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Karazapryanov PA, Gabrovski KR, Milenova Y, Pavlov VK, Karameshev A, Damianova M, Sirakov S, Minkin K. Mapping of Capsular Side Effects by using Intraoperative Motor-Evoked Potentials during Asleep Deep Brain Stimulation Surgery of the Subthalamic Nucleus for Parkinson's Disease. Stereotact Funct Neurosurg 2024:1-9. [PMID: 38934180 DOI: 10.1159/000539433] [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: 01/29/2024] [Accepted: 05/16/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION The aim of this study was to present a novel technique for subthalamic nucleus (STN) deep brain stimulation (DBS) implantation under general anesthesia by using intraoperative motor-evoked potentials (MEPs) through direct lead stimulation and determining their correlation to the thresholds of postoperative stimulation-induced side effects. METHODS This study included 22 consecutive patients with advanced Parkinson's disease who underwent surgery in our institution between January 2021 and September 2023. All patients underwent bilateral implantation in the STN (44 leads) under general anesthesia without microelectrode recordings (MERs) by using MEPs with electrostimulation directly through the DBS lead. No cortical stimulation was performed during this process. Intraoperative fluoroscopic guidance and immediate postoperative computed tomography were used to verify the electrode's position. The lowest MEP thresholds were recorded and were correlated to the postoperative stimulation-induced side-effect threshold. The predictive values of the MEPs were analyzed. Five DBS leads were repositioned intraoperatively due to the MEP results. RESULTS A moderately strong positive correlation was found between the MEP threshold and the capsular side-effect threshold (RS = 0.425, 95% CI, 0.17-0.67, p = 0.004). The highest sensitivity and specificity for predicting a side-effect threshold of 5 mA were found to be at 2.4 mA MEP threshold (sensitivity 97%, specificity 87.5%, positive predictive value 97%, and negative predictive value 87.5%). We also found high sensitivity and specificity (100%) at 1.15 mA MEP threshold and 3 mA side-effect threshold. Out of the total 44 leads, 5 (11.3%) leads were repositioned intraoperatively due to MEP thresholds lower than 1 mA (4 leads) or higher than 5 mA (1 lead). The mean accuracy on postoperative CT was 1.05 mm, and there were no postoperative side-effects under 2.8 mA. CONCLUSION Intraoperative MEPs with electrostimulation directly through the contacts of the DBS lead correlate with the stimulation-induced capsular side effects. The lead reposition based on intraoperative MEP may enlarge the therapeutic window of DBS stimulation.
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Affiliation(s)
| | | | - Yoana Milenova
- Department of Neurosurgery, University Hospital St. Ivan Rilski, Sofia, Bulgaria
| | | | | | - Maria Damianova
- Department of Neurosurgery, University Hospital St. Ivan Rilski, Sofia, Bulgaria
| | - Stanimir Sirakov
- Department of Interventional Radiology, University Hospital St. Ivan Rilski, Sofia, Bulgaria
| | - Krasimir Minkin
- Department of Neurosurgery, University Hospital St. Ivan Rilski, Sofia, Bulgaria
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Borgheai SB, Opri E, Isbaine F, Cole E, Deligani RJ, Laxpati N, Risk BB, Willie JT, Gross RE, Yong NA, McIntyre CC, Miocinovic S. Neural pathway activation in the subthalamic region depends on stimulation polarity. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.05.01.24306044. [PMID: 38746250 PMCID: PMC11092741 DOI: 10.1101/2024.05.01.24306044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Deep brain stimulation (DBS) is an effective treatment for Parkinson's disease (PD); however, there is limited understanding of which subthalamic pathways are recruited in response to stimulation. Here, by focusing on the polarity of the stimulus waveform (cathodic vs. anodic), our goal was to elucidate biophysical mechanisms that underlie electrical stimulation in the human brain. In clinical studies, cathodic stimulation more easily triggers behavioral responses, but anodic DBS broadens the therapeutic window. This suggests that neural pathways involved respond preferentially depending on stimulus polarity. To experimentally compare the activation of therapeutically relevant pathways during cathodic and anodic subthalamic nucleus (STN) DBS, pathway activation was quantified by measuring evoked potentials resulting from antidromic or orthodromic activation in 15 PD patients undergoing DBS implantation. Cortical evoked potentials (cEP) were recorded using subdural electrocorticography, DBS local evoked potentials (DLEP) were recorded from non-stimulating contacts and EMG activity was recorded from arm and face muscles. We measured: 1) the amplitude of short-latency cEP, previously demonstrated to reflect activation of the cortico-STN hyperdirect pathway, 2) DLEP amplitude thought to reflect activation of STN-globus pallidus (GP) pathway, and 3) amplitudes of very short-latency cEP and motor evoked potentials (mEP) for activation of cortico-spinal/bulbar tract (CSBT). We constructed recruitment and strength-duration curves for each EP/pathway to compare the excitability for different stimulation polarities. We compared experimental data with the most advanced DBS computational models. Our results provide experimental evidence that subcortical cathodic and anodic stimulation activate the same pathways in the STN region and that cathodic stimulation is in general more efficient. However, relative efficiency varies for different pathways so that anodic stimulation is the least efficient in activating CSBT, more efficient in activating the HDP and as efficient as cathodic in activating STN-GP pathway. Our experiments confirm biophysical model predictions regarding neural activations in the central nervous system and provide evidence that stimulus polarity has differential effects on passing axons, terminal synapses, and local neurons. Comparison of experimental results with clinical DBS studies provides further evidence that the hyperdirect pathway may be involved in the therapeutic mechanisms of DBS.
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Bower KL, Noecker AM, Frankemolle-Gilbert AM, McIntyre CC. Model-Based Analysis of Pathway Recruitment During Subthalamic Deep Brain Stimulation. Neuromodulation 2024; 27:455-463. [PMID: 37097269 PMCID: PMC10598236 DOI: 10.1016/j.neurom.2023.02.084] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/06/2023] [Accepted: 02/27/2023] [Indexed: 04/26/2023]
Abstract
BACKGROUND Subthalamic deep brain stimulation (DBS) is an established clinical therapy, but an anatomically clear definition of the underlying neural target(s) of the stimulation remains elusive. Patient-specific models of DBS are commonly used tools in the search for stimulation targets, and recent iterations of those models are focused on characterizing the brain connections that are activated by DBS. OBJECTIVE The goal of this study was to quantify axonal pathway activation in the subthalamic region from DBS at different electrode locations and stimulation settings. MATERIALS AND METHODS We used an anatomically and electrically detailed computational model of subthalamic DBS to generate recruitment curves for eight different axonal pathways of interest, at three generalized DBS electrode locations in the subthalamic nucleus (STN) (ie, central STN, dorsal STN, posterior STN). These simulations were performed with three levels of DBS electrode localization uncertainty (ie, 0.5 mm, 1.0 mm, 1.5 mm). RESULTS The recruitment curves highlight the diversity of pathways that are theoretically activated with subthalamic DBS, in addition to the dependence of the stimulation location and parameter settings on the pathway activation estimates. The three generalized DBS locations exhibited distinct pathway recruitment curve profiles, suggesting that each stimulation location would have a different effect on network activity patterns. We also found that the use of anodic stimuli could help limit activation of the internal capsule relative to other pathways. However, incorporating realistic levels of DBS electrode localization uncertainty in the models substantially limits their predictive capabilities. CONCLUSIONS Subtle differences in stimulation location and/or parameter settings can impact the collection of pathways that are activated during subthalamic DBS.
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Affiliation(s)
- Kelsey L Bower
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Angela M Noecker
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | | | - Cameron C McIntyre
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA; Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Neurosurgery, Duke University, Durham, NC, USA.
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Hu Y, Feng Z, Zheng L, Ye X. Interactions between cathodic- and anodic-pulses during high-frequency stimulations with the monophasic-pulses alternating in polarity at axons-experiment and simulation studies. J Neural Eng 2023; 20:056021. [PMID: 37703869 DOI: 10.1088/1741-2552/acf959] [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: 04/30/2023] [Accepted: 09/13/2023] [Indexed: 09/15/2023]
Abstract
Background. Electrical neuromodulation therapies commonly utilize high-frequency stimulations (HFS) of biphasic-pulses to treat neurological disorders. The biphasic pulse consists of a leading cathodic-phase to activate neurons and a lagging anodic-phase to balance electrical charges. Because both monophasic cathodic- and anodic-pulses can depolarize neuronal membranes, splitting biphasic-pulses into alternate cathodic- and anodic-pulses could be a feasible strategy to improve stimulation efficiency.Objective. We speculated that neurons in the volume initially activated by both polarity pulses could change to be activated only by anodic-pulses during sustained HFS of alternate monophasic-pulses. To verify the hypothesis, we investigated the interactions of the monophasic pulses during HFS and revealed possible underlying mechanisms.Approach. Different types of pulse stimulations were applied at the alvear fibers (i.e. the axons of CA1 pyramidal neurons) to antidromically activate the neuronal cell bodies in the hippocampal CA1 region of anesthetized ratsin-vivo. Sequences of antidromic HFS (A-HFS) were applied with alternate monophasic-pulses or biphasic-pulses. The pulse frequency in the A-HFS sequences was 50 or 100 Hz. The A-HFS duration was 120 s. The amplitude of antidromically-evoked population spike was measured to evaluate the neuronal firing induced by each pulse. A computational model of axon was used to explore the possible mechanisms of neuronal modulations. The changes of model variables during sustained A-HFS were analyzed.Main results. In rat experiments, with a same pulse intensity, the activation volume of a cathodic-pulse was greater than that of an anodic-pulse. In paired-pulse tests, a preceding cathodic-pulse was able to prevent a following anodic-pulse from activating neurons due to refractory period. This indicated that the activation volume of a cathodic-pulse covered that of an anodic-pulse. However, during sustained A-HFS of alternate monophasic-pulses, the anodic-pulses were able to prevail over the cathodic-pulses in activating neurons in the overlapped activation volume. Model simulation results show the mechanisms of the activation failures of cathodic-pulses. They include the excessive membrane depolarization caused by an accumulation of potassium ions, the obstacle of hyperpolarization in the conduction pathway and the interactions from anodic-pulses.Significance. The study firstly showed the domination of anodic-pulses over cathodic-pulses in their competitions to activate neurons during sustained HFS. The finding provides new clues for designing HFS paradigms to improve the efficiency of neuromodulation therapies.
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Affiliation(s)
- Yifan Hu
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Zhouyan Feng
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Lvpiao Zheng
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
| | - Xiangyu Ye
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, Zhejiang, People's Republic of China
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Campbell BA, Favi Bocca L, Tiefenbach J, Hogue O, Nagel SJ, Rammo R, Escobar Sanabria D, Machado AG, Baker KB. Myogenic and cortical evoked potentials vary as a function of stimulus pulse geometry delivered in the subthalamic nucleus of Parkinson's disease patients. Front Neurol 2023; 14:1216916. [PMID: 37693765 PMCID: PMC10484227 DOI: 10.3389/fneur.2023.1216916] [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: 05/04/2023] [Accepted: 08/10/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction The therapeutic efficacy of deep brain stimulation (DBS) of the subthalamic nucleus (STN) for Parkinson's disease (PD) may be limited for some patients by the presence of stimulation-related side effects. Such effects are most often attributed to electrical current spread beyond the target region. Prior computational modeling studies have suggested that changing the degree of asymmetry of the individual phases of the biphasic, stimulus pulse may allow for more selective activation of neural elements in the target region. To the extent that different neural elements contribute to the therapeutic vs. side-effect inducing effects of DBS, such improved selectivity may provide a new parameter for optimizing DBS to increase the therapeutic window. Methods We investigated the effect of six different pulse geometries on cortical and myogenic evoked potentials in eight patients with PD whose leads were temporarily externalized following STN DBS implant surgery. DBS-cortical evoked potentials were quantified using peak to peak measurements and wavelets and myogenic potentials were quantified using RMS. Results We found that the slope of the recruitment curves differed significantly as a function of pulse geometry for both the cortical- and myogenic responses. Notably, this effect was observed most frequently when stimulation was delivered using a monopolar, as opposed to a bipolar, configuration. Discussion Manipulating pulse geometry results in differential physiological effects at both the cortical and neuromuscular level. Exploiting these differences may help to expand DBS' therapeutic window and support the potential for incorporating pulse geometry as an additional parameter for optimizing therapeutic benefit.
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Affiliation(s)
- Brett A. Campbell
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, United States
- Department of Neurosciences, Cleveland Clinic, Cleveland, OH, United States
| | - Leonardo Favi Bocca
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
| | - Jakov Tiefenbach
- Department of Neurosciences, Cleveland Clinic, Cleveland, OH, United States
| | - Olivia Hogue
- Center for Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States
| | - Sean J. Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, United States
| | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, United States
| | - David Escobar Sanabria
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
- Department of Biomedical Engineering, Cleveland Clinic, Cleveland, OH, United States
| | - Andre G. Machado
- Department of Neurosciences, Cleveland Clinic, Cleveland, OH, United States
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, United States
| | - Kenneth B. Baker
- Department of Neurosciences, Cleveland Clinic, Cleveland, OH, United States
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, OH, United States
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Gilbert Z, Mason X, Sebastian R, Tang AM, Martin Del Campo-Vera R, Chen KH, Leonor A, Shao A, Tabarsi E, Chung R, Sundaram S, Kammen A, Cavaleri J, Gogia AS, Heck C, Nune G, Liu CY, Kellis SS, Lee B. A review of neurophysiological effects and efficiency of waveform parameters in deep brain stimulation. Clin Neurophysiol 2023; 152:93-111. [PMID: 37208270 DOI: 10.1016/j.clinph.2023.04.007] [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: 09/20/2022] [Revised: 02/09/2023] [Accepted: 04/15/2023] [Indexed: 05/21/2023]
Abstract
Neurostimulation has diverse clinical applications and potential as a treatment for medically refractory movement disorders, epilepsy, and other neurological disorders. However, the parameters used to program electrodes-polarity, pulse width, amplitude, and frequency-and how they are adjusted have remained largely untouched since the 1970 s. This review summarizes the state-of-the-art in Deep Brain Stimulation (DBS) and highlights the need for further research to uncover the physiological mechanisms of neurostimulation. We focus on studies that reveal the potential for clinicians to use waveform parameters to selectively stimulate neural tissue for therapeutic benefit, while avoiding activating tissue associated with adverse effects. DBS uses cathodic monophasic rectangular pulses with passive recharging in clinical practice to treat neurological conditions such as Parkinson's Disease. However, research has shown that stimulation efficiency can be improved, and side effects reduced, through modulating parameters and adding novel waveform properties. These developments can prolong implantable pulse generator lifespan, reducing costs and surgery-associated risks. Waveform parameters can stimulate neurons based on axon orientation and intrinsic structural properties, providing clinicians with more precise targeting of neural pathways. These findings could expand the spectrum of diseases treatable with neuromodulation and improve patient outcomes.
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Affiliation(s)
- Zachary Gilbert
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States.
| | - Xenos Mason
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Rinu Sebastian
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Austin M Tang
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Roberto Martin Del Campo-Vera
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Kuang-Hsuan Chen
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Andrea Leonor
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Arthur Shao
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Emiliano Tabarsi
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Ryan Chung
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Shivani Sundaram
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Alexandra Kammen
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Jonathan Cavaleri
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Angad S Gogia
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Christi Heck
- Department of Neurology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - George Nune
- Department of Neurology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Charles Y Liu
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; Department of Neurology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Spencer S Kellis
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Brian Lee
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
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Munhoz RP, Albuainain G. Deep brain stimulation - New programming algorithms and teleprogramming. Expert Rev Neurother 2023; 23:467-478. [PMID: 37115193 DOI: 10.1080/14737175.2023.2208749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
INTRODUCTION Thanks to a variety of factors, the field of neuromodulation has evolved significantly over the past decade. Developments include new indications and innovations of hardware, software, and stimulation techniques leading to an expansion in scope and role of these techniques as powerful therapies. They also imply the realization that practical application involves new nuances that make patient selection, surgical technique and the programming process even more complex, requiring continuous education and an organized structured approach. AREAS COVERED In this review, the authors explore the developments in deep brain stimulation technology, including electrodes, implantable pulse generators, contact configurations (i.e, directional leads and independent current control), remote programming and sensing using local field potentials. EXPERT OPINION The innovations in the field of deep brain stimulation discussed in this review potentially provide increased effectiveness and flexibility not only to improve therapeutic response but also to address troubleshooting challenges seen in clinical practice. Directional leads and shorter pulse widths may broaden the therapeutic window of stimulation, avoiding current spread to structures that might trigger stimulation-related side effects. Similarly, independent control of current to individual contacts allows for the shaping of the electric field. Finally, sensing and remote programming represent important developments for more effective and individualized patient care.
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Affiliation(s)
- Renato Puppi Munhoz
- Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Krembil Research Institute, Toronto, ON, M5T 2S8, Canada
| | - Ghadh Albuainain
- Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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Sarikhani P, Ferleger B, Mitchell K, Ostrem J, Herron J, Mahmoudi B, Miocinovic S. Automated deep brain stimulation programming with safety constraints for tremor suppression in patients with Parkinson's Disease and essential tremor. J Neural Eng 2022; 19. [PMID: 35921806 DOI: 10.1088/1741-2552/ac86a2] [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: 04/14/2022] [Accepted: 08/03/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVES Deep brain stimulation programming for movement disorders requires systematic fine tuning of stimulation parameters to ameliorate tremor and other symptoms while avoiding side effects. DBS programming can be a time-consuming process and requires clinical expertise to assess response to DBS to optimize therapy for each patient. In this study, we describe and evaluate an automated, closed-loop, and patient-specific framework for DBS programming that measures tremor using a smartwatch and automatically changes DBS parameters based on the recommendations from a closed-loop optimization algorithm thus eliminating the need for an expert clinician. APPROACH Bayesian optimization which is a sample-efficient global optimization method was used as the core of this DBS programming framework to adaptively learn each patient's response to DBS and suggest the next best settings to be evaluated. Input from a clinician was used initially to define a maximum safe amplitude, but we also implemented 'safe Bayesian optimization' to automatically discover tolerable exploration boundaries. RESULTS We tested the system in 15 patients (9 with Parkinson's disease and 6 with essential tremor). Tremor suppression at best automated settings was statistically comparable to previously established clinical settings. The optimization algorithm converged after testing 15.1±0.7 settings when maximum safe exploration boundaries were predefined, and 17.7±4.9 when the algorithm itself determined safe exploration boundaries. SIGNIFICANCE We demonstrate that fully automated DBS programming framework for treatment of tremor is efficient and safe while providing outcomes comparable to that achieved by expert clinicians.
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Affiliation(s)
- Parisa Sarikhani
- Emory University, 101 Woodruff Cir, Suite 4137, Atlanta, Georgia, 30322-1007, UNITED STATES
| | - Benjamin Ferleger
- University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, Pennsylvania, 19104-6243, UNITED STATES
| | - Kyle Mitchell
- Neurology, Duke University, 932 Morreene Rd, Durham, North Carolina, 2770, UNITED STATES
| | - Jill Ostrem
- Neurology, University of California, San Francisco, 1651 Fourth St., Suite 232, San Francisco, California, 94158, UNITED STATES
| | - Jeffrey Herron
- Electrical Engineering, University of Washington, 185 Stevens Way, Room AE100R, Campus Box 352500, Seattle, Washington, 98195, UNITED STATES
| | - Babak Mahmoudi
- Biomedical Informatics, Emory University, 101 Woodruff Cir, Atlanta, Georgia, 30322, UNITED STATES
| | - Svjetlana Miocinovic
- Neurology, Emory University, 12 Executive Park Drive Northeast, Atlanta, Georgia, 30329, UNITED STATES
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Bhaskara S, Sakorikar T, Chatterjee S, Shabari Girishan K, Pandya HJ. Recent advancements in Micro-engineered devices for surface and deep brain animal studies: A review. SENSING AND BIO-SENSING RESEARCH 2022. [DOI: 10.1016/j.sbsr.2022.100483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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10
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Sarica C, Iorio-Morin C, Aguirre-Padilla DH, Najjar A, Paff M, Fomenko A, Yamamoto K, Zemmar A, Lipsman N, Ibrahim GM, Hamani C, Hodaie M, Lozano AM, Munhoz RP, Fasano A, Kalia SK. Implantable Pulse Generators for Deep Brain Stimulation: Challenges, Complications, and Strategies for Practicality and Longevity. Front Hum Neurosci 2021; 15:708481. [PMID: 34512295 PMCID: PMC8427803 DOI: 10.3389/fnhum.2021.708481] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/30/2021] [Indexed: 11/29/2022] Open
Abstract
Deep brain stimulation (DBS) represents an important treatment modality for movement disorders and other circuitopathies. Despite their miniaturization and increasing sophistication, DBS systems share a common set of components of which the implantable pulse generator (IPG) is the core power supply and programmable element. Here we provide an overview of key hardware and software specifications of commercially available IPG systems such as rechargeability, MRI compatibility, electrode configuration, pulse delivery, IPG case architecture, and local field potential sensing. We present evidence-based approaches to mitigate hardware complications, of which infection represents the most important factor. Strategies correlating positively with decreased complications include antibiotic impregnation and co-administration and other surgical considerations during IPG implantation such as the use of tack-up sutures and smaller profile devices.Strategies aimed at maximizing battery longevity include patient-related elements such as reliability of IPG recharging or consistency of nightly device shutoff, and device-specific such as parameter delivery, choice of lead configuration, implantation location, and careful selection of electrode materials to minimize impedance mismatch. Finally, experimental DBS systems such as ultrasound, magnetoelectric nanoparticles, and near-infrared that use extracorporeal powered neuromodulation strategies are described as potential future directions for minimally invasive treatment.
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Affiliation(s)
- Can Sarica
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Christian Iorio-Morin
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of Neurosurgery, Department of Surgery, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - David H Aguirre-Padilla
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Neurology & Neurosurgery, Center Campus, Universidad de Chile, Santiago, Chile
| | - Ahmed Najjar
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Surgery, College of Medicine, Taibah University, Almadinah Almunawwarah, Saudi Arabia
| | - Michelle Paff
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Neurosurgery, University of California, Irvine, Irvine, CA, United States
| | - Anton Fomenko
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kazuaki Yamamoto
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Ajmal Zemmar
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Neurosurgery, Henan University School of Medicine, Zhengzhou, China.,Department of Neurosurgery, University of Louisville School of Medicine, Louisville, KY, United States
| | - Nir Lipsman
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - George M Ibrahim
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Clement Hamani
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Harquail Centre for Neuromodulation, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mojgan Hodaie
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Krembil Research Institute, University Health Network, Toronto, ON, Canada.,CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Krembil Research Institute, University Health Network, Toronto, ON, Canada.,CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada
| | - Renato P Munhoz
- Krembil Research Institute, University Health Network, Toronto, ON, Canada.,Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, and Division of Neurology, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Alfonso Fasano
- Krembil Research Institute, University Health Network, Toronto, ON, Canada.,CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada.,Edmond J. Safra Program in Parkinson's Disease Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, and Division of Neurology, Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Suneil K Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Krembil Research Institute, University Health Network, Toronto, ON, Canada.,CRANIA Center for Advancing Neurotechnological Innovation to Application, University of Toronto, ON, Canada.,KITE, University Health Network, Toronto, ON, Canada
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11
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Juárez-Paz LM. In silico Accuracy and Energy Efficiency of Two Steering Paradigms in Directional Deep Brain Stimulation. Front Neurol 2020; 11:593798. [PMID: 33193061 PMCID: PMC7661934 DOI: 10.3389/fneur.2020.593798] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/30/2020] [Indexed: 01/11/2023] Open
Abstract
Background: In Deep Brain Stimulation (DBS), stimulation field steering is used to achieve stimulation spatial specificity, which is critical to obtain clinical benefits and avoid side effects. Multiple Independent Current Control (MICC) and Interleaving/Multi Stim Set (Interleaving/MSS) are two stimulation field steering paradigms in commercially available DBS systems. This work investigates the stimulation field steering accuracy and energy efficiency of these two paradigms in directional DBS. Methods: Volumes of Tissue Activated (VTAs) were generated in silico using pulse widths of 60 μs and five pulse amplitude fractionalizations intended to steer the VTAs radially in 12° steps. For each fractionalization, VTAs were generated with nine pre-defined target radii. Stimulation field steering accuracy was assessed based on the VTAs rotation angle. Energy efficiency was inferred from current draw from battery values, which were calculated based on the pulse amplitudes needed to generate and steer the VTAs, as well as electrode impedance measurements of clinically implanted directional leads. Results: For radial steering, MICC needed a single VTA. In contrast, Interleaving/MSS required the generation of two VTAs, whose union and intersection created an Interleaving/MSS VTA and an Intersection VTA, respectively. MICC VTAs were 6.8 (−3.2–11.8)% larger than Interleaving/MSS VTAs. The Intersection VTAs accounted for 26.2 (16.0–32.8)% of Interleaving/MSS VTAs and were exposed to a higher stimulation frequency. For all VTA radius-fractionalization combinations, steering accuracy was 7.0 (4.5–10.5)° for MICC and 24.0 (9.0–25.3)° for Interleaving/MSS. Pulse amplitudes were 16.1 (9.2–28.6)% lower for MICC than for Interleaving/MSS, leading to a 45.9 (18.8–72.6)% lower current draw from battery for MICC. Conclusions: The results of this work show that in silico, MICC achieves a significantly better stimulation field steering accuracy and has a significantly higher energy efficiency than Interleaving/MSS. Although direct evidence still needs to be generated to translate the results of this work to clinical practice, clinical outcomes may profit from the better stimulation field steering accuracy of MICC and longevity of DBS systems may profit from its higher energy efficiency.
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Affiliation(s)
- León Mauricio Juárez-Paz
- Neuromodulation Research and Advanced Concepts, Boston Scientific Corporation, Valencia, CA, United States
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12
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Kramme J, Dembek TA, Treuer H, Dafsari HS, Barbe MT, Wirths J, Visser-Vandewalle V. Potentials and Limitations of Directional Deep Brain Stimulation: A Simulation Approach. Stereotact Funct Neurosurg 2020; 99:65-74. [PMID: 33080600 DOI: 10.1159/000509781] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 06/22/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Directional leads are increasingly used in deep brain stimulation. They allow shaping the electrical field in the axial plane. These new possibilities increase the complexity of programming. Thus, optimized programming approaches are needed to assist clinical testing and to obtain full clinical benefit. OBJECTIVES This simulation study investigates to what extent the electrical field can be shaped by directional steering to compensate for lead malposition. METHOD Binary volumes of tissue activated (VTA) were simulated, by using a finite element method approach, for different amplitude distributions on the three directional electrodes. VTAs were shifted from 0 to 2 mm at different shift angles with respect to the lead orientation, to determine the best compensation of a target volume. RESULTS Malpositions of 1 mm can be compensated with the highest gain of overlap with directional leads. For larger shifts, an improvement of overlap of 10-30% is possible, depending on the stimulation amplitude and shift angle of the lead. Lead orientation and shift determine the amplitude distribution of the electrodes. CONCLUSION To get full benefit from directional leads, both the shift angle as well as the shift to target volume are required to choose the correct amplitude distribution on the electrodes. Current directional leads have limitations when compensating malpositions >1 mm; however, they still outperform conventional leads in reducing overstimulation. Further, their main advantage probably lies in the reduction of side effects. Databases like the one from this simulation could serve for optimized lead programming algorithms in the future.
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Affiliation(s)
- Johanna Kramme
- Department of Stereotactic and Functional Neurosurgery, University of Cologne Faculty of Medicine and University Hospital Cologne, Cologne, Germany,
| | - Till A Dembek
- Department of Neurology, University of Cologne Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Harald Treuer
- Department of Stereotactic and Functional Neurosurgery, University of Cologne Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Haidar S Dafsari
- Department of Neurology, University of Cologne Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Michael T Barbe
- Department of Neurology, University of Cologne Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Jochen Wirths
- Department of Stereotactic and Functional Neurosurgery, University of Cologne Faculty of Medicine and University Hospital Cologne, Cologne, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, University of Cologne Faculty of Medicine and University Hospital Cologne, Cologne, Germany
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13
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Paff M, Loh A, Sarica C, Lozano AM, Fasano A. Update on Current Technologies for Deep Brain Stimulation in Parkinson's Disease. J Mov Disord 2020; 13:185-198. [PMID: 32854482 PMCID: PMC7502302 DOI: 10.14802/jmd.20052] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 06/22/2020] [Accepted: 07/05/2020] [Indexed: 01/19/2023] Open
Abstract
Deep brain stimulation (DBS) is becoming increasingly central in the treatment of patients with Parkinson's disease and other movement disorders. Recent developments in DBS lead and implantable pulse generator design provide increased flexibility for programming, potentially improving the therapeutic benefit of stimulation. Directional DBS leads may increase the therapeutic window of stimulation by providing a means of avoiding current spread to structures that might give rise to stimulation-related side effects. Similarly, control of current to individual contacts on a DBS lead allows for shaping of the electric field produced between multiple active contacts. The following review aims to describe the recent developments in DBS system technology and the features of each commercially available DBS system. The advantages of each system are reviewed, and general considerations for choosing the most appropriate system are discussed.
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Affiliation(s)
- Michelle Paff
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Canada
| | - Aaron Loh
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Canada
| | - Can Sarica
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Canada
| | - Andres M. Lozano
- Division of Neurosurgery, University Health Network, University of Toronto, Toronto, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson’s Disease, Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto, Toronto, Canada
- Krembil Brain Institute, Toronto, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Canada
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14
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Steffen JK, Reker P, Mennicken FK, Dembek TA, Dafsari HS, Fink GR, Visser‐Vandewalle V, Barbe MT. Bipolar Directional Deep Brain Stimulation in Essential and Parkinsonian Tremor. Neuromodulation 2020; 23:543-549. [DOI: 10.1111/ner.13109] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 11/30/2019] [Accepted: 01/08/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Julia K. Steffen
- Faculty of Medicine and University Hospital Cologne, Department of Neurology University of Cologne Cologne, Germany
| | - Paul Reker
- Faculty of Medicine and University Hospital Cologne, Department of Neurology University of Cologne Cologne, Germany
| | - Fiona K. Mennicken
- Faculty of Medicine and University Hospital Cologne, Department of Neurology University of Cologne Cologne, Germany
| | - Till A. Dembek
- Faculty of Medicine and University Hospital Cologne, Department of Neurology University of Cologne Cologne, Germany
| | - Haidar S. Dafsari
- Faculty of Medicine and University Hospital Cologne, Department of Neurology University of Cologne Cologne, Germany
| | - Gereon R. Fink
- Faculty of Medicine and University Hospital Cologne, Department of Neurology University of Cologne Cologne, Germany
- Cognitive Neuroscience Institute of Neuroscience and Medicine (INM‐3), Research Center Jülich Jülich, Germany
| | - Veerle Visser‐Vandewalle
- Faculty of Medicine and University Hospital Cologne, Department of Stereotactic and Functional Neurosurgery University of Cologne Cologne, Germany
| | - Michael T. Barbe
- Faculty of Medicine and University Hospital Cologne, Department of Neurology University of Cologne Cologne, Germany
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15
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Vorwerk J, Brock AA, Anderson DN, Rolston JD, Butson CR. A retrospective evaluation of automated optimization of deep brain stimulation parameters. J Neural Eng 2019; 16:064002. [PMID: 31344689 PMCID: PMC7759010 DOI: 10.1088/1741-2552/ab35b1] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE We performed a retrospective analysis of an optimization algorithm for the computation of patient-specific multipolar stimulation configurations employing multiple independent current/voltage sources. We evaluated whether the obtained stimulation configurations align with clinical data and whether the optimized stimulation configurations have the potential to lead to an equal or better stimulation of the target region as manual programming, while reducing the time required for programming sessions. APPROACH For three patients (five electrodes) diagnosed with essential tremor, we derived optimized multipolar stimulation configurations using an approach that is suitable for the application in clinical practice. To evaluate the automatically derived stimulation settings, we compared them to the results of the monopolar review. MAIN RESULTS We observe a good agreement between the findings of the monopolar review and the optimized stimulation configurations, with the algorithm assigning the maximal voltage in the optimized multipolar pattern to the contact that was found to lead to the best therapeutic effect in the clinical monopolar review in all cases. Additionally, our simulation results predict that the optimized stimulation settings lead to the activation of an equal or larger volume fraction of the target compared to the manually determined settings in all cases. SIGNIFICANCE Our results demonstrate the feasibility of an automatic determination of optimal DBS configurations and motivate a further evaluation of the applied optimization algorithm.
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Affiliation(s)
- Johannes Vorwerk
- Scientific Computing & Imaging (SCI) Institute, University of Utah, Salt Lake City, Utah, USA,Institute of Electrical and Biomedical Engineering, UMIT - Private University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
| | - Andrea A. Brock
- Scientific Computing & Imaging (SCI) Institute, University of Utah, Salt Lake City, Utah, USA,Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Daria N. Anderson
- Scientific Computing & Imaging (SCI) Institute, University of Utah, Salt Lake City, Utah, USA,Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - John D. Rolston
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA,Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - Christopher R. Butson
- Scientific Computing & Imaging (SCI) Institute, University of Utah, Salt Lake City, Utah, USA,Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA,Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA,Departments of Psychiatry and Neurology, University of Utah, Salt Lake City, Utah, USA,Correspondig Author.
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