Electrocardiographic approach strategies in patients with Parkinson disease treated with deep brain stimulation

Deep brain stimulation (DBS) is an interdisciplinary and reversible therapy that uses high-frequency electrical stimulation to correct aberrant neural pathways in motor and cognitive neurological disorders. However, the high frequency of the waves used in DBS can interfere with electrical recording devices (e.g., electrocardiogram, electroencephalogram, cardiac monitor), creating artifacts that hinder their interpretation. The compatibility of DBS with these devices varies and depends on factors such as the underlying disease and the configuration of the neurostimulator. In emergencies where obtaining an electrocardiogram is crucial, the need for more consensus on reducing electrical artifacts in patients with DBS becomes a significant challenge. Various strategies have been proposed to attenuate the artifact generated by DBS, such as changing the DBS configuration from monopolar to bipolar, temporarily deactivating DBS during electrocardiographic recording, applying frequency filters both lower and higher than those used by DBS, and using non-standard leads. However, the inexperience of medical personnel, variability in DBS models, or the lack of a controller at the time of approach limit the application of these strategies. Current evidence on their reproducibility and efficacy is limited. Due to the growing elderly population and the rising utilization of DBS, it is imperative to create electrocardiographic methods that are easily accessible and reproducible for general physicians and emergency services.

Perioperative and anesthetic considerations for the management of neuromodulation systems

The use of neuromodulation systems is increasing for the treatment of various pathologies ranging from movement disorders to urinary incontinence to chronic pain syndromes. While the type of neuromodulation devices varies, they are largely categorized as intracranial (eg, deep brain stimulation), neuraxial (eg, spinal cord stimulation, dorsal root ganglion stimulation, and intrathecal drug delivery systems), or peripheral (eg, sacral nerve stimulation and peripheral nerve stimulation) systems. Given the increasing prevalence of these systems in the overall population, it is important for anesthesiologists, surgeons, and the perioperative healthcare team to familiarize themselves with these systems and their unique perioperative considerations. In this review, we explore and highlight the various neuromodulation systems, their general perioperative considerations, and notable special circumstances for perioperative management.

Management of vagus nerve simulation therapy in the peri-operative period: Guidelines from the Association of Anaesthetists: Guidelines from the Association of Anaesthetists

Vagus nerve stimulation is a well-established treatment option for patients with drug-resistant epilepsy and has an expanding range of other clinical indications. Side effects of vagus nerve stimulation therapy include: cough; voice changes; vocal cord adduction; rarely, obstructive sleep apnoea; and arrhythmia. Patients with implanted vagus nerve stimulation devices may present for unrelated surgery and critical care to clinicians who are unfamiliar with their function and safe management. These guidelines have been formulated by multidisciplinary consensus based on case reports, case series and expert opinion to support clinicians in the management of patients with these devices. The aim is to provide specific guidance on the management of vagus nerve stimulation devices in the following scenarios: the peri-operative period; peripartum period; during critical illness; and in the MRI suite. Patients should be aware of the importance of carrying their personal vagus nerve stimulation device magnet with them at all times to facilitate urgent device deactivation if necessary. We advise that it is generally safer to formally deactivate vagus nerve stimulation devices before general and spinal anaesthesia. During periods of critical illness associated with haemodynamic instability, we also advise cessation of vagus nerve stimulation and early consultation with neurology services.

Electrodiagnostic artifacts due to neurostimulation devices for drug resistant epilepsy

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Neurostimulation devices for epilepsy commonly induce EEG and/or ECG artifacts.

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Neurostimulation-related artifacts are intermittent and could mimic ictal EEG changes or cardiac rhythm abnormalities.

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Clinicians should be aware of different EEG and ECG artifact patterns to accurately interpret test findings and avoid unnecessary diagnostics and treatment.

Background

Methods

Results

Conclusions

Feasibility of MRI in patients with non-Pacemaker/Defibrillator metallic devices and abandoned leads

Objective

To evaluate feasibility of MRI in patients with non-pacemaker (PM)/ Implantable cardioverter defibrillator (ICD) metallic devices and abandoned leads.

Background

Relative safety of MRI performed using specified protocol has been established in MR non-conditional PM/ICDs. With limited safety data, many non-PM/ICD metallic devices and abandoned leads continue to be a contraindication for MRI.

Methods

We retrospectively analyzed consecutive patients with extra-cardiac devices, non-programmable cardiac devices, and abandoned leads, who underwent MRI (GE 1.5 Tesla, WI) at a single tertiary care center over a span of 13 years. Scan protocol was designed to maintain specific absorption rate (SAR) < 4.0 W/kg and scan time < 60 minutes.

Results

The cohort comprised 127 MRI exams representing 94 patients, with 13 patients having two or more scans. The devices consisted of: 23 vagal nerve stimulators (VNS), 22 implantable loop recorders, 16 spinal stimulators, 5 peripheral nerve stimulators, 3 bladder stimulators, 2 deep brain stimulators, 1 gastric stimulator, 1 bone stimulator, 1 WATCHMAN device, 22 abandoned PM/lCD leads and 1 VNS lead. There was no immediate (peri-MRI exam) morbidity or mortality. Patients did not report any discomfort, palpitations, heating, or sensation of device migration during the exam. Local follow-up data was available in 65% (100% for thoracic imaging) with a mean of 190±475 days (median 13 days). No device malfunction reported during follow-up.

Conclusions

With appropriate precautions, MRI is feasible in patients with extracardiac devices, nonprogrammable cardiac devices, and abandoned leads.

Electrocardiographic interference: know your patient well

Two cases of paediatric patients with gastric pacemakers causing distinct electrocardiographic artefact. Recognition of extracardiac artefact is essential for proper ECG interpretation in patients.

Neurostimulator-induced ECG artefacts: A systematic analysis

OBJECTIVES

Deep brain stimulation (DBS) is known to interfere with electrocardiographic (ECG) examinations. In emergency situations, such electrical interferences can not only thwart ECG diagnostics, but even induce an ECG pattern that causes the emergency medical service to initiate inadequate or even harmful therapy. Aim of this prospective study was to evaluate factors influencing ECG interpretation in DBS and to evaluate the susceptibility of ECG criteria 'frequency', 'rhythm', 'regularity', 'QRS-configuration', and 'ST-segment' on neurostimulation.

PATIENTS AND METHODS

In 33 DBS patients (17 male, 16 female, mean age 64 years), limb-, 12 channel-, Nehb, and adhesive paddle-lead ECG were performed in activated (n = 33) and deactivated (n = 31) stimulation mode during outpatient follow-up examinations. The examinations were carried out using three different ECG devices (two portable emergency ECG-monitor/defibrillation/pacer-devices, one stationary hospital device), resulting in 4096 ECG leads. Statistics have been based on regression analyses and on a maximum likelihood estimation regression model.

RESULTS

Monopolar settings were found to be a relevant factor interfering significantly more often with ECG recording than bipolar parameters (p < 0.0001). Due to recurring movement artefacts, deactivation of bipolar stimulation might even significantly worsen ECG quality (p < 0.0001). Interpretability of 'rhythm' (β = -0.088, p = 0.03) and 'frequency' (β = -0.110, p = 0.02) revealed significant negative correlation to the applied neurostimulation voltage. Nehb lead yielded in highest ECG interpretability.

CONCLUSION

Bipolar neurostimulation mode barely affected the ECGs; furthermore, the suppression of motion artefacts by neurostimulation can improve ECG quality. If monopolar neurostimulation is required, at least, stimulation voltage should be as low as possible to obtain good stimulation results.

Prodromal Markers of Parkinson's Disease in Patients With Essential Tremor

Background: Essential tremor (ET) is manifested as an isolated syndrome of bilateral upper limb action tremor. Parkinson's disease (PD) is the second most common neurodegenerative disease, with typical motor symptoms of bradykinesia, rigidity, and resting tremor. ET-PD describes the new-onset of PD in ET patients. Recently, numerous studies on epidemiology, genetics, pathology, clinical features, and neuroimaging studies are challenging the idea that ET is an isolated disease, suggesting that patients with ET have the tendency to develop PD. Methods: In this review article, we collected recent findings that reveal prodromal markers of PD in patients with ET. Results: Substantia nigra hyperechogenicity serves as a prodromal marker for predicting the development of PD in patients with ET and provides a reference for therapeutic strategies. Additional potential markers include other neuroimaging, clinical features, heart rate, and genetics, whereas others lack sufficient evidence. Conclusion: In consideration of the limited research of PD in patients with ET, we are still far from revealing the prodromal markers. However, from the existing follow-up studies on ET patients, Substantia nigra hyperechogenicity may enable further exploration of the relationship between ET and PD and the search for pathogenesis-based therapies.

Chest radiographs of cardiac devices (Part 1): Lines, tubes, non-cardiac medical devices and materials

Chest radiographs (CXRs) are the most common imaging investigations undertaken because of their value in evaluating the cardiorespiratory system. They play a vital role in intensive care units for evaluating the critically ill. It is therefore very common for the radiologist to encounter tubes, lines, medical devices and materials on a daily basis. It is important for the interpreting radiologist not only to identify these iatrogenic objects, but also to look for their accurate placement as well as for any complications related to their placement, which may be seen either on the immediate post-procedural CXR or on a follow-up CXR. In this article, we discussed and illustrated the routinely encountered tubes and lines that one may see on a CXR as well as some of their complications. In addition, we also provide a brief overview of other important non-cardiac medical devices and materials that may be seen on CXRs.

What uro-gynecologists should know about sacral neuromodulation (SNM) for the treatment of refractory overactive bladder

PURPOSE

To inform uro-gynecologists about the current standards and latest developments of sacral neuromodulation (SNM) in women with overactive bladder (OAB).

METHODS

Literature search in the PubMed database for articles published between 1988 and 2019 on SNM for OAB in women.

RESULTS

In total, 361 articles were identified and 51 articles retrieved for the review. SNM shows an objective success rate of 70-80%, OAB cure rate of 17-47% and a subjective satisfaction rate of 80-90%. These benefits have to be weighed against an adverse event rate of approx. 40%. SNM is significantly more successful than switching to another antimuscarinic after failed antimuscarinic drug therapy. Efficacy of SNM is slightly lower compared to bladder wall injections with 200 U botulinum toxin in the first months but efficacy of both treatments appears to be similar after 24 months. MRI examinations of patients with a sacral neurostimulator should only be performed after radiologist consultation. Sacral neurostimulators in patients with another pacemaker system should only be implanted after interdisciplinary consultation. The sacral neuromodulator should be turned off during pregnancy and delivery. SNM for OAB in patients with concomitant female sexual dysfunction or fecal incontinence seems to be beneficial.

CONCLUSIONS

SNM is a successful and recommended second-line treatment of OAB. Sacral neurostimulators should preferably be implanted in SNM-centers because complications and the frequency of revisions are significantly reduced with increasing experience of the surgeon.