). However, the majority (n = 24), regarded time-consuming programming as the main disadvantage of this technology. Innovations that were highly valued by most participants included full 3T MRI compatibility, remote programming, and closed loop technology. Discussion and conclusion Directional leads are widely used by European DBS specialists. Despite challenges with programming time, users report that dLeads have had a positive impact and maintain an optimistic view of future technological advances.
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Affiliation(s)
- P. Krauss
- Department of Neurosurgery, University Hospital Augsburg, Augsburg, Germany
| | - P. Duarte-Batista
- Neurosurgery Department, North Lisbon University Hospital Centre, Lisbon, Portugal
| | - M.G. Hart
- St George's, University of London & St George's University Hospitals NHS Foundation Trust, Institute of Molecular and Clinical Sciences, Neurosciences Research Centre, Cranmer Terrace, London, United Kingdom
| | - J.M. Avecillas-Chasin
- Department of Neurosurgery. University of Nebraska Medical Center. Omaha, Nebraska, USA
| | - M.M. Bercu
- Department of Pediatric Neurosurgery, Helen DeVos Children's Hospital, Corewell, USA
| | - V. Hvingelby
- Department of Clinical Medicine - Nuclear Medicine and PET Center, Aarhus University, Aarhus, Denmark
| | - F. Massey
- Unit of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, United Kingdom
| | - L. Ackermans
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - P.L. Kubben
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - N.A. van der Gaag
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
- Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - M.T. Krüger
- Unit of Neurosurgery, National Hospital of Neurology and Neurosurgery, London, United Kingdom
- Department of Neurosurgery, University Medical Centre Freiburg, Germany
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Carl B, Bopp M, SAß B, Waldthaler J, Timmermann L, Nimsky C. Visualization of volume of tissue activated modeling in a clinical planning system for deep brain stimulation. J Neurosurg Sci 2024; 68:59-69. [PMID: 32031356 DOI: 10.23736/s0390-5616.19.04827-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pathway activating models try to describe stimulation spread in deep brain stimulation (DBS). Volume of tissue activated (VTA) models are simplified model variants allowing faster and easier computation. Our study aimed to investigate, how VTA visualization can be integrated into a clinical workflow applying directional electrodes using a standard clinical DBS planning system. METHODS Twelve patients underwent DBS, using directional electrodes for bilateral subthalamic nucleus (STN) stimulation in Parkinson's disease. Preoperative 3T magnetic resonance imaging was used for automatic visualization of the STN outline, as well as for fiber tractography. Intraoperative computed tomography was used for automatic lead detection. The Guide XT software, closely integrated into the DBS planning software environment, was used for VTA calculation and visualization. RESULTS VTA visualization was possible in all cases. The percentage of VTA covering the STN volume ranged from 25% to 100% (mean: 60±25%) on the left side and from 0% to 98% (51±30%) on the right side. The mean coordinate of all VTA centers was: 12.6±1.2 mm lateral, 2.1±1.2 mm posterior, and 2.3±1.4 mm inferior in relation to the midcommissural point. Stimulation effects can be compared to the VTA visualization in relation to surrounding structures, potentially facilitating programming, which might be especially beneficial in case of suboptimal lead placement. CONCLUSIONS VTA visualization in a clinical planning system allows an intuitive adjustment of the stimulation parameters, supports programming, and enhances understanding of effects and side effects of DBS.
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Affiliation(s)
- Barbara Carl
- Department of Neurosurgery, University of Marburg, Marburg, Germany
- Department of Neurosurgery, Helios Dr. Horst Schmidt Kliniken, Wiesbaden, Germany
| | - Miriam Bopp
- Department of Neurosurgery, University of Marburg, Marburg, Germany
- Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
| | - Benjamin SAß
- Department of Neurosurgery, University of Marburg, Marburg, Germany
| | | | - Lars Timmermann
- Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
- Department of Neurology, University Marburg, Marburg, Germany
| | - Christopher Nimsky
- Department of Neurosurgery, University of Marburg, Marburg, Germany -
- Marburg Center for Mind, Brain and Behavior (MCMBB), Marburg, Germany
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Maçaneiro MT, Azevedo AC, Poerner BM, da Silva MD, Koerbel A. Directional deep brain stimulation in the management of Parkinson's disease: efficacy and constraints-an analytical appraisal. Neurosurg Rev 2024; 47:43. [PMID: 38216697 DOI: 10.1007/s10143-023-02268-x] [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: 08/09/2023] [Revised: 11/14/2023] [Accepted: 12/24/2023] [Indexed: 01/14/2024]
Abstract
Deep brain stimulation (DBS) is a widely employed treatment for Parkinson's disease. However, conventional DBS utilizing ring-shaped leads can often result in undesirable side effects by stimulating nearby brain structures, thus limiting its effectiveness. To address this issue, a novel DBS electrode was developed to allow for directional stimulation, avoiding neighboring structures. This literature review aims to analyze the disparities between conventional and directional DBS and discuss the benefits and limitations associated with this innovative electrode design, focusing on the stimulation-induced side effects it can or cannot mitigate. A comprehensive search was conducted in MEDLINE/PubMed, ScienceDirect, and EBSCO databases using the Boolean search criteria: "Deep brain stimulation" AND "Parkinson" AND "Directional." Following the application of inclusion and exclusion criteria, the selected articles were downloaded for full-text reading. Subsequently, the results were organized and analyzed to compose this article. Numerous studies have demonstrated that directional DBS effectively reduces side effects associated with brain stimulation, prevents the stimulation of non-targeted structures, and expands the therapeutic window, among other advantages. However, it has been observed that directional DBS may be more challenging to program and requires higher energy consumption. Furthermore, there is a lack of standardization among different manufacturers of directional DBS electrodes. Various stimulation-induced side effects, including dysarthria, dyskinesia, paresthesias, and symptoms of pyramidal tract activation, have been shown to be mitigated with the use of directional DBS. Moreover, directional electrodes offer a wider therapeutic window and a reduced incidence of undesired effects, requiring the same or lower minimum current for symptom relief compared to conventional DBS. The utilization of directional leads in DBS offers numerous advantages over conventional electrodes without significant drawbacks for patients undergoing directional DBS therapy.
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Affiliation(s)
| | - Ana Clara Azevedo
- Medical Department at Universidade da Região de Joinville - UNIVILLE, Joinville, Santa Catarina, Brazil
| | - Bruna Maurício Poerner
- Medical Department at Universidade da Região de Joinville - UNIVILLE, Joinville, Santa Catarina, Brazil
| | - Milena Dangui da Silva
- Medical Department at Universidade da Região de Joinville - UNIVILLE, Joinville, Santa Catarina, Brazil
| | - Andrei Koerbel
- Universidade da Região de Joinville - UNIVILLE, Joinville, Santa Catarina, Brazil
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Krishnan J, Joseph R, Vayalappil MC, Krishnan S, Kishore A. A Review on Implantable Neuroelectrodes. Crit Rev Biomed Eng 2024; 52:21-39. [PMID: 37938182 DOI: 10.1615/critrevbiomedeng.2023049282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
The efficacy of every neuromodulation modality depends upon the characteristics of the electrodes used to stimulate the chosen target. The geometrical, chemical, mechanical and physical configuration of electrodes used in neurostimulation affects several performance attributes like stimulation efficiency, selectivity, tissue response, etc. The efficiency of stimulation in relation to electrode impedance is influenced by the electrode material and/or its geometry. The nature of the electrode material determines the charge transfer across the electrode-tissue interface, which also relates to neuronal tissue damage. Electrode morphology or configuration pattern can facilitate the modulation of extracellular electric field (field shaping). This enables selective activation of neurons and minimizes side effects. Biocompatibility and biostability of the electrode materials or electrode coating have a role in glial formation and tissue damage. Mechanical and electrochemical stability (corrosion resistance) determines the long-term efficacy of any neuromodulation technique. Here, a review of electrodes typically used for implantable neuromodulation is discussed. Factors affecting the performance of electrodes like stimulation efficiency, selectivity and tissue responses to the electrode-tissue interface are discussed. Technological advancements to improve electrode characteristics are also included.
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Affiliation(s)
- Jithin Krishnan
- Department of Medical Devices Engineering, BMT Wing, SCTIMST, Kerala, India
| | - Roy Joseph
- Department of Medical Devices Engineering, BMT Wing, SCTIMST, Kerala, India
| | | | | | - Asha Kishore
- Aster Parkinson & Movement Disorder Centre, Senior Consultant Neurologist and Movement Disorder Specialist
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Budnick HC, Schneider D, Zauber SE, Witt TC, Gupta K. Susceptibility-Weighted MRI Approximates Intraoperative Microelectrode Recording During Deep Brain Stimulation of the Subthalamic Nucleus for Parkinson's Disease. World Neurosurg 2024; 181:e346-e355. [PMID: 37839566 DOI: 10.1016/j.wneu.2023.10.053] [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: 10/09/2023] [Accepted: 10/10/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Deep brain stimulation of the subthalamic nucleus (STN-DBS) for Parkinson's disease can be performed with intraoperative neurophysiological and radiographic guidance. Conventional T2-weighted magnetic resonance imaging sequences, however, often fail to provide definitive borders of the STN. Novel magnetic resonance imaging sequences, such as susceptibility-weighted imaging (SWI), might better localize the STN borders and facilitate radiographic targeting. We compared the radiographic location of the dorsal and ventral borders of the STN using SWI with intraoperative microelectrode recording (MER) during awake STN-DBS for Parkinson's disease. METHODS Thirteen consecutive patients who underwent placement of 24 STN-DBS leads for Parkinson's disease were analyzed retrospectively. Preoperative targeting was performed with SWI, and MER data were obtained from intraoperative electrophysiology records. The boundaries of the STN on SWI were identified by a blinded investigator. RESULTS The final electrode position differed significantly from the planned coordinates in depth but not in length or width, indicating that MER guided the final electrode depth. When we compared the boundaries of the STN by MER and SWI, SWI accurately predicted the entry into the STN but underestimated the length and ventral boundary of the STN by 1.2 mm. This extent of error approximates the span of a DBS contact and could affect the placement of directional contacts within the STN. CONCLUSIONS MER might continue to have a role in STN-DBS. This could potentially be mitigated by further refinement of imaging protocols to better image the ventral boundary of the STN.
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Affiliation(s)
- Hailey C Budnick
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Dylan Schneider
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - S Elizabeth Zauber
- Indiana University School of Medicine, Indianapolis, Indiana, USA; Department of Neurology, Indiana University, Indianapolis, Indiana, USA
| | - Thomas C Witt
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kunal Gupta
- Department of Neurological Surgery, Indiana University, Indianapolis, Indiana, USA; Indiana University School of Medicine, Indianapolis, Indiana, USA; Stark Neurosciences Research Institute, Indiana University, Indianapolis, Indiana, USA; Department of Anatomy, Cell Biology & Physiology, Indiana University, Indianapolis, Indiana, USA; Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.
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Rolland AS, Touzet G, Carriere N, Mutez E, Kreisler A, Simonin C, Kuchcinski G, Chalhoub N, Pruvo JP, Defebvre L, Reyns N, Devos D, Moreau C. The Use of Image Guided Programming to Improve Deep Brain Stimulation Workflows with Directional Leads in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2024; 14:111-119. [PMID: 38189764 PMCID: PMC10836544 DOI: 10.3233/jpd-225126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a preferred treatment for parkinsonian patients with severe motor fluctuations. Proper targeting of the STN sensorimotor segment appears to be a crucial factor for success of the procedure. The recent introduction of directional leads theoretically increases stimulation specificity in this challenging area but also requires more precise stimulation parameters. OBJECTIVE We investigated whether commercially available software for image guided programming (IGP) could maximize the benefits of DBS by informing the clinical standard care (CSC) and improving programming workflows. METHODS We prospectively analyzed 32 consecutive parkinsonian patients implanted with bilateral directional leads in the STN. Double blind stimulation parameters determined by CSC and IGP were assessed and compared at three months post-surgery. IGP was used to adjust stimulation parameters if further clinical refinement was required. Overall clinical efficacy was evaluated one-year post-surgery. RESULTS We observed 78% concordance between the two electrode levels selected by the blinded IGP prediction and CSC assessments. In 64% of cases requiring refinement, IGP improved clinical efficacy or reduced mild side effects, predominantly by facilitating the use of directional stimulation (93% of refinements). CONCLUSIONS The use of image guided programming saves time and assists clinical refinement, which may be beneficial to the clinical standard care for STN-DBS and further improve the outcomes of DBS for PD patients.
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Affiliation(s)
- Anne-Sophie Rolland
- Department of Medical Pharmacology, LICEND COEN Center, I-SITE ULNE, Lille Neuroscience & Cognition, INSERM UMR S1172, CHU Lille, University Lille, Lille, France
| | - Gustavo Touzet
- Department of Neurosurgery, CHU Lille, LICEND COEN Center, Lille, France
| | - Nicolas Carriere
- Department of Neurology, LICEND COEN Center, I-SITE ULNE, Lille Neuroscience & Cognition, INSERM UMR S1172, CHU Lille, University Lille, Lille, France
| | - Eugenie Mutez
- Department of Neurology, LICEND COEN Center, I-SITE ULNE, Lille Neuroscience & Cognition, INSERM UMR S1172, CHU Lille, University Lille, Lille, France
| | - Alexandre Kreisler
- Department of Neurology, LICEND COEN Center, I-SITE ULNE, Lille Neuroscience & Cognition, INSERM UMR S1172, CHU Lille, University Lille, Lille, France
| | - Clemence Simonin
- Department of Neurology, LICEND COEN Center, I-SITE ULNE, Lille Neuroscience & Cognition, INSERM UMR S1172, CHU Lille, University Lille, Lille, France
| | - Gregory Kuchcinski
- Department of Neuroradiology, LICEND COEN Center, Lille Neuroscience & Cognition, INSERM UMR S1172, CHU Lille, Lille, France
| | - Najib Chalhoub
- Diagnostic and interventional neuroradiology, Lille University Hospital, Lille, France
| | - Jean-Pierre Pruvo
- Diagnostic and interventional neuroradiology, Lille University Hospital, Lille, France
| | - Luc Defebvre
- Department of Neurology, LICEND COEN Center, I-SITE ULNE, Lille Neuroscience & Cognition, INSERM UMR S1172, CHU Lille, University Lille, Lille, France
| | - Nicolas Reyns
- Department of Neurosurgery, CHU Lille, LICEND COEN Center, Lille, France
| | - David Devos
- Department of Medical Pharmacology, LICEND COEN Center, I-SITE ULNE, Lille Neuroscience & Cognition, INSERM UMR S1172, CHU Lille, University Lille, Lille, France
- Department of Neurology, LICEND COEN Center, I-SITE ULNE, Lille Neuroscience & Cognition, INSERM UMR S1172, CHU Lille, University Lille, Lille, France
| | - Caroline Moreau
- Department of Neurology, LICEND COEN Center, I-SITE ULNE, Lille Neuroscience & Cognition, INSERM UMR S1172, CHU Lille, University Lille, Lille, France
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13
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di Biase L, Piano C, Bove F, Ricci L, Caminiti ML, Stefani A, Viselli F, Modugno N, Cerroni R, Calabresi P, Bentivoglio AR, Tufo T, Di Lazzaro V. Intraoperative Local Field Potential Beta Power and Three-Dimensional Neuroimaging Mapping Predict Long-Term Clinical Response to Deep Brain Stimulation in Parkinson Disease: A Retrospective Study. Neuromodulation 2023; 26:1724-1732. [PMID: 36774326 DOI: 10.1016/j.neurom.2022.12.013] [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: 09/10/2022] [Revised: 11/27/2022] [Accepted: 12/15/2022] [Indexed: 02/12/2023]
Abstract
BACKGROUND Directional deep brain stimulation (DBS) leads allow a fine-tuning control of the stimulation field, however, this new technology could increase the DBS programming time because of the higher number of the possible combinations used in directional DBS than in standard nondirectional electrodes. Neuroimaging leads localization techniques and local field potentials (LFPs) recorded from DBS electrodes implanted in basal ganglia are among the most studied biomarkers for DBS programing. OBJECTIVE This study aimed to evaluate whether intraoperative LFPs beta power and neuroimaging reconstructions correlate with contact selection in clinical programming of DBS in patients with Parkinson disease (PD). MATERIALS AND METHODS In this retrospective study, routine intraoperative LFPs recorded from all contacts in the subthalamic nucleus (STN) of 14 patients with PD were analyzed to calculate the beta band power for each contact. Neuroimaging reconstruction obtained through Brainlab Elements Planning software detected contacts localized within the STN. Clinical DBS programming contact scheme data were collected after one year from the implant. Statistical analysis evaluated the diagnostic performance of LFPs beta band power and neuroimaging data for identification of the contacts selected with clinical programming. We evaluated whether the most effective contacts identified based on the clinical response after one year from implant were also those with the highest level of beta activity and localized within the STN in neuroimaging reconstruction. RESULTS LFPs beta power showed a sensitivity of 67%, a negative predictive value (NPV) of 84%, a diagnostic odds ratio (DOR) of 2.7 in predicting the most effective contacts as evaluated through the clinical response. Neuroimaging reconstructions showed a sensitivity of 62%, a NPV of 77%, a DOR of 1.20 for contact effectivity prediction. The combined use of the two methods showed a sensitivity of 87%, a NPV of 87%, a DOR of 2.7 for predicting the clinically more effective contacts. CONCLUSIONS The combined use of LFPs beta power and neuroimaging localization and segmentations predict which are the most effective contacts as selected on the basis of clinical programming after one year from implant of DBS. The use of predictors in contact selection could guide clinical programming and reduce time needed for it.
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Affiliation(s)
- Lazzaro di Biase
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Rome, Italy; Operative Research Unit of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, Rome, Italy; Brain Innovations Lab, Università Campus Bio-Medico di Roma, Via Álvaro del Portillo, Rome, Italy.
| | - Carla Piano
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy; Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Francesco Bove
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Lorenzo Ricci
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Rome, Italy; Operative Research Unit of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, Rome, Italy
| | - Maria Letizia Caminiti
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Rome, Italy; Operative Research Unit of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, Rome, Italy
| | - Alessandro Stefani
- Department of System Medicine, Unità Operativa Semplice Dipartimentale Parkinson, University of Rome Tor Vergata, Rome, Italy
| | - Fabio Viselli
- Department of Neurology, St John the Baptist Hospital, Associazione dei Cavalieri Italiani del Sovrano Militare Ordine di Malta (ACISMOM), Rome, Italy
| | | | - Rocco Cerroni
- Department of System Medicine, Unità Operativa Semplice Dipartimentale Parkinson, University of Rome Tor Vergata, Rome, Italy
| | - Paolo Calabresi
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy; Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Rita Bentivoglio
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli Istituti di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy; Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tommaso Tufo
- Neurosurgery Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Neurosurgery Department, Fakeeh University Hospital, Dubai Silicon Oasis, Dubai
| | - Vincenzo Di Lazzaro
- Research Unit of Neurology, Neurophysiology and Neurobiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, Rome, Italy; Operative Research Unit of Neurology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, Rome, Italy
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14
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Xu W, Wang J, Li XN, Liang J, Song L, Wu Y, Liu Z, Sun B, Li WG. Neuronal and synaptic adaptations underlying the benefits of deep brain stimulation for Parkinson's disease. Transl Neurodegener 2023; 12:55. [PMID: 38037124 PMCID: PMC10688037 DOI: 10.1186/s40035-023-00390-w] [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: 08/01/2023] [Accepted: 11/19/2023] [Indexed: 12/02/2023] Open
Abstract
Deep brain stimulation (DBS) is a well-established and effective treatment for patients with advanced Parkinson's disease (PD), yet its underlying mechanisms remain enigmatic. Optogenetics, primarily conducted in animal models, provides a unique approach that allows cell type- and projection-specific modulation that mirrors the frequency-dependent stimulus effects of DBS. Opto-DBS research in animal models plays a pivotal role in unraveling the neuronal and synaptic adaptations that contribute to the efficacy of DBS in PD treatment. DBS-induced neuronal responses rely on a complex interplay between the distributions of presynaptic inputs, frequency-dependent synaptic depression, and the intrinsic excitability of postsynaptic neurons. This orchestration leads to conversion of firing patterns, enabling both antidromic and orthodromic modulation of neural circuits. Understanding these mechanisms is vital for decoding position- and programming-dependent effects of DBS. Furthermore, patterned stimulation is emerging as a promising strategy yielding long-lasting therapeutic benefits. Research on the neuronal and synaptic adaptations to DBS may pave the way for the development of more enduring and precise modulation patterns. Advanced technologies, such as adaptive DBS or directional electrodes, can also be integrated for circuit-specific neuromodulation. These insights hold the potential to greatly improve the effectiveness of DBS and advance PD treatment to new levels.
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Affiliation(s)
- Wenying Xu
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jie Wang
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
- Department of Neurology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Xin-Ni Li
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
| | - Jingxue Liang
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
- Department of Neurology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Lu Song
- Department of Neurology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Yi Wu
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
| | - Zhenguo Liu
- Department of Neurology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China.
| | - Bomin Sun
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Wei-Guang Li
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China.
- Ministry of Education-Shanghai Key Laboratory for Children's Environmental Health, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China.
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15
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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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16
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Henry KR, Miulli MM, Nuzov NB, Nolt MJ, Rosenow JM, Elahi B, Pilitsis J, Golestanirad L. Variations in Determining Actual Orientations of Segmented Deep Brain Stimulation Leads Using the DiODe Algorithm: A Retrospective Study Across Different Lead Designs and Medical Institutions. Stereotact Funct Neurosurg 2023; 101:338-347. [PMID: 37717576 PMCID: PMC10866684 DOI: 10.1159/000531644] [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: 03/11/2023] [Accepted: 06/12/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Directional deep brain stimulation (DBS) leads have become widely used in the past decade. Understanding the asymmetric stimulation provided by directional leads requires precise knowledge of the exact orientation of the lead in respect to its anatomical target. Recently, the DiODe algorithm was developed to automatically determine the orientation angle of leads from the artifact on postoperative computed tomography (CT) images. However, manual DiODe results are user-dependent. This study analyzed the extent of lead rotation as well as the user agreement of DiODe calculations across the two most common DBS systems, namely, Boston Scientific's Vercise and Abbott's Infinity, and two independent medical institutions. METHODS Data from 104 patients who underwent an anterior-facing unilateral/bilateral directional DBS implantation at either Northwestern Memorial Hospital (NMH) or Albany Medical Center (AMC) were retrospectively analyzed. Actual orientations of the implanted leads were independently calculated by three individual users using the DiODe algorithm in Lead-DBS and patients' postoperative CT images. The deviation from the intended orientation and user agreement were assessed. RESULTS All leads significantly deviated from the intended 0° orientation (p < 0.001), regardless of DBS lead design (p < 0.05) or institution (p < 0.05). However, the Boston Scientific leads showed an implantation bias toward the left at both institutions (p = 0.014 at NMH, p = 0.029 at AMC). A difference of 10° between at least two users occurred in 28% (NMH) and 39% (AMC) of all Boston Scientific and 76% (NMH) and 53% (AMC) of all Abbott leads. CONCLUSION Our results show that there is a significant lead rotation from the intended surgical orientation across both DBS systems and both medical institutions; however, a bias toward a single direction was only seen in the Boston Scientific leads. Additionally, these results raise questions into the user error that occurs when manually refining the orientation angles calculated with DiODe.
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Affiliation(s)
- Kaylee R Henry
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA,
| | - Milina Michelle Miulli
- Department of Neuroscience and Department of Global Health Studies, Northwestern University, Evanston, Illinois, USA
| | - Noa B Nuzov
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
| | - Mark J Nolt
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Joshua M Rosenow
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Behzad Elahi
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, Chicago, Illinois, USA
- Department of Neurology, Loyola Medical Center, Maywood, Illinois, USA
| | - Julie Pilitsis
- Department of Neurosciences and Experimental Therapeutics, Albany Medical College, Albany, New York, USA
| | - Laleh Golestanirad
- Department of Biomedical Engineering, Northwestern University, Evanston, Illinois, USA
- Department of Radiology, Northwestern University, Chicago, Illinois, USA
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Nowacki A, Zhang D, Wermelinger J, Abel Alvarez Abut P, Rosner J, Pollo C, Seidel K. Directional recordings of somatosensory evoked potentials from the sensory thalamus in chronic poststroke pain patients. Clin Neurophysiol 2023; 151:50-58. [PMID: 37156120 DOI: 10.1016/j.clinph.2023.03.359] [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: 12/22/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 05/10/2023]
Abstract
OBJECTIVE The aim of this feasibility study was to investigate the properties of median nerve somatosensory evoked potential (SEPs) recorded from segmented Deep Brain Stimulation (DBS) leads in the sensory thalamus (VP) and how they relate to clinical and anatomical findings. METHODS We analyzed four patients with central post-stroke pain and DBS electrodes placed in the VP. Median nerve SEPs were recorded with referential and bipolar montages. Electrode positions were correlated with thalamus anatomy and tractography-based medial lemniscus. Early postoperative clinical paresthesia mapping was performed by an independent pain nurse. Finally, we performed frequency and time-frequency analyses of the signals. RESULTS We observed differences of SEP amplitudes recorded along different directions in the VP. SEP amplitudes did not clearly correlate to both atlas-based anatomical position and fiber-tracking results of the medial lemniscus. However, the contacts of highest SEP amplitude correlated with the contacts of lowest effect-threshold to induce paraesthesia. CONCLUSIONS SEP recordings from directional DBS leads offer additional information about the neurophysiological (re)organization of the sensory thalamus. SIGNIFICANCE Directional recordings of thalamic SEPs bear the potential to assist clinical decision-making in DBS for pain.
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Affiliation(s)
- Andreas Nowacki
- Department of Neurosurgery, Inselspital, Bern University Hospital, University Bern, Bern, Switzerland.
| | - David Zhang
- Department of Neurosurgery, Inselspital, Bern University Hospital, University Bern, Bern, Switzerland
| | - Jonathan Wermelinger
- Department of Neurosurgery, Inselspital, Bern University Hospital, University Bern, Bern, Switzerland
| | - Pablo Abel Alvarez Abut
- Department of Neurosurgery, Inselspital, Bern University Hospital, University Bern, Bern, Switzerland
| | - Jan Rosner
- Department of Neurology, Inselspital, Bern University Hospital, University Bern, Bern, Switzerland; Spinal Cord Injury Center, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Claudio Pollo
- Department of Neurosurgery, Inselspital, Bern University Hospital, University Bern, Bern, Switzerland
| | - Kathleen Seidel
- Department of Neurosurgery, Inselspital, Bern University Hospital, University Bern, Bern, Switzerland
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18
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Bronte-Stewart H, Merola A. Hope vs. Hype: Closed loop technology will provide more meaningful improvement vs. directional leads in deep brain stimulation. Parkinsonism Relat Disord 2023:105452. [PMID: 37355400 DOI: 10.1016/j.parkreldis.2023.105452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/20/2023] [Indexed: 06/26/2023]
Affiliation(s)
- Helen Bronte-Stewart
- Department of Neurology and Neurological Sciences, Stanford Comprehensive Movement Disorders Center, United States.
| | - Aristide Merola
- Center for Parkinson's Disease and Related Movement Disorders, Wexner Medical Center, The Ohio State University, Columbus, United States.
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19
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Iess G, Bonomo G, Levi V, Aquino D, Zekaj E, Mezza F, Servello D. MER and increased operative time are not risk factors for the formation of pneumocephalus during DBS. Sci Rep 2023; 13:9324. [PMID: 37291256 PMCID: PMC10250399 DOI: 10.1038/s41598-023-30289-5] [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: 10/20/2022] [Accepted: 02/21/2023] [Indexed: 06/10/2023] Open
Abstract
Although only recently directional leads have proven their potential to compensate for sub-optimally placed electrodes, optimal lead positioning remains the most critical factor in determining Deep Brain Stimulation (DBS) outcome. Pneumocephalus is a recognized source of error, but the factors that contribute to its formation are still a matter of debate. Among these, operative time is one of the most controversial. Because cases of DBS performed with Microelectrode Recordings (MER) are affected by an increase in surgical length, it is useful to analyze whether MER places patients at risk for increased intracranial air entry. Data of 94 patients from two different institutes who underwent DBS for different neurologic and psychiatric conditions were analyzed for the presence of postoperative pneumocephalus. Operative time and use of MER, as well as other potential risk factors for pneumocephalus (age, awake vs. asleep surgery, number of MER passages, burr hole size, target and unilateral vs. bilateral implants) were examined. Mann-Whitney U and Kruskal-Wallis tests were utilized to compare intracranial air distributions across groups of categorical variables. Partial correlations were used to assess the association between time and volume. A generalized linear model was created to predict the effects of time and MER on the volume of intracranial air, controlling for other potential risk factors identified: age, number of MER passages, awake vs. asleep surgery, burr hole size, target, unilateral vs. bilateral surgery. Significantly different distributions of air volume were noted between different targets, unilateral vs. bilateral implants, and number of MER trajectories. Patients undergoing DBS with MER did not present a significant increase in pneumocephalus compared to patients operated without (p = 0.067). No significant correlation was found between pneumocephalus and time. Using multivariate analysis, unilateral implants exhibited lower volumes of pneumocephalus (p = 0.002). Two specific targets exhibited significantly different volumes of pneumocephalus: the bed nucleus of the stria terminalis with lower volumes (p < 0.001) and the posterior hypothalamus with higher volumes (p = 0.011). MER, time, and other parameters analyzed failed to reach statistical significance. Operative time and use of intraoperative MER are not significant predictors of pneumocephalus during DBS. Air entry is greater for bilateral surgeries and may be also influenced by the specific stimulated target.
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Affiliation(s)
- Guglielmo Iess
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy.
- Università degli Studi di Milano, Milan, Italy.
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
| | - Giulio Bonomo
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
- Università degli Studi di Milano, Milan, Italy
| | - Vincenzo Levi
- Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Domenico Aquino
- Neuroradiology Department, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Edvin Zekaj
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Federica Mezza
- Department of Economics, University of California, Los Angeles, USA
| | - Domenico Servello
- Department of Neurosurgery, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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20
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Radcliffe EM, Baumgartner AJ, Kern DS, Al Borno M, Ojemann S, Kramer DR, Thompson JA. Oscillatory beta dynamics inform biomarker-driven treatment optimization for Parkinson's disease. J Neurophysiol 2023; 129:1492-1504. [PMID: 37198135 DOI: 10.1152/jn.00055.2023] [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: 02/03/2023] [Revised: 04/23/2023] [Accepted: 05/17/2023] [Indexed: 05/19/2023] Open
Abstract
Parkinson's disease (PD) is a neurodegenerative disorder characterized by loss of dopaminergic neurons and dysregulation of the basal ganglia. Cardinal motor symptoms include bradykinesia, rigidity, and tremor. Deep brain stimulation (DBS) of select subcortical nuclei is standard of care for medication-refractory PD. Conventional open-loop DBS delivers continuous stimulation with fixed parameters that do not account for a patient's dynamic activity state or medication cycle. In comparison, closed-loop DBS, or adaptive DBS (aDBS), adjusts stimulation based on biomarker feedback that correlates with clinical state. Recent work has identified several neurophysiological biomarkers in local field potential recordings from PD patients, the most promising of which are 1) elevated beta (∼13-30 Hz) power in the subthalamic nucleus (STN), 2) increased beta synchrony throughout basal ganglia-thalamocortical circuits, notably observed as coupling between the STN beta phase and cortical broadband gamma (∼50-200 Hz) amplitude, and 3) prolonged beta bursts in the STN and cortex. In this review, we highlight relevant frequency and time domain features of STN beta measured in PD patients and summarize how spectral beta power, oscillatory beta synchrony, phase-amplitude coupling, and temporal beta bursting inform PD pathology, neurosurgical targeting, and DBS therapy. We then review how STN beta dynamics inform predictive, biomarker-driven aDBS approaches for optimizing PD treatment. We therefore provide clinically useful and actionable insight that can be applied toward aDBS implementation for PD.
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Affiliation(s)
- Erin M Radcliffe
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Alexander J Baumgartner
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Drew S Kern
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Mazen Al Borno
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Department of Computer Science and Engineering, University of Colorado Denver, Denver, Colorado, United States
| | - Steven Ojemann
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - Daniel R Kramer
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
| | - John A Thompson
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Department of Bioengineering, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States
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21
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Thompson JA, Hirt L, David‐Gerecht P, Fasano A, Kramer DR, Ojemann SG, Kern DS. Comparison of Monopolar Review to Fixed Parameter Fractionation in Deep Brain Stimulation. Mov Disord Clin Pract 2023; 10:987-991. [PMID: 37332654 PMCID: PMC10272899 DOI: 10.1002/mdc3.13750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/21/2023] [Accepted: 03/29/2023] [Indexed: 06/20/2023] Open
Abstract
Background Technological advancements in deep brain stimulation (DBS) require methodological changes in programming. Fractionalization poses significant practical challenges for the most common approach for assessing DBS efficacy, monopolar review (MR). Objectives Two DBS programming methods: MR and fixed parameter vertical and horizontal fractionalization (FPF) were compared. Methods A two-phase process of vertical and horizontal FPF was performed. MR was conducted thereafter. After a short wash-out period, both optimal configurations determined by MR and FPF were tested in a double-blind randomized manner. Results Seven PD patients were enrolled, providing 11 hemispheres to compare the two conditions. In all subjects, the blinded examiner selected a directional or fractionalization configuration. There was no significant difference in clinical benefits between MR and FPF. FPF was the preferred method for initial programming as selected by subject and clinician. Conclusions FPF programming is a viable and efficient methodology that may be incorporated into clinical practice.
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Affiliation(s)
- John A. Thompson
- Department of NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of NeurosurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Lisa Hirt
- Department of NeurosurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Pamela David‐Gerecht
- Department of NeurosurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Alfonso Fasano
- Department of NeurologyUniversity of TorontoTorontoOntarioUSA
| | - Daniel R. Kramer
- Department of NeurosurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Steven G. Ojemann
- Department of NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of NeurosurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Drew S. Kern
- Department of NeurologyUniversity of Colorado School of MedicineAuroraColoradoUSA
- Department of NeurosurgeryUniversity of Colorado School of MedicineAuroraColoradoUSA
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22
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DBS-evoked cortical responses index optimal contact orientations and motor outcomes in Parkinson's disease. NPJ Parkinsons Dis 2023; 9:37. [PMID: 36906723 PMCID: PMC10008535 DOI: 10.1038/s41531-023-00474-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/13/2023] [Indexed: 03/13/2023] Open
Abstract
Although subthalamic deep brain stimulation (DBS) is a highly-effective treatment for alleviating motor dysfunction in patients with Parkinson's disease (PD), clinicians currently lack reliable neurophysiological correlates of clinical outcomes for optimizing DBS parameter settings, which may contribute to treatment inefficacies. One parameter that could aid DBS efficacy is the orientation of current administered, albeit the precise mechanisms underlying optimal contact orientations and associated clinical benefits are not well understood. Herein, 24 PD patients received monopolar stimulation of the left STN during magnetoencephalography and standardized movement protocols to interrogate the directional specificity of STN-DBS current administration on accelerometer metrics of fine hand movements. Our findings demonstrate that optimal contact orientations elicit larger DBS-evoked cortical responses in the ipsilateral sensorimotor cortex, and importantly, are differentially predictive of smoother movement profiles in a contact-dependent manner. Moreover, we summarize traditional evaluations of clinical efficacy (e.g., therapeutic windows, side effects) for a comprehensive review of optimal/non-optimal STN-DBS contact settings. Together, these data suggest that DBS-evoked cortical responses and quantitative movement outcomes may provide clinical insight for characterizing the optimal DBS parameters necessary for alleviating motor symptoms in patients with PD in the future.
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23
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Brinda A, Slopsema JP, Butler RD, Ikramuddin S, Beall T, Guo W, Chu C, Patriat R, Braun H, Goftari M, Palnitkar T, Aman J, Schrock L, Cooper SE, Matsumoto J, Vitek JL, Harel N, Johnson MD. Lateral cerebellothalamic tract activation underlies DBS therapy for Essential Tremor. Brain Stimul 2023; 16:445-455. [PMID: 36746367 PMCID: PMC10200026 DOI: 10.1016/j.brs.2023.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 01/17/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND While deep brain stimulation (DBS) therapy can be effective at suppressing tremor in individuals with medication-refractory Essential Tremor, patient outcome variability remains a significant challenge across centers. Proximity of active electrodes to the cerebellothalamic tract (CTT) is likely important in suppressing tremor, but how tremor control and side effects relate to targeting parcellations within the CTT and other pathways in and around the ventral intermediate (VIM) nucleus of thalamus remain unclear. METHODS Using ultra-high field (7T) MRI, we developed high-dimensional, subject-specific pathway activation models for 23 directional DBS leads. Modeled pathway activations were compared with post-hoc analysis of clinician-optimized DBS settings, paresthesia thresholds, and dysarthria thresholds. Mixed-effect models were utilized to determine how the six parcellated regions of the CTT and how six other pathways in and around the VIM contributed to tremor suppression and induction of side effects. RESULTS The lateral portion of the CTT had the highest activation at clinical settings (p < 0.05) and a significant effect on tremor suppression (p < 0.001). Activation of the medial lemniscus and posterior-medial CTT was significantly associated with severity of paresthesias (p < 0.001). Activation of the anterior-medial CTT had a significant association with dysarthria (p < 0.05). CONCLUSIONS This study provides a detailed understanding of the fiber pathways responsible for therapy and side effects of DBS for Essential Tremor, and suggests a model-based programming approach will enable more selective activation of lateral fibers within the CTT.
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Affiliation(s)
- AnneMarie Brinda
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Julia P Slopsema
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Rebecca D Butler
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Salman Ikramuddin
- Department of Neurology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Thomas Beall
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, 55455, USA
| | - William Guo
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Cong Chu
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Remi Patriat
- Department of Radiology, CMRR, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Henry Braun
- Department of Radiology, CMRR, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Mojgan Goftari
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Tara Palnitkar
- Department of Radiology, CMRR, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Joshua Aman
- Department of Neurology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Lauren Schrock
- Department of Neurology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Scott E Cooper
- Department of Neurology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Joseph Matsumoto
- Department of Neurology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Jerrold L Vitek
- Department of Neurology, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Noam Harel
- Department of Radiology, CMRR, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Matthew D Johnson
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, 55455, USA; Institute for Translational Neuroscience, University of Minnesota, Minneapolis, MN, 55455, USA.
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24
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Debove I, Petermann K, Nowacki A, Nguyen TK, Tinkhauser G, Michelis JP, Muellner J, Amstutz D, Bargiotas P, Fichtner J, Schlaeppi JA, Krack P, Schuepbach M, Pollo C, Lachenmayer ML. Deep Brain Stimulation: When to Test Directional? Mov Disord Clin Pract 2023; 10:434-439. [PMID: 36949800 PMCID: PMC10026308 DOI: 10.1002/mdc3.13667] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 12/09/2022] [Accepted: 01/08/2023] [Indexed: 01/26/2023] Open
Abstract
Background Directional deep brain stimulation (DBS) allows for steering of the stimulation field, but extensive and time-consuming testing of all segmented contacts is necessary to identify the possible benefit of steering. It is therefore important to determine under which circumstances directional current steering is advantageous. Methods Fifty two Parkinson's disease patients implanted in the STN with a directional DBS system underwent a standardized monopolar programming session 5 to 9 months after implantation. Individual contacts were tested for a potential advantage of directional stimulation. Results were used to build a prediction model for the selection of ring levels that would benefit from directional stimulation. Results On average, there was no significant difference in therapeutic window between ring-level contact and best directional contact. However, according to our standardized protocol, 35% of the contacts and 66% of patients had a larger therapeutic window under directional stimulation compared to ring-mode. The segmented contacts warranting directional current steering could be predicted with a sensitivity of 79% and a specificity of 57%. Conclusion To reduce time required for DBS programming, we recommend additional directional contact testing initially only on ring-level contacts with a therapeutic window of less than 2.0 mA.
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Affiliation(s)
- Ines Debove
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Katrin Petermann
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Andreas Nowacki
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Thuy‐Anh Khoa Nguyen
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
- ARTORG Center for Biomedical Engineering ResearchUniversity of BernBernSwitzerland
| | - Gerd Tinkhauser
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Joan Philipp Michelis
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Julia Muellner
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Deborah Amstutz
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Panagiotis Bargiotas
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
- Department of Neurology, Medical SchoolUniversity of CyprusNicosiaCyprus
| | - Jens Fichtner
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
- Cantonal Medical Service, Department of Health of the Canton of BernBernSwitzerland
| | - Janine Ai Schlaeppi
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Paul Krack
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Michael Schuepbach
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Claudio Pollo
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
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25
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Pintér D, Járdaházi E, Balás I, Harmat M, Makó T, Juhász A, Janszky J, Kovács N. Antiparkinsonian Drug Reduction After Directional Versus Omnidirectional Bilateral Subthalamic Deep Brain Stimulation. Neuromodulation 2023; 26:374-381. [PMID: 35190245 DOI: 10.1016/j.neurom.2022.01.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 12/15/2021] [Accepted: 01/08/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Several pilot trials and the Clinical Evaluation of the Infinity Deep Brain Stimulation System (PROGRESS) study have found that directional stimulation can provide a wider therapeutic window and lower therapeutic current strength than omnidirectional stimulation. OBJECTIVE We conducted a single-center, open-label, registry-based, comparative trial to test the hypothesis that directional stimulation can be associated with a greater reduction in the total daily dose of antiparkinsonian medications (ApMeds) than omnidirectional stimulation. MATERIALS AND METHODS A total of 52 patients with directional and 57 subjects with omnidirectional bilateral subthalamic deep brain stimulation (STN-DBS) were enrolled. Preoperatively and 12 months postoperatively, the dose of different ApMeds, the number of tablets used daily, the severity of motor and nonmotor symptoms using the Movement Disorder Society-sponsored Unified Parkinson Disease Rating Scale, and the health-related quality of life (HRQoL) using the 39-item Parkinson's Disease Questionnaire (PDQ-39) were assessed. RESULTS According to the changes in the levodopa equivalent daily dose, directional STN-DBS led to a 13% greater reduction in the total daily dose of ApMed. The 10.3% greater reduction in the dose of levodopa was the main contributor to this difference. The number of different ApMed types also could be decreased in a greater manner with directional stimulation. The improvement in the severity of motor and nonmotor symptoms was comparable; however, we detected a 15.8% greater improvement in the global HRQoL among patients with directional stimulation according to the changes in the summary index of the PDQ-39. The total electrical energy delivered per second was comparable between the groups at 12-month postoperative visit, whereas the amplitude of stimulation was significantly lower and the impedance was significantly higher with directional leads. CONCLUSIONS Directional programming can further increase the reduction in the total daily dose of ApMed after STN-DBS. In addition, directional stimulation can have additional beneficial effects on the global HRQoL. The greater reduction of ApMed doses did not require more energy-consuming stimulation with directional stimulation.
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Affiliation(s)
- Dávid Pintér
- Department of Neurology, Medical School, University of Pécs, Pécs, Hungary.
| | - Evelyn Járdaházi
- Department of Neurology, Medical School, University of Pécs, Pécs, Hungary
| | - István Balás
- Department of Neurosurgery, Medical School, University of Pécs, Pécs, Hungary
| | - Márk Harmat
- Department of Neurology, Medical School, University of Pécs, Pécs, Hungary
| | - Tamás Makó
- Department of Neurology, Medical School, University of Pécs, Pécs, Hungary
| | - Annamária Juhász
- Department of Neurology, Medical School, University of Pécs, Pécs, Hungary
| | - József Janszky
- Department of Neurology, Medical School, University of Pécs, Pécs, Hungary; MTA-PTE Clinical Neuroscience MR Research Group, Pécs, Hungary
| | - Norbert Kovács
- Department of Neurology, Medical School, University of Pécs, Pécs, Hungary; MTA-PTE Clinical Neuroscience MR Research Group, Pécs, Hungary
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26
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Kleinholdermann U, Bacara B, Timmermann L, Pedrosa DJ. Prediction of Movement Ratings and Deep Brain Stimulation Parameters in Idiopathic Parkinson's Disease. Neuromodulation 2023; 26:356-363. [PMID: 36396526 DOI: 10.1016/j.neurom.2022.09.010] [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: 06/06/2022] [Revised: 08/24/2022] [Accepted: 09/13/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) parameter fine-tuning after lead implantation is laborious work because of the almost uncountable possible combinations. Patients and practitioners often gain the perception that assistive devices could be beneficial for adjusting settings effectively. OBJECTIVE We aimed at a proof-of-principle study to assess the benefits of noninvasive movement recordings as a means to predict best DBS settings. MATERIALS AND METHODS For this study, 32 patients with idiopathic Parkinson's disease, under chronic subthalamic nucleus stimulation with directional leads, were recorded. During monopolar review, each available contact was activated with currents between 0.5 and 5 mA, and diadochokinesia, rigidity, and tapping ability were rated clinically. Moreover, participants' movements were measured during four simple hand movement tasks while wearing a commercially available armband carrying an inertial measurement unit (IMU). We trained random forest models to learn the relations between clinical ratings, electrode settings, and movement features obtained from the IMU. RESULTS Firstly, we could show that clinical mobility ratings can be predicted from IMU features with correlations of up to r = 0.68 between true and predicted values. Secondly, these features also enabled a prediction of DBS parameters, which showed correlations of up to approximately r = 0.8 with clinically optimal DBS settings and were associated with congruent volumes of tissue activated. CONCLUSION Movement recordings from customer-grade mobile IMU carrying devices are promising candidates, not only for remote symptom assessment but also for closed-loop DBS parameter adjustment, and could thus extend the list of available aids for effective programming beyond imaging techniques.
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Affiliation(s)
- Urs Kleinholdermann
- Department of Neurology, University Hospital of Marburg and Gießen, Baldingerstraße, Marburg, Germany
| | - Bugrahan Bacara
- Department of Neurology, University Hospital of Marburg and Gießen, Baldingerstraße, Marburg, Germany
| | - Lars Timmermann
- Department of Neurology, University Hospital of Marburg and Gießen, Baldingerstraße, Marburg, Germany; Center of Mind, Brain and Behaviour, Philipps University Marburg, Hans-Meerwein-Straße, Marburg, Germany
| | - David J Pedrosa
- Department of Neurology, University Hospital of Marburg and Gießen, Baldingerstraße, Marburg, Germany; Center of Mind, Brain and Behaviour, Philipps University Marburg, Hans-Meerwein-Straße, Marburg, Germany.
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27
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Peeters J, Boogers A, Van Bogaert T, Davidoff H, Gransier R, Wouters J, Nuttin B, Mc Laughlin M. Electrophysiologic Evidence That Directional Deep Brain Stimulation Activates Distinct Neural Circuits in Patients With Parkinson Disease. Neuromodulation 2023; 26:403-413. [PMID: 35088733 DOI: 10.1016/j.neurom.2021.11.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Deep brain stimulation (DBS) delivered via multicontact leads implanted in the basal ganglia is an established therapy to treat Parkinson disease (PD). However, the different neural circuits that can be modulated through stimulation on different DBS contacts are poorly understood. Evidence shows that electrically stimulating the subthalamic nucleus (STN) causes a therapeutic effect through antidromic activation of the hyperdirect pathway-a monosynaptic connection from the cortex to the STN. Recent studies suggest that stimulating the substantia nigra pars reticulata (SNr) may improve gait. The advent of directional DBS leads now provides a spatially precise means to probe these neural circuits and better understand how DBS affects distinct neural networks. MATERIALS AND METHODS We measured cortical evoked potentials (EPs) using electroencephalography (EEG) in response to low-frequency DBS using the different directional DBS contacts in eight patients with PD. RESULTS A short-latency EP at 3 milliseconds originating from the primary motor cortex appeared largest in amplitude when stimulating DBS contacts closest to the dorsolateral STN (p < 0.001). A long-latency EP at 10 milliseconds originating from the premotor cortex appeared strongest for DBS contacts closest to the SNr (p < 0.0001). CONCLUSIONS Our results show that at the individual patient level, electrical stimulation of different nuclei produces distinct EP signatures. Our approach could be used to identify the functional location of each DBS contact and thus help patient-specific DBS programming. CLINICAL TRIAL REGISTRATION The ClinicalTrials.gov registration number for the study is NCT04658641.
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Affiliation(s)
- Jana Peeters
- Research Group Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium.
| | - Alexandra Boogers
- Research Group Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium; Department of Neurology, UZ Leuven, Leuven, Belgium
| | - Tine Van Bogaert
- Research Group Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Hannah Davidoff
- Division of Animal and Human Health Engineering, Department of Biosystems, KU Leuven, Leuven, Belgium
| | - Robin Gransier
- Research Group Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Jan Wouters
- Research Group Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Bart Nuttin
- Division of Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium; Department of Neurosurgery, UZ Leuven, Leuven, Belgium
| | - Myles Mc Laughlin
- Research Group Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
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Probabilistic Subthalamic Nucleus Stimulation Sweet Spot Integration Into a Commercial Deep Brain Stimulation Programming Software Can Predict Effective Stimulation Parameters. Neuromodulation 2023; 26:348-355. [PMID: 35088739 DOI: 10.1016/j.neurom.2021.10.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/24/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Subthalamic nucleus (STN) deep brain stimulation (DBS) programming in patients with Parkinson disease (PD) may be challenging, especially when using segmented leads. In this study, we integrated a previously validated probabilistic STN sweet spot into a commercially available software to evaluate its predictive value for clinically effective DBS programming. MATERIALS AND METHODS A total of 14 patients with PD undergoing bilateral STN DBS with segmented leads were included. A nonlinear co-registration of a previously defined probabilistic sweet spot onto the manually segmented STN was performed together with lead reconstruction and tractography of the corticospinal tract (CST) in each patient. Contacts were ranked (level and direction), and corresponding effect and side-effect thresholds were predicted based on the overlap of the volume of activated tissue (VTA) with the sweet spot and CST. Image-based findings were correlated with postoperative clinical testing results during monopolar contact review and chronic stimulation parameter settings used after 12 months. RESULTS Image-based contact prediction showed high interrater reliability (Cohen kappa 0.851-0.91). Image-based and clinical ranking of the most efficient ring level and direction of stimulation were matched in 72% (95% CI 57.0-83.3) and 65% (95% CI 44.9-81.2), respectively, across the whole cohort. The mean difference between the predicted and clinically observed effect thresholds was 0.79 ± 0.69 mA (p = 0.72). The median difference between the predicted and clinically observed side-effect thresholds was -0.5 mA (p < 0.001, Wilcoxon paired signed rank test). CONCLUSIONS Integration of a probabilistic STN functional sweet spot into a surgical programming software shows a promising capability to predict the best level and directional contact(s) as well as stimulation settings in DBS for PD and could be used to optimize programming with segmented lead technology. This integrated image-based programming approach still needs to be evaluated on a bigger data set and in a future prospective multicenter cohort.
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Waldthaler J, Sperlich A, Stüssel C, Steidel K, Timmermann L, Pedrosa DJ. Stimulation of non-motor subthalamic nucleus impairs selective response inhibition via prefrontal connectivity. Brain Commun 2023; 5:fcad121. [PMID: 37113315 PMCID: PMC10128876 DOI: 10.1093/braincomms/fcad121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/03/2023] [Indexed: 04/29/2023] Open
Abstract
Given the inconsistent results in the past, there is an ongoing debate whether and how deep brain stimulation in the subthalamic nucleus modifies cognitive control processes like response inhibition in persons with Parkinson's disease. In this study, we examined how the location of the stimulation volume within the subthalamic nucleus affects the performance in an antisaccade task but also how its structural connectivity is related to response inhibition. Antisaccade error rates and latencies were collected in 14 participants on and off deep brain stimulation in a randomized order. Stimulation volumes were computed based on patient-specific lead localizations using preoperative MRI and postoperative CT scans. Structural connectivity of the stimulation volumes with pre-defined cortical oculomotor control regions as well as whole-brain connectivity was estimated using a normative connectome. We showed that the detrimental effect of deep brain stimulation on response inhibition, measured as antisaccade error rate, depended upon the magnitude of the intersection of volumes of activated tissue with the non-motor subregion of the subthalamic nucleus and on its structural connectivity with regions of the prefrontal oculomotor network including bilateral frontal eye fields and right anterior cingulate cortex. Our results corroborate previous recommendations for avoidance of stimulation in the ventromedial non-motor subregion of the subthalamic nucleus which connects to the prefrontal cortex to prevent stimulation-induced impulsivity. Furthermore, antisaccades were initiated faster with deep brain stimulation when the stimulation volume was connected to fibres passing the subthalamic nucleus laterally and projecting onto the prefrontal cortex, indicating that improvement of voluntary saccade generation with deep brain stimulation may be an off-target effect driven by stimulation of corticotectal fibres directly projecting from the frontal and supplementary eye fields onto brainstem gaze control areas. Taken together, these findings could help implement individualized circuit-based deep brain stimulation strategies that avoid impulsive side effects while improving voluntary oculomotor control.
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Affiliation(s)
- Josefine Waldthaler
- Correspondence to: Josefine Waldthaler, Department of Neurology, University Hospitals Gießen and Marburg, Baldingerstraße, 35033 Marburg, Hesse, Germany E-mail:
| | - Alexander Sperlich
- Department of Neurology, University Hospital Gießen and Marburg, 35033 Marburg, Germany
| | - Charlotte Stüssel
- Department of Neurology, University Hospital Gießen and Marburg, 35033 Marburg, Germany
| | - Kenan Steidel
- Department of Neurology, University Hospital Gießen and Marburg, 35033 Marburg, Germany
| | - Lars Timmermann
- Department of Neurology, University Hospital Gießen and Marburg, 35033 Marburg, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps-University Marburg and Justus-Liebig-University Giessen, 35033 Marburg, Germany
| | - David J Pedrosa
- Department of Neurology, University Hospital Gießen and Marburg, 35033 Marburg, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps-University Marburg and Justus-Liebig-University Giessen, 35033 Marburg, Germany
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Gülke E, Juárez Paz L, Scholtes H, Gerloff C, Kühn AA, Pötter-Nerger M. Multiple input algorithm-guided Deep Brain stimulation-programming for Parkinson's disease patients. NPJ Parkinsons Dis 2022; 8:144. [PMID: 36309508 PMCID: PMC9617933 DOI: 10.1038/s41531-022-00396-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/14/2022] [Indexed: 12/04/2022] Open
Abstract
Technological advances of Deep Brain Stimulation (DBS) within the subthalamic nucleus (STN) for Parkinson's disease (PD) provide increased programming options with higher programming burden. Reducing the effort of DBS optimization requires novel programming strategies. The objective of this study was to evaluate the feasibility of a semi-automatic algorithm-guided-programming (AgP) approach to obtain beneficial stimulation settings for PD patients with directional DBS systems. The AgP evaluates iteratively the weighted combination of sensor and clinician assessed responses of multiple PD symptoms to suggested DBS settings until it converges to a final solution. Acute clinical effectiveness of AgP DBS settings and DBS settings that were found following a standard of care (SoC) procedure were compared in a randomized, crossover and double-blind fashion in 10 PD subjects from a single center. Compared to therapy absence, AgP and SoC DBS settings significantly improved (p = 0.002) total Unified Parkinson's Disease Rating Scale III scores (median 69.8 interquartile range (IQR) 64.6|71.9% and 66.2 IQR 58.1|68.2%, respectively). Despite their similar clinical results, AgP and SoC DBS settings differed substantially. Per subject, AgP tested 37.0 IQR 34.0|37 settings before convergence, resulting in 1.7 IQR 1.6|2.0 h, which is comparable to previous reports. Although AgP long-term clinical results still need to be investigated, this approach constitutes an alternative for DBS programming and represents an important step for future closed-loop DBS optimization systems.
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Affiliation(s)
- Eileen Gülke
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - León Juárez Paz
- grid.418905.10000 0004 0437 5539Boston Scientific, Valencia, CA Spain
| | - Heleen Scholtes
- grid.418905.10000 0004 0437 5539Boston Scientific, Valencia, CA Spain
| | - Christian Gerloff
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andrea A. Kühn
- grid.6363.00000 0001 2218 4662Department of Neurology, Movement disorders & Neuromodulation section, Charité – University Medicine Berlin, Berlin, Germany
| | - Monika Pötter-Nerger
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Cometa A, Falasconi A, Biasizzo M, Carpaneto J, Horn A, Mazzoni A, Micera S. Clinical neuroscience and neurotechnology: An amazing symbiosis. iScience 2022; 25:105124. [PMID: 36193050 PMCID: PMC9526189 DOI: 10.1016/j.isci.2022.105124] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
In the last decades, clinical neuroscience found a novel ally in neurotechnologies, devices able to record and stimulate electrical activity in the nervous system. These technologies improved the ability to diagnose and treat neural disorders. Neurotechnologies are concurrently enabling a deeper understanding of healthy and pathological dynamics of the nervous system through stimulation and recordings during brain implants. On the other hand, clinical neurosciences are not only driving neuroengineering toward the most relevant clinical issues, but are also shaping the neurotechnologies thanks to clinical advancements. For instance, understanding the etiology of a disease informs the location of a therapeutic stimulation, but also the way stimulation patterns should be designed to be more effective/naturalistic. Here, we describe cases of fruitful integration such as Deep Brain Stimulation and cortical interfaces to highlight how this symbiosis between clinical neuroscience and neurotechnology is closer to a novel integrated framework than to a simple interdisciplinary interaction.
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Koivu M, Scheperjans F, Eerola-Rautio J, Vartiainen N, Resendiz-Nieves J, Kivisaari R, Pekkonen E. Real-Life Experience on Directional Deep Brain Stimulation in Patients with Advanced Parkinson’s Disease. J Pers Med 2022; 12:jpm12081224. [PMID: 36013173 PMCID: PMC9410362 DOI: 10.3390/jpm12081224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 07/21/2022] [Accepted: 07/23/2022] [Indexed: 11/29/2022] Open
Abstract
Directional deep brain stimulation (dDBS) is preferred by patients with advanced Parkinson’s disease (PD) and by programming neurologists. However, real-life data of dDBS use is still scarce. We reviewed the clinical data of 53 PD patients with dDBS to 18 months of follow-up. Directional stimulation was favored in 70.5% of dDBS leads, and single segment activation (SSA) was used in 60% of dDBS leads. Current with SSA was significantly lower than with other stimulation types. During the 6-month follow-up, a 44% improvement in the Unified Parkinson’s Disease Rating Scale (UPDRS-III) points and a 43% decline in the levodopa equivalent daily dosage (LEDD) was observed. After 18 months of follow-up, a 35% LEDD decrease was still noted. The Hoehn and Yahr (H&Y) stages and scores on item no 30 “postural stability” in UPDRS-III remained lower throughout the follow-up compared to baseline. Additionally, dDBS relieved non-motor symptoms during the 6 months of follow-up. Patients with bilateral SSA had similar clinical outcomes to those with other stimulation types. Directional stimulation appears to effectively reduce both motor and non-motor symptoms in advanced PD with minimal adverse effects in real-life clinical care.
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Affiliation(s)
- Maija Koivu
- Department of Neurology, Helsinki University Hospital and Department of Clinical Neurosciences (Neurology), University of Helsinki, PL 00029 Helsinki, Finland; (F.S.); (J.E.-R.); (E.P.)
- Correspondence:
| | - Filip Scheperjans
- Department of Neurology, Helsinki University Hospital and Department of Clinical Neurosciences (Neurology), University of Helsinki, PL 00029 Helsinki, Finland; (F.S.); (J.E.-R.); (E.P.)
| | - Johanna Eerola-Rautio
- Department of Neurology, Helsinki University Hospital and Department of Clinical Neurosciences (Neurology), University of Helsinki, PL 00029 Helsinki, Finland; (F.S.); (J.E.-R.); (E.P.)
| | - Nuutti Vartiainen
- Department of Neurosurgery, Helsinki University Hospital, PL 00029 Helsinki, Finland; (N.V.); (J.R.-N.); (R.K.)
| | - Julio Resendiz-Nieves
- Department of Neurosurgery, Helsinki University Hospital, PL 00029 Helsinki, Finland; (N.V.); (J.R.-N.); (R.K.)
| | - Riku Kivisaari
- Department of Neurosurgery, Helsinki University Hospital, PL 00029 Helsinki, Finland; (N.V.); (J.R.-N.); (R.K.)
| | - Eero Pekkonen
- Department of Neurology, Helsinki University Hospital and Department of Clinical Neurosciences (Neurology), University of Helsinki, PL 00029 Helsinki, Finland; (F.S.); (J.E.-R.); (E.P.)
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Peeters J, Boogers A, Van Bogaert T, Gransier R, Wouters J, Nuttin B, Mc Laughlin M. Current Steering Using Multiple Independent Current Control Deep Brain Stimulation Technology Results in Distinct Neurophysiological Responses in Parkinson’s Disease Patients. Front Hum Neurosci 2022; 16:896435. [PMID: 35721356 PMCID: PMC9203070 DOI: 10.3389/fnhum.2022.896435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/16/2022] [Indexed: 12/04/2022] Open
Abstract
Background Deep brain stimulation (DBS) is an effective neuromodulation therapy to treat people with medication-refractory Parkinson’s disease (PD). However, the neural networks affected by DBS are not yet fully understood. Recent studies show that stimulating on different DBS-contacts using a single current source results in distinct EEG-based evoked potentials (EPs), with a peak at 3 ms (P3) associated with dorsolateral subthalamic nucleus stimulation and a peak at 10 ms associated with substantia nigra stimulation. Multiple independent current control (MICC) technology allows the center of the electric field to be moved in between two adjacent DBS-contacts, offering a potential advantage in spatial precision. Objective Determine if MICC precision targeting results in distinct neurophysiological responses recorded via EEG. Materials and Methods We recorded cortical EPs in five hemispheres (four PD patients) using EEG whilst employing MICC to move the electric field from the most dorsal DBS-contact to the most ventral in 15 incremental steps. Results The center of the electric field location had a significant effect on both the P3 and P10 amplitude in all hemispheres where a peak was detected (P3, detected in 4 of 5 hemispheres, p < 0.0001; P10, detected in 5 of 5 hemispheres, p < 0.0001). Post hoc analysis indicated furthermore that MICC technology can significantly refine the resolution of steering. Conclusion Using MICC to incrementally move the center of the electric field to locations between adjacent DBS-contacts resulted in significantly different neurophysiological responses that may allow further precision of the programming of individual patients.
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Affiliation(s)
- Jana Peeters
- Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- *Correspondence: Jana Peeters,
| | - Alexandra Boogers
- Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- Department of Neurology, UZ Leuven, Leuven, Belgium
| | - Tine Van Bogaert
- Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Robin Gransier
- Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Jan Wouters
- Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Bart Nuttin
- Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- Department of Neurosurgery, UZ Leuven, Leuven, Belgium
| | - Myles Mc Laughlin
- Experimental Oto-rhino-laryngology, Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
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Schmidt JM, Buentjen L, Kaufmann J, Gruber D, Treuer H, Haghikia A, Voges J. Deviation of the orientation angle of directional deep brain stimulation leads quantified by intraoperative stereotactic X-ray imaging. Neurosurg Rev 2022; 45:2975-2982. [PMID: 35554745 PMCID: PMC9349129 DOI: 10.1007/s10143-022-01801-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/05/2022] [Accepted: 04/27/2022] [Indexed: 11/21/2022]
Abstract
Directional deep brain stimulation (dDBS) provides multiple programming options. Knowledge of the spatial lead orientation is useful for time-efficient programming. Recent studies demonstrated deviations of up to 90° from the intended orientation angle. We examined the deviation of dDBS-lead orientation for leads from two different manufacturers using intraoperative stereotactic (STX) X-ray images. Intraoperative 2D-X-ray images were acquired after implantation of the first lead (TP1) and the second lead (TP2) enabling the estimation of the spatial position of the first lead at TP1 and TP2 and of changes of the orientation for a defined time period. Two investigators retrospectively estimated the orientation of the directional marker for 64 patients. The mean deviation from intended spatial orientation was 40.8° ± 46.1° for all examined leads. The spatial orientation of the first lead did not significantly change within a period of approximately 1 h. The degree of deviation did not differ significantly between two lead manufacturers but depended on the lead fixation technique. Our results showed deviations from the intended orientation angle immediately after the insertion of dDBS leads. The initial spatial orientation remained stable for approximately 1 h and was not caused by technical properties of the implanted lead. Hence, it was most probably the result of unintended mechanical torsion during insertion and/or fixation. Because precise determination of the lead orientation is mandatory for target-oriented dDBS programming, the use of additional imaging suitable for precise 3D visualization of lead contacts and/or the positioning marker is recommended.
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Affiliation(s)
- Josephiene M Schmidt
- Department of Neurology, University Hospital of Magdeburg, Leipziger Straße 44Saxony-Anhalt, 39108, Magdeburg, Germany.
| | - Lars Buentjen
- Department of Stereotactic Neurosurgery, University Hospital of Magdeburg, Magdeburg, Germany
| | - Joern Kaufmann
- Department of Neurology, University Hospital of Magdeburg, Leipziger Straße 44Saxony-Anhalt, 39108, Magdeburg, Germany
| | - Doreen Gruber
- Kliniken Beelitz, Movement Disorders Clinic, Beelitz-Heilstätten, Germany
| | - Harald Treuer
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Aiden Haghikia
- Department of Neurology, University Hospital of Magdeburg, Leipziger Straße 44Saxony-Anhalt, 39108, Magdeburg, Germany
| | - Jürgen Voges
- Department of Stereotactic Neurosurgery, University Hospital of Magdeburg, Magdeburg, Germany
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Hidding U, Schaper M, Gulberti A, Buhmann C, Gerloff C, Moll CKE, Hamel W, Choe CU, Pötter-Nerger M. Short pulse and directional thalamic deep brain stimulation have differential effects in parkinsonian and essential tremor. Sci Rep 2022; 12:7251. [PMID: 35508680 PMCID: PMC9068767 DOI: 10.1038/s41598-022-11291-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 04/05/2022] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to assess the effects of novel stimulation algorithms of deep brain stimulation (short pulse and directional stimulation) in the ventrointermediate thalamus and posterior subthalamic area (VIM/PSA-DBS) on tremor in Parkinson’s disease (PD) and to compare the effects with those in essential tremor (ET). We recruited six PD patients (70.8 ± 10.4 years) and seven ET patients (64.4 ± 9.9 years) with implanted VIM/PSA-DBS in a stable treatment condition (> 3 months postoperatively). Tremor severity and ataxia were assessed in four different stimulation conditions in a randomized order: DBS switched off (STIM OFF), omnidirectional stimulation with 60 µs (oDBS60), omnidirectional stimulation with 30 µs (oDBS30), directional stimulation at the best segment with 60 µs (dDBS60). In both patient groups, all three DBS stimulation modes reduced the total tremor score compared to STIM OFF, whereas stimulation-induced ataxia was reduced by oDBS30 and partially by dDBS60 compared to oDBS60. Tremor reduction was more pronounced in PD than in ET due to a limited DBS effect on intention and action-specific drawing tremor in ET. In PD and ET tremor, short pulse or directional VIM/PSA-DBS is an effective and well tolerated therapeutic option. Trial registration: The study was registered in the DRKS (ID DRKS00025329, 18.05.2021, German Clinical Trials Register, DRKS—Deutsches Register Klinischer Studien).
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Affiliation(s)
- Ute Hidding
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Miriam Schaper
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Alessandro Gulberti
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christian K E Moll
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Chi-Un Choe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Kochanski RB, Slavin KV. The future perspectives of psychiatric neurosurgery. PROGRESS IN BRAIN RESEARCH 2022; 270:211-228. [PMID: 35396029 DOI: 10.1016/bs.pbr.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The future of psychiatric neurosurgery can be viewed from two separate perspectives: the immediate future and the distant future. Both show promise, but the treatment strategy for mental diseases and the technology utilized during these separate periods will likely differ dramatically. It can be expected that the initial advancements will be built upon progress of neuroimaging and stereotactic targeting while surgical technology becomes adapted to patient-specific symptomatology and structural/functional imaging parameters. This individualized approach has already begun to show significant promise when applied to deep brain stimulation for treatment-resistant depression and obsessive-compulsive disorder. If effectiveness of these strategies is confirmed by well designed, double-blind, placebo-controlled clinical studies, further technological advances will continue into the distant future, and will likely involve precise neuromodulation at the cellular level, perhaps using wireless technology with or without closed-loop design. This approach, being theoretically less invasive and carrying less risk, may ultimately propel psychiatric neurosurgery to the forefront in the treatment algorithm of mental illness. Despite prominent development of non-invasive therapeutic options, such as stereotactic radiosurgery or transcranial magnetic resonance-guided focused ultrasound, chances are there will still be a need in surgical management of patients with most intractable psychiatric conditions.
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Affiliation(s)
- Ryan B Kochanski
- Neurosurgery, Methodist Healthcare System, San Antonio, TX, United States
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, United States; Neurology Service, Jesse Brown Veterans Administration Medical Center, Chicago, IL, United States.
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Fernández-García C, Monje MH, Gómez-Mayordomo V, Foffani G, Herranz R, Catalán MJ, González-Hidalgo M, Matias-Guiu J, Alonso-Frech F. Long-term directional deep brain stimulation: Monopolar review vs. local field potential guided programming. Brain Stimul 2022; 15:727-736. [DOI: 10.1016/j.brs.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 01/16/2022] [Accepted: 04/20/2022] [Indexed: 11/02/2022] Open
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Oertel MF, Krayenbühl N, Baumann CR, Regli L, Stieglitz LH. The History of Stereotactic and Functional Neurosurgery in Zurich. NEUROSURGERY OPEN 2022. [DOI: 10.1227/neuopn.0000000000000004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Combining Multimodal Biomarkers to Guide Deep Brain Stimulation Programming in Parkinson Disease. Neuromodulation 2022; 26:320-332. [PMID: 35219571 PMCID: PMC7614142 DOI: 10.1016/j.neurom.2022.01.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 12/24/2021] [Accepted: 01/13/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) programming of multicontact DBS leads relies on a very time-consuming manual screening procedure, and strategies to speed up this process are needed. Beta activity in subthalamic nucleus (STN) local field potentials (LFP) has been suggested as a promising marker to index optimal stimulation contacts in patients with Parkinson disease. OBJECTIVE In this study, we investigate the advantage of algorithmic selection and combination of multiple resting and movement state features from STN LFPs and imaging markers to predict three relevant clinical DBS parameters (clinical efficacy, therapeutic window, side-effect threshold). MATERIALS AND METHODS STN LFPs were recorded at rest and during voluntary movements from multicontact DBS leads in 27 hemispheres. Resting- and movement-state features from multiple frequency bands (alpha, low beta, high beta, gamma, fast gamma, high frequency oscillations [HFO]) were used to predict the clinical outcome parameters. Subanalyses included an anatomical stimulation sweet spot as an additional feature. RESULTS Both resting- and movement-state features contributed to the prediction, with resting (fast) gamma activity, resting/movement-modulated beta activity, and movement-modulated HFO being most predictive. With the proposed algorithm, the best stimulation contact for the three clinical outcome parameters can be identified with a probability of almost 90% after considering half of the DBS lead contacts, and it outperforms the use of beta activity as single marker. The combination of electrophysiological and imaging markers can further improve the prediction. CONCLUSION LFP-guided DBS programming based on algorithmic selection and combination of multiple electrophysiological and imaging markers can be an efficient approach to improve the clinical routine and outcome of DBS patients.
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Alonso-Frech F, Fernandez-Garcia C, Gómez-Mayordomo V, Monje MHG, Delgado-Suarez C, Villanueva-Iza C, Catalan-Alonso MJ. Non-motor Adverse Effects Avoided by Directional Stimulation in Parkinson's Disease: A Case Report. Front Neurol 2022; 12:786166. [PMID: 35173666 PMCID: PMC8843015 DOI: 10.3389/fneur.2021.786166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/29/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction Deep brain stimulation (DBS) is widely used for treatment of advanced, medication-refractory Parkinson's disease (PD). However, a significant proportion of patients may suffer adverse effects; up to 10% will present one or more transient or permanent neurobehavioral events. Patient and Methods In our case study, a 44-year-old woman diagnosed with PD 6 years previously who was suffering from motor fluctuations, dyskinesia, and freezing of gait episodes was submitted for DBS and implanted with directional electrodes. Intraoperative local field potentials (LFPs) were recorded. After surgery, conventional monopolar revision was performed. Preoperative 3T MRI studies and postoperative 3D and X-ray data were integrated using the Guide DTI software application (Brainlab), and diffusion tensor imaging tractography traced from cortical areas to each subthalamic nucleus (STN) using Elements software (Brainlab). Results We observed that left STN stimulation in the ring mode significantly improved motor symptoms, but the patient presented uncontrollable mirthful laughter. Stimulation was then switched to the directional mode; laughter remained when using the more posteromedial contact (3-C+) but not 2-C+ or 4-C+ at the same parameters. Interestingly, LFP recordings showed the highest beta-band activity over contacts 4 and 2, and very scarce beta power over contact 3. The orientation of the directional leads was selected based on the 3D postoperative X-rays. Associative fibers showed the shortest distance to contact number 3. Conclusion Stimulation of the STN can affect motor and associative loops. The use of directional electrodes is a good option to avoid not only undesirable capsular or lemniscal effects, but also limbic/associative events. Oscillatory activity in the beta range that preferentially takes place over the somatomotor STN region and is closely related to motor improvement, provides a reliable guide for optimizing the DBS programming. The importance of the exact location of electrical stimulation to determine the non-motor symptoms such as mood, apathy, attention, and memory, as well as the usefulness of biological markers such as LFP for optimal programming, is discussed in relation to this case.
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Affiliation(s)
- Fernando Alonso-Frech
- Department of Neurology, San Carlos Research Health Institute (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
- *Correspondence: Fernando Alonso-Frech
| | - Carla Fernandez-Garcia
- Department of Neurosurgery, San Carlos Research Health Institute (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
- Carla Fernandez-Garcia
| | - Victor Gómez-Mayordomo
- Department of Neurology, San Carlos Research Health Institute (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Mariana H. G. Monje
- Department of Neurology, San Carlos Research Health Institute (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | | | - Clara Villanueva-Iza
- Department of Neurology, San Carlos Research Health Institute (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
| | - Maria Jose Catalan-Alonso
- Department of Neurology, San Carlos Research Health Institute (IdISSC), Hospital Clínico San Carlos, Madrid, Spain
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Klassen BT, Rotter J, Crane C, Kaufmann TJ, Miller KJ. Elevated Electrode Impedances During Deep Brain Stimulation Surgery May Be Due to Peri-Electrode Air Collections. Cureus 2022; 14:e21518. [PMID: 35223294 PMCID: PMC8862689 DOI: 10.7759/cureus.21518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/05/2022] Open
Abstract
Deep brain stimulation (DBS) is a commonly used treatment for medically refractory movement disorders and epilepsy. Intraoperative testing of electrode impedances is routinely done during DBS surgery to identify electrical conduction defects in the system. We present two illustrative cases involving elevated intraoperative impedances. In the first case, the temporal evolution of impedance changes and a postoperative head CT were consistent with a small and slowly resolving air collection along the lead. In the second case, an abnormally high impedance reading was observed at a single electrode and then “transferred” to be observed at an adjacent electrode upon adjustments of the electrode position, likely due to small air collection at a fixed position in the brain tissue. In both cases, careful troubleshooting allowed identification of the issue and avoidance of unnecessary surgical revisions. A thorough understanding of the possible sources of, and troubleshooting for, abnormal impedance readings is needed for effective intraoperative DBS monitoring.
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Yalaz M, Maling N, Deuschl G, Juárez-Paz LM, Butz M, Schnitzler A, Helmers AK, Höft M. MaDoPO: Magnetic Detection of Positions and Orientations of Segmented Deep-Brain Stimulation Electrodes: A Radiation-Free Method Based on Magnetoencephalography. Brain Sci 2022; 12:brainsci12010086. [PMID: 35053829 PMCID: PMC8774199 DOI: 10.3390/brainsci12010086] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Current approaches to detect the positions and orientations of directional deep-brain stimulation (DBS) electrodes rely on radiative imaging data. In this study, we aim to present an improved version of a radiation-free method for magnetic detection of the position and the orientation (MaDoPO) of directional electrodes based on a series of magnetoencephalography (MEG) measurements and a possible future solution for optimized results using emerging on-scalp MEG systems. Methods: A directional DBS system was positioned into a realistic head–torso phantom and placed in the MEG scanner. A total of 24 measurements of 180 s each were performed with different predefined electrode configurations. Finite element modeling and model fitting were used to determine the position and orientation of the electrode in the phantom. Related measurements were fitted simultaneously, constraining solutions to the a priori known geometry of the electrode. Results were compared with the results of the high-quality CT imaging of the phantom. Results: The accuracy in electrode localization and orientation detection depended on the number of combined measurements. The localization error was minimized to 2.02 mm by considering six measurements with different non-directional bipolar electrode configurations. Another six measurements with directional bipolar stimulations minimized the orientation error to 4°. These values are mainly limited due to the spatial resolution of the MEG. Moreover, accuracies were investigated as a function of measurement time, number of sensors, and measurement direction of the sensors in order to define an optimized MEG device for this application. Conclusion: Although MEG introduces inaccuracies in the detection of the position and orientation of the electrode, these can be accepted when evaluating the benefits of a radiation-free method. Inaccuracies can be further reduced by the use of on-scalp MEG sensor arrays, which may find their way into clinics in the foreseeable future.
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Affiliation(s)
- Mevlüt Yalaz
- Microwave Engineering, Christian-Albrechts-Universität zu Kiel, 24143 Kiel, Germany;
- Correspondence:
| | - Nicholas Maling
- Boston Scientific Corporation, Santa Clarita, CA 91355, USA; (N.M.); (L.M.J.-P.)
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-Universität zu Kiel, 24105 Kiel, Germany;
| | - León M. Juárez-Paz
- Boston Scientific Corporation, Santa Clarita, CA 91355, USA; (N.M.); (L.M.J.-P.)
| | - Markus Butz
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine-Universität Düsseldorf, 40225 Düsseldorf, Germany; (M.B.); (A.S.)
| | - Alfons Schnitzler
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine-Universität Düsseldorf, 40225 Düsseldorf, Germany; (M.B.); (A.S.)
| | - Ann-Kristin Helmers
- Department of Neurosurgery, Christian-Albrechts-Universität zu Kiel, 24105 Kiel, Germany;
| | - Michael Höft
- Microwave Engineering, Christian-Albrechts-Universität zu Kiel, 24143 Kiel, Germany;
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Mohammed M, Ivica N, Bjartmarz H, Thorbergsson PT, Pettersson LME, Thelin J, Schouenborg J. Microelectrode clusters enable therapeutic deep brain stimulation without noticeable side-effects in a rodent model of Parkinson's disease. J Neurosci Methods 2022; 365:109399. [PMID: 34695455 DOI: 10.1016/j.jneumeth.2021.109399] [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: 07/16/2021] [Revised: 10/01/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Deep Brain Stimulation (DBS) is an established treatment for motor symptoms in Parkinson's disease (PD). However, side effects often limit the usefulness of the treatment. NEW METHOD To mitigate this problem, we developed a novel cluster of ultrathin platinum-iridium microelectrodes (n = 16) embedded in a needle shaped gelatin vehicle. In an established rodent PD-model (6-OHDA unilateral lesion), the clusters were implanted in the subthalamic area for up to 8 weeks. In an open field setting, combinations of microelectrodes yielding therapeutic effects were identified using statistical methods. Immunofluorescence techniques were used for histological assessments of biocompatibility. RESULTS In all rats tested (n = 5), we found subsets of 3-4 microelectrodes which, upon stimulation (160 Hz, 60 μs pulse width, 25-40 μA/microelectrode), prompted normal movements without noticeable side effects. Other microelectrode subsets often caused side effects such as rotation, dyskinesia and tremor. The threshold (per microelectrode) to elicit normal movements strongly depended on the number of activated microelectrodes in the selected subset. The histological analysis revealed viable neurons close to the electrode contacts, minor microglial and astrocytic reactions and no major changes in the vasculature, indicating high biocompatibility. COMPARISON TO EXISTING METHODS AND CONCLUSION By contrast to the continuous and relatively large stimulation fields produced by existing DBS electrodes, the developed microelectrode cluster enables a fine-tuned granular and individualized microstimulation. This granular type of stimulation pattern provided powerful and specific therapeutic effects, free of noticeable side effects, in a PD animal model.
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Affiliation(s)
| | | | - Hjalmar Bjartmarz
- Neuronano Research Center, Lund University, Lund, Sweden; Department of Neurosurgery, Lund University and Skåne University Hospital in Lund, Lund, Sweden
| | | | - Lina M E Pettersson
- Neuronano Research Center, Lund University, Lund, Sweden; NanoLund, Lund University, Lund, Sweden
| | - Jonas Thelin
- Neuronano Research Center, Lund University, Lund, Sweden
| | - Jens Schouenborg
- Neuronano Research Center, Lund University, Lund, Sweden; NanoLund, Lund University, Lund, Sweden.
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Mishra A, Ramdhani RA. Directional Deep Brain Stimulation in the Treatment of Parkinson's Disease. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Deep brain stimulation (DBS) is a treatment modality that has been shown to improve the clinical outcomes of individuals with movement disorders, including Parkinson's disease. Directional DBS represents an advance in the field that allows clinicians to better modulate the electrical stimulation to increase therapeutic gains while minimizing side effects. In this review, we summarize the principles of directional DBS, including available technologies and stimulation paradigms, and examine the growing clinical study data with respect to its use in Parkinson's disease.
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Bunyaratavej K, Phokaewvarangkul O, Wangsawatwong P. Placement accuracy of the second electrode in bilateral deep brain stimulation surgery. Br J Neurosurg 2021:1-8. [PMID: 34939521 DOI: 10.1080/02688697.2021.2019677] [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: 11/03/2020] [Revised: 11/26/2021] [Accepted: 12/14/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Due to brain shift during bilateral deep brain stimulation (DBS) surgery, placement of the second electrode may be subjected to more error than that of the first electrode. The authors aimed to investigate the accuracy of second electrode placement in this setting. MATERIALS AND METHODS Fifty-five patients with Parkinson's disease who underwent bilateral DBS surgery (110 electrodes) were retrospectively evaluated. The targets were subthalamic nucleus (STN) and globus pallidus interna (GPi) in 40 and 15 cases, respectively. Preoperative planning and postoperative electrode images were co-registered to compare the error margin between the two sides. RESULTS There is a statistically significant difference in the directional axis error along the y axis only when comparing each laterality (posterior 0.04 ± 1.21 mm vs anterior 0.41 ± 1.07 mm, p = 0.006). There is no significant difference of other error parameters, final track location, and number of microelectrode recording passes between the two sides. In a subgroup analysis, there is a significant difference in directional axis error along the y axis only in the STN subgroup (posterior 0.40 ± 1.05 mm vs anterior 0.18 ± 1.04 mm, p = 0.003). CONCLUSION Although a statistically significant difference in directional axis error along the y axis was found between first and second electrode placements in the STN group but not in the GPi group, its magnitude is well below the clinically significant threshold.
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Affiliation(s)
- Krishnapundha Bunyaratavej
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Onanong Phokaewvarangkul
- Chulalongkorn Center of Excellence for Parkinson's Disease and Related Disorders, Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Piyanat Wangsawatwong
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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Role of Directional Configuration in Deep Brain Stimulation for Essential Tremor: A Single Center Experience. Tremor Other Hyperkinet Mov (N Y) 2021; 11:47. [PMID: 34824890 PMCID: PMC8588889 DOI: 10.5334/tohm.628] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/02/2021] [Indexed: 11/20/2022] Open
Abstract
Background Traditionally, the standard of care for medication refractory essential tremor has been to utilize omnidirectional deep brain stimulation of the ventral intermediate nucleus. The advent of directional stimulation allows for spatial restriction of the stimulation on selected targets without involving the neighboring structures, thereby limiting off-target side effects and improving clinical utility. Methods We performed a retrospective review of patients between February 2017 and September 2019 who had received ventral intermediate nucleus deep brain stimulation that allowed for directional programming (specifically Abbott/St. Jude). Initial and final major programming sessions post-operatively (approximately 30- and 90-days post-surgery) were examined to determine frequency and reason for use of directional programming. Results A total of 33 total patients were identified. A little over half were males (58%, N = 19), with an average age of 68 years old (SD 9.3) at the time of surgery, and a disease duration of almost 30 years (27.2, SD 19) with a wide range from 2-62 years. After initial programming, over 50% (17 of 33) of patients were using directional configurations. This increased to 85% (28 of 33) at the 90-day programming. Reasons for conversion to directional configuration included avoidance of side effects (specifically, muscle contractions (9/33), paresthesia (5/33), dysarthria (1/33) and gait ataxia (1/33)) or improved tremor control (12/33). Discussion Our single-center experience suggests that in the large majority of cases, directional leads were utilized and offered advantages in tremor control or side effect avoidance.
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Knorr S, Musacchio T, Paulat R, Matthies C, Endres H, Wenger N, Harms C, Ip CW. Experimental deep brain stimulation in rodent models of movement disorders. Exp Neurol 2021; 348:113926. [PMID: 34793784 DOI: 10.1016/j.expneurol.2021.113926] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 09/14/2021] [Accepted: 11/11/2021] [Indexed: 12/21/2022]
Abstract
Deep brain stimulation (DBS) is the preferred treatment for therapy-resistant movement disorders such as dystonia and Parkinson's disease (PD), mostly in advanced disease stages. Although DBS is already in clinical use for ~30 years and has improved patients' quality of life dramatically, there is still limited understanding of the underlying mechanisms of action. Rodent models of PD and dystonia are essential tools to elucidate the mode of action of DBS on behavioral and multiscale neurobiological levels. Advances have been made in identifying DBS effects on the central motor network, neuroprotection and neuroinflammation in DBS studies of PD rodent models. The phenotypic dtsz mutant hamster and the transgenic DYT-TOR1A (ΔETorA) rat proved as valuable models of dystonia for preclinical DBS research. In addition, continuous refinements of rodent DBS technologies are ongoing and have contributed to improvement of experimental quality. We here review the currently existing literature on experimental DBS in PD and dystonia models regarding the choice of models, experimental design, neurobiological readouts, as well as methodological implications. Moreover, we provide an overview of the technical stage of existing DBS devices for use in rodent studies.
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Affiliation(s)
- Susanne Knorr
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider-Straße 11, Würzburg, Germany.
| | - Thomas Musacchio
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider-Straße 11, Würzburg, Germany.
| | - Raik Paulat
- Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany.
| | - Cordula Matthies
- Department of Neurosurgery, University Hospital of Würzburg, Josef-Schneider-Straße 11, Würzburg, Germany.
| | - Heinz Endres
- University of Applied Science Würzburg-Schweinfurt, Schweinfurt, Germany.
| | - Nikolaus Wenger
- Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany.
| | - Christoph Harms
- Department of Neurology, Charité - Universitätsmedizin Berlin, Charitéplatz 1, Berlin, Germany.
| | - Chi Wang Ip
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider-Straße 11, Würzburg, Germany.
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Masuda H, Shirozu H, Ito Y, Fukuda M, Fujii Y. Surgical Strategy for Directional Deep Brain Stimulation. Neurol Med Chir (Tokyo) 2021; 62:1-12. [PMID: 34719582 PMCID: PMC8754682 DOI: 10.2176/nmc.ra.2021-0214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Deep brain stimulation (DBS) is a well-established treatment for drug-resistant involuntary movements. However, the conventional quadripole cylindrical lead creates electrical fields in all directions, and the resulting spread to adjacent eloquent structures may induce unintended effects. Novel directional leads have therefore been designed to allow directional stimulation (DS). Directional leads have the advantage of widening the therapeutic window (TW), compensating for slight misplacement of the lead and requiring less electrical power to provide the same effect as a cylindrical lead. Conversely, the increase in the number of contacts from four to eight and the addition of directional elements has made stimulation programming more complex. For these reasons, new treatment strategies are required to allow effective directional DBS. During lead implantation, the directional segment should be placed in a "sweet spot," and the orientation of the directional segment is important for programming. Trial-and-error testing of a large number of contacts is unnecessary, and efficient and systematic execution of the programmed procedure is desirable. Recent improvements in imaging technologies have enabled image-guided programming. In the future, optimal stimulations are expected to be programmed by directional recording of local field potentials.
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Affiliation(s)
- Hiroshi Masuda
- Division of Functional Neurosurgery, Nishiniigata National Hospital
| | - Hiroshi Shirozu
- Division of Functional Neurosurgery, Nishiniigata National Hospital
| | - Yosuke Ito
- Division of Functional Neurosurgery, Nishiniigata National Hospital
| | - Masafumi Fukuda
- Division of Functional Neurosurgery, Nishiniigata National Hospital
| | - Yukihiko Fujii
- Department of Neurosurgery, Brain Research Institute, Niigata University
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Yalaz M, Deuschl G, Sohail Noor M, Butz M, Schnitzler A, Helmers AK, Höft M. Determining the rotational orientation of directional deep brain stimulation electrodes using magnetoencephalography. J Neural Eng 2021; 18. [PMID: 34598173 DOI: 10.1088/1741-2552/ac2c4d] [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: 06/02/2021] [Accepted: 10/01/2021] [Indexed: 11/11/2022]
Abstract
Objective.The aim of the present study was to evaluate the effect of different electrode configurations on the accuracy of determining the rotational orientation of the directional deep brain stimulation (DBS) electrode with our previously published magnetoencephalography (MEG)-based method.Approach.A directional DBS electrode, along with its implantable pulse generator, was integrated into a head phantom and placed within the MEG sensor array. Predefined bipolar electrode configurations, based on activation of different directional and omnidirectional contacts of the electrode, were set to generate a defined magnetic field during stimulation. This magnetic field was then measured with MEG. Finite element modeling and model fitting approach were used to calculate electrode orientation.Main results.The accuracy of electrode orientation detection depended on the electrode configuration: the vertical configuration (activation of two directional contacts arranged one above the other) achieved an average accuracy of only about 41 ∘. The diagonal configuration (activation of the electrode tip and a single directional contact at the next higher level of the electrode) achieved an accuracy of 13∘, while the horizontal electrode configuration (activation of two adjacent directional contacts at the same electrode level) achieved the best accuracy of 6∘. The accuracy of orientation detection of the DBS electrode depends on the change in spatial distribution of the magnetic field with the rotation of the electrode along its own axis. In the vertical configuration, rotation of the electrode has a small effect on the magnetic field distribution, while in the diagonal or horizontal configuration, electrode rotation has a significant effect on the magnetic field distribution.Significance.Our work suggests that in order to determine rotational orientation of a DBS electrode using MEG, horizontal configuration should be used as it provides the most accurate results compared to other possible configurations.
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Affiliation(s)
- Mevlüt Yalaz
- Chair of Microwave Engineering, Christian-Albrechts-Universität zu Kiel, 24143 Kiel, Germany
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-Universität zu Kiel, 24105 Kiel, Germany
| | - M Sohail Noor
- Department of Biomedical Engineering, Duke University, Durham, NC, United States of America
| | - Markus Butz
- Institute of Clinical Neuroscience and Medical iPsychology, Medical Faculty of HHU, 40225 Düsseldorf, Germany
| | - Alfons Schnitzler
- Institute of Clinical Neuroscience and Medical iPsychology, Medical Faculty of HHU, 40225 Düsseldorf, Germany
| | - Ann-Kristin Helmers
- Department of Neurosurgery, Christian-Albrechts-Universität zu Kiel, 24105 Kiel, Germany
| | - Michael Höft
- Chair of Microwave Engineering, Christian-Albrechts-Universität zu Kiel, 24143 Kiel, Germany
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Roque DA, Hadar E, Zhang Y, Zou F, Murrow R. Reducing Ataxic Side Effects from Ventral Intermediate Nucleus of the Thalamus Deep Brain Stimulation Implantation in Essential Tremor: Potential Advantages of Directional Stimulation. Stereotact Funct Neurosurg 2021; 100:35-43. [PMID: 34535594 DOI: 10.1159/000518238] [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: 05/06/2021] [Accepted: 06/30/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The aim of the study was to retrospectively evaluate the effect of directional deep brain stimulation (DBS) on ataxia in an essential tremor patient population. MATERIALS AND METHODS A retrospective chart review of documented Scale for Assessment and Rating of Ataxia (SARA) scores were analyzed using a case-control design. All subjects we evaluated were treated at a single, tertiary care academic center. We reviewed 14 patients who underwent bilateral ventral intermediate nucleus of the thalamus (VIM) implantation with microelectrode recording, with electrodeposition and segmented contact orientation confirmed via postoperative computed tomography. The main outcome was to determine change in ataxia scores between directional versus monopolar circumferential stimulation. RESULTS Fourteen patients (9 males, median age at implantation 69 [range 63-82]) underwent surgery between October 2017 and July 2020 at the UNC Movement Disorders Center. SARA scores between directional stimulation and monopolar circumferential stimulation demonstrated a significant reduction in total scores with best possible segmented stimulation (n = 13, p < 0.0001, 95% confidence interval [CI] -3.496 to -6.789). This difference remained statistically significant even after removing the SARA tremor subscore (n = 13, p < 0.0001, 95% CI -3.155 to -6.274). In line with prior reports, SARA score changes from the preoperative state were generally worsened when applying monopolar circumferential stimulation bilaterally (n = 13, p = 0.655; 95% CI -2.836 to 4.359), but improved with directional stimulation (n = 13, p = 0.010; 95% CI -1.216 to -7.547). CONCLUSION This retrospective analysis appears to show evidence for improved outcomes through directional stimulation in bilateral VIM DBS implantation with reduction of ataxic side effects that have traditionally plagued postoperative results, all while providing optimized tremor reduction via stimulation.
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Affiliation(s)
- Daniel Alberto Roque
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Eldad Hadar
- Department of Neurosurgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ying Zhang
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Fei Zou
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Richard Murrow
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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