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Patel R, Burroughs L, Higgins A, Zauber SE, Isbaine F, Schneider D, Hohman R, Gupta K. Bilateral Deep Brain Stimulation of the Ventral Intermediate Nucleus of the Thalamus Improves Objective Acoustic Measures of Essential Vocal Tremor. Neurosurgery 2024; 95:915-923. [PMID: 38787392 DOI: 10.1227/neu.0000000000002955] [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: 11/16/2023] [Accepted: 02/28/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Deep brain stimulation of the ventral intermediate nucleus of the thalamus (VIM-DBS) is an established treatment for medically refractory essential tremor. However, the effect of VIM-DBS on vocal tremor remains poorly understood, with results varying by method of vocal tremor assessment and stimulation laterality. This single-center study measures the effect of bilateral VIM-DBS on essential vocal tremor using blinded objective acoustic voice analysis. METHODS Ten patients with consecutive essential tremor with comorbid vocal tremor receiving bilateral VIM-DBS underwent voice testing before and after implantation of DBS in this prospective cohort study. Objective acoustic measures were extracted from the middle one second of steady-state phonation including cepstral peak prominence, signal-to-noise ratio, percentage voicing, tremor rate, extent of fundamental frequency modulation, and extent of intensity modulation. DBS surgery was performed awake with microelectrode recording and intraoperative testing. Postoperative voice testing was performed after stable programming. RESULTS Patients included 6 female and 4 male, with a mean age of 67 ± 6.7 years. The VIM was targeted with the following coordinates relative to the mid-anterior commissure:posterior commissure point: 13.2 ± 0.6 mm lateral, 6.2 ± 0.7 mm posterior, and 0.0 mm below. Mean programming parameters were amplitude 1.72.0 ± 0.6 mA, pulse width 63.0 ± 12.7 µs, and rate 130.6 ± 0.0 Hz. VIM-DBS significantly improved tremor rate from 4.43 ± 0.8 Hz to 3.2 ± 0.8 Hz ( P = .001) CI (0.546, 1.895), jitter from 1 ± 0.94 to 0.53 ± 0.219 ( P = .02) CI (-0.124, 1.038), cepstral peak prominence from 13.6 ± 3.9 to 18.8 ± 2.9 ( P = .016) CI (-4.100, -0.235), signal-to-noise ratio from 15.7 ± 3.9 to 18.5 ± 3.7 ( P = .02) CI (-5.598, -0.037), and articulation rate from 0.77 ± 0.2 to 0.82 ± .14 ( P = .04) CI (-0.097, 0.008). There were no major complications in this series. CONCLUSION Objective acoustic voice analyses suggest that bilateral VIM-DBS effectively reduces vocal tremor rate and improves voicing. Further studies using objective acoustic analyses and laryngeal imaging may help refine surgical and stimulation techniques and evaluate the effect of laterality on vocal tremor.
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Affiliation(s)
- Rita Patel
- Department of Otolaryngology Head & Neck Surgery, Indiana University School of Medicine, Indianapolis/Indiana University Bloomington, Bloomington , Indiana , USA
| | - Leah Burroughs
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - Alexis Higgins
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - S Elizabeth Zauber
- Department of Neurology, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - Faical Isbaine
- Department of Neurosurgery, Emory University, Atlanta , Georgia , USA
| | - Dylan Schneider
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
| | - Ryane Hohman
- Department of Speech, Language and Hearing Sciences, Indiana University Bloomington, Bloomington , Indiana , USA
| | - Kunal Gupta
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis , Indiana , USA
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee , Wisconsin , USA
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Khoury S, Randall DR. Treatment of Essential Vocal Tremor: A Scoping Review of Evidence-Based Therapeutic Modalities. J Voice 2024; 38:922-930. [PMID: 35022154 DOI: 10.1016/j.jvoice.2021.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/08/2021] [Accepted: 12/13/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVES/HYPOTHESIS Essential vocal tremor (EVT) is an uncommon but challenging condition to manage. Several medical and interventional treatment options have been reported but efficacy remains unclear. We performed a scoping review of high-quality clinical trials to identify effective evidence-based treatments for EVT. STUDY DESIGN Scoping review. METHODS Relevant studies were identified using the databases MedLine, Cochrane Central Register of Controlled Trials, and Embase. Subjective and objective outcomes for each modality were analyzed and the effect sizes were quantified using Hedges' g measure to allow comparison between studies. RESULTS We identified 421 studies eligible for screening with 11 included in the final analysis. Evidence supporting effective EVT treatments was found for bilateral versus unilateral deep brain stimulation (DBS) (Hedges' g 0.65, 95% CI = 0.10-1.20) and octanoic acid (Hedges' g 1.15, 95% CI = 0.40-1.90). Evidence to support the use of methazolamide was not sufficient (Hedges' g 0.51, 95% CI = -0.64 to 1.66). Botulinum toxin (BT) injections were equivalent when comparing unilateral versus bilateral (Hedges' g -0.18, 95% CI = -1.06 to 0.70); BT did not display any advantage over propranolol (Hedges' g -0.47, 95% CI = -1.73 to 0.78) or injection augmentation (Hedges' g 0.068, 95% CI = -0.98 to 1.12). CONCLUSIONS Our review finds very little high-quality evidence supporting any treatment for EVT. Octanoic acid reduced fluctuations in EVT but did not affect the perception of the tremor. In refractory cases, bilateral DBS was superior to unilateral DBS in improving subjective voice outcomes. Unilateral and bilateral BT injections were equivalent, and BT injection was not more effective than injection augmentation. Further direct comparison in well-designed prospective studies may help clarify optimal treatment for EVT patients.
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Affiliation(s)
- Sami Khoury
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Derrick R Randall
- Section of Otolaryngology - Head & Neck Surgery, Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Sajonz BEA, Brugger TS, Reisert M, Büchsel M, Schröter N, Rau A, Egger K, Reinacher PC, Urbach H, Coenen VA, Kaller CP. Cerebral Intraparenchymal Hemorrhage due to Implantation of Electrodes for Deep Brain Stimulation: Insights from a Large Single-Center Retrospective Cross-Sectional Analysis. Brain Sci 2024; 14:612. [PMID: 38928612 PMCID: PMC11201406 DOI: 10.3390/brainsci14060612] [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: 04/29/2024] [Revised: 06/12/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
Cerebral intraparenchymal hemorrhage due to electrode implantation (CIPHEI) is a rare but serious complication of deep brain stimulation (DBS) surgery. This study retrospectively investigated a large single-center cohort of DBS implantations to calculate the frequency of CIPHEI and identify patient- and procedure-related risk factors for CIPHEI and their potential interactions. We analyzed all DBS implantations between January 2013 and December 2021 in a generalized linear model for binomial responses using bias reduction to account for sparse sampling of CIPHEIs. As potential risk factors, we considered age, gender, history of arterial hypertension, level of invasivity, types of micro/macroelectrodes, and implanted DBS electrodes. If available, postoperative coagulation and platelet function were exploratorily assessed in CIPHEI patients. We identified 17 CIPHEI cases across 839 electrode implantations in 435 included procedures in 418 patients (3.9%). Exploration and cross-validation analyses revealed that the three-way interaction of older age (above 60 years), high invasivity (i.e., use of combined micro/macroelectrodes), and implantation of directional DBS electrodes accounted for 82.4% of the CIPHEI cases. Acquired platelet dysfunction was present only in one CIPHEI case. The findings at our center suggested implantation of directional DBS electrodes as a new potential risk factor, while known risks of older age and high invasivity were confirmed. However, CIPHEI risk is not driven by the three factors alone but by their combined presence. The contributions of the three factors to CIPHEI are hence not independent, suggesting that potentially modifiable procedural risks should be carefully evaluated when planning DBS surgery in patients at risk.
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Affiliation(s)
- Bastian E. A. Sajonz
- Department of Stereotactic and Functional Neurosurgery, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Timo S. Brugger
- Department of Stereotactic and Functional Neurosurgery, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Department of Neuroradiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Institute for Evidence in Medicine, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79110 Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, 79110 Freiburg, Germany
| | - Marco Reisert
- Department of Stereotactic and Functional Neurosurgery, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Medical Physics, Department of Radiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Martin Büchsel
- Institute of Clinical Chemistry and Laboratory Medicine, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Nils Schröter
- Department of Neurology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Alexander Rau
- Department of Neuroradiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Karl Egger
- Department of Neuroradiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Department of Radiology, Tauernklinikum, 5700 Zell am See, Austria
- Paracelsus Medical Private University (PMU), 5020 Salzburg, Austria
| | - Peter C. Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Fraunhofer Institute for Laser Technology (ILT), 52074 Aachen, Germany
| | - Horst Urbach
- Department of Neuroradiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Volker A. Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Center for Deep Brain Stimulation, University of Freiburg, 79106 Freiburg, Germany
| | - Christoph P. Kaller
- Department of Neuroradiology, Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
- Freiburg Optical NeuroImaging [FrONI], Medical Center — University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
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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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Neudorfer C, Kultas-Ilinsky K, Ilinsky I, Paschen S, Helmers AK, Cosgrove GR, Richardson RM, Horn A, Deuschl G. The role of the motor thalamus in deep brain stimulation for essential tremor. Neurotherapeutics 2024; 21:e00313. [PMID: 38195310 PMCID: PMC11103222 DOI: 10.1016/j.neurot.2023.e00313] [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] [Revised: 12/10/2023] [Accepted: 12/27/2023] [Indexed: 01/11/2024] Open
Abstract
The advent of next-generation technology has significantly advanced the implementation and delivery of Deep Brain Stimulation (DBS) for Essential Tremor (ET), yet controversies persist regarding optimal targets and networks responsible for tremor genesis and suppression. This review consolidates key insights from anatomy, neurology, electrophysiology, and radiology to summarize the current state-of-the-art in DBS for ET. We explore the role of the thalamus in motor function and describe how differences in parcellations and nomenclature have shaped our understanding of the neuroanatomical substrates associated with optimal outcomes. Subsequently, we discuss how seminal studies have propagated the ventral intermediate nucleus (Vim)-centric view of DBS effects and shaped the ongoing debate over thalamic DBS versus stimulation in the posterior subthalamic area (PSA) in ET. We then describe probabilistic- and network-mapping studies instrumental in identifying the local and network substrates subserving tremor control, which suggest that the PSA is the optimal DBS target for tremor suppression in ET. Taken together, DBS offers promising outcomes for ET, with the PSA emerging as a better target for suppression of tremor symptoms. While advanced imaging techniques have substantially improved the identification of anatomical targets within this region, uncertainties persist regarding the distinct anatomical substrates involved in optimal tremor control. Inconsistent subdivisions and nomenclature of motor areas and other subdivisions in the thalamus further obfuscate the interpretation of stimulation results. While loss of benefit and habituation to DBS remain challenging in some patients, refined DBS techniques and closed-loop paradigms may eventually overcome these limitations.
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Affiliation(s)
- Clemens Neudorfer
- Brain Modulation Lab, Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Center for Brain Circuit Therapeutics Department of Neurology Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA; Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
| | | | - Igor Ilinsky
- Department of Anatomy and Cell Biology, The University of Iowa, Iowa City, IA, USA
| | - Steffen Paschen
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | | | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - R Mark Richardson
- Brain Modulation Lab, Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andreas Horn
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Center for Brain Circuit Therapeutics Department of Neurology Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA; Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
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6
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Shepherd H, Heartshorne R, Osman-Farah J, Macerollo A. Dual target deep brain stimulation for complex essential and dystonic tremor - A 5-year follow up. J Neurol Sci 2024; 457:122887. [PMID: 38295533 DOI: 10.1016/j.jns.2024.122887] [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: 07/17/2023] [Revised: 12/12/2023] [Accepted: 01/11/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Essential tremor (ET) is characterized by action tremor of the upper limbs, head tremor and voice tremor. Dystonic tremor (DT) is produced by muscle contractions in a body affected by dystonia. Deep brain stimulation (DBS) of ventral intermediate nucleus of the thalamus (VIM) is the most well-known advanced treatment for medication-refractory tremor. However, decline in efficacy overtime has led to explore other targets. This study aimed to measure the efficacy of bilateral dual targeting ViM/caudal Zona Incerta (cZI) stimulation on tremor control. A secondary aim was to evaluate if there was a difference in the efficacy between ET and DT. METHODS 36 patients were retrospectively recruited at the Walton NHS Foundation Trust, Liverpool, UK. Patients were assessed pre-operatively, and then at 1-year, 3-years, and 5-years post-operatively with the following scales: Fahn-Tolosa-Marin tremor rating (FTMTR) scale, EuroQol-5D, and Hospital Anxiety and Depression Scale. RESULTS Bilateral ViM-cZI DBS significantly improved overall tremor score by 45.1% from baseline to 3-years post-operatively (p < 0.001). It continued to show improvement in overall FTMTR score by 30.7% at 5-years but this failed to meet significance. However, there was no significant improvement of mood or quality of life (QoL) scores. ET group on average showed a significant better clinical outcome compared to the DT group (p > 0.001). CONCLUSIONS Our study found that bilateral ViM-cZI DBS treatment had a favourable effect on motor symptoms sustained over the 5-years in tremor patients, especially in ET group. There was limited effect on mood and QoL with similar trends in outcomes for both tremor types.
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Affiliation(s)
- Hilary Shepherd
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK; University of Liverpool Medical School, Liverpool, UK.
| | - Rosie Heartshorne
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK
| | - Jibril Osman-Farah
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK
| | - Antonella Macerollo
- The Walton Centre NHS Foundation Trust for Neurology and Neurosurgery, Liverpool, UK; Institute of Systems, Molecular and Integrative Biology, University of Liverpool, UK
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Hidding U, Lezius S, Schaper M, Buhmann C, Gerloff C, Pötter-Nerger M, Hamel W, Moll CKE, Choe CU. Combined Short-Pulse and Directional Deep Brain Stimulation of the Thalamic Ventral Intermediate Area for Essential Tremor. Neuromodulation 2023; 26:1680-1688. [PMID: 36369082 DOI: 10.1016/j.neurom.2022.09.009] [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: 01/31/2022] [Revised: 08/30/2022] [Accepted: 09/20/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Novel deep brain stimulation (DBS) systems allow directional and short-pulse stimulation to potentially improve symptoms and reduce side effects. The aim of this study was to investigate the effect of short-pulse and directional stimulation, in addition to a combination of both, in the ventral intermediate thalamus (VIM)/posterior subthalamic area (PSA) on tremor and stimulation-induced side effects in patients with essential tremor. MATERIALS AND METHODS We recruited 11 patients with essential tremor and VIM/PSA-DBS. Tremor severity (Fahn-Tolosa-Marin), ataxia (International Cooperative Ataxia Rating Scale), and paresthesia (visual analog scale) were assessed with conventional omnidirectional and directional stimulation with pulse width of 60 μs and 30 μs. RESULTS All stimulation conditions reduced tremor. The best directional stimulation with 60 μs reduced more tremor than did most other stimulation settings. The best directional stimulation, regardless of pulse width, effectively reduced stimulation-induced ataxia compared with the conventional stimulation (ring 60 μs) or worst directional stimulation with 60 μs. All new stimulation modes reduced occurrence of paresthesia, but only the best directional stimulation with 30 μs attenuated paresthesia compared with the conventional stimulation (ring 60 μs) or worst directional stimulation with 60 μs. The best directional stimulation with 30 μs reduced tremor, ataxia, and paresthesia compared with conventional stimulation in most patients. Correlation analyses indicated that more anterior stimulation sites are associated with stronger ataxia reduction with directional 30 μs than with conventional 60 μs stimulation. CONCLUSION Directional and short-pulse stimulation, and a combination of both, revealed beneficial effects on stimulation-induced adverse effects.
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Affiliation(s)
- Ute Hidding
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Susanne Lezius
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miriam Schaper
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K E Moll
- Department of Neurophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chi-Un Choe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Olivier C, Lamy JC, Kosutzka Z, Van Hamme A, Cherif S, Lau B, Vidailhet M, Karachi C, Welter ML. Cerebellar Transcranial Alternating Current Stimulation in Essential Tremor Patients with Thalamic Stimulation: A Proof-of-Concept Study. Neurotherapeutics 2023; 20:1109-1119. [PMID: 37097344 PMCID: PMC10457262 DOI: 10.1007/s13311-023-01372-6] [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] [Accepted: 03/19/2023] [Indexed: 04/26/2023] Open
Abstract
Essential tremor (ET) is a disabling condition resulting from a dysfunction of cerebello-thalamo-cortical circuitry. Deep brain stimulation (DBS) or lesion of the ventral-intermediate thalamic nucleus (VIM) is an effective treatment for severe ET. Transcranial cerebellar brain stimulation has recently emerged as a non-invasive potential therapeutic option. Here, we aim to investigate the effects of high-frequency non-invasive cerebellar transcranial alternating current stimulation (tACS) in severe ET patients already operated for VIM-DBS. Eleven ET patients with VIM-DBS, and 10 ET patients without VIM-DBS and matched for tremor severity, were included in this double-blind proof-of-concept controlled study. All patients received unilateral cerebellar sham-tACS and active-tACS for 10 min. Tremor severity was blindly assessed at baseline, without VIM-DBS, during sham-tACS, during and at 0, 20, 40 min after active-tACS, using kinetic recordings during holding posture and action ('nose-to-target') task and videorecorded Fahn-Tolosa-Marin (FTM) clinical scales. In the VIM-DBS group, active-tACS significantly improved both postural and action tremor amplitude and clinical (FTM scales) severity, relative to baseline, whereas sham-tACS did not, with a predominant effect for the ipsilateral arm. Tremor amplitude and clinical severity were also not significantly different between ON VIM-DBS and active-tACS conditions. In the non-VIM-DBS group, we also observed significant improvements in ipsilateral action tremor amplitude, and clinical severity after cerebellar active-tACS, with a trend for improved postural tremor amplitude. In non-VIM-DBS group, sham- active-tACS also decreased clinical scores. These data support the safety and potential efficacy of high-frequency cerebellar-tACS to reduce ET amplitude and severity.
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Affiliation(s)
- Claire Olivier
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- PANAM Core Facility, Institut du Cerveau - Paris Brain Institute, Paris, France
| | - Jean-Charles Lamy
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- PANAM Core Facility, Institut du Cerveau - Paris Brain Institute, Paris, France
- Department of Neurology, AP-HP, Hôpital Salpetriere, DMU Neuroscience 6, Paris, France
| | - Zuzana Kosutzka
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- Department of Neurology, AP-HP, Hôpital Salpetriere, DMU Neuroscience 6, Paris, France
| | - Angèle Van Hamme
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- PANAM Core Facility, Institut du Cerveau - Paris Brain Institute, Paris, France
| | - Saoussen Cherif
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
| | - Brian Lau
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
| | - Marie Vidailhet
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- Department of Neurology, AP-HP, Hôpital Salpetriere, DMU Neuroscience 6, Paris, France
| | - Carine Karachi
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France
- Department of Neurosurgery, AP-HP, Hôpital Salpetriere, Paris, France
| | - Marie-Laure Welter
- Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Sorbonne Université, 47 Bd de L'Hôpital, 75013, Paris, France.
- PANAM Core Facility, Institut du Cerveau - Paris Brain Institute, Paris, France.
- Clinical Investigation Center, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France.
- Department of Neurophysiology, Rouen University Hospital, University of Rouen, Rouen, France.
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Ferreira Felloni Borges Y, Cheyuo C, Lozano AM, Fasano A. Essential Tremor - Deep Brain Stimulation vs. Focused Ultrasound. Expert Rev Neurother 2023; 23:603-619. [PMID: 37288812 DOI: 10.1080/14737175.2023.2221789] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Essential Tremor (ET) is one of the most common tremor syndromes typically presented as action tremor, affecting mainly the upper limbs. In at least 30-50% of patients, tremor interferes with quality of life, does not respond to first-line therapies and/or intolerable adverse effects may occur. Therefore, surgery may be considered. AREAS COVERED In this review, the authors discuss and compare unilateral ventral intermedius nucleus deep brain stimulation (VIM DBS) and bilateral DBS with Magnetic Resonance-guided Focused Ultrasound (MRgFUS) thalamotomy, which comprises focused acoustic energy generating ablation under real-time MRI guidance. Discussion includes their impact on tremor reduction and their potential complications. Finally, the authors provide their expert opinion. EXPERT OPINION DBS is adjustable, potentially reversible and allows bilateral treatments; however, it is invasive requires hardware implantation, and has higher surgical risks. Instead, MRgFUS is less invasive, less expensive, and requires no hardware maintenance. Beyond these technical differences, the decision should also involve the patient, family, and caregivers.
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Affiliation(s)
- Yuri Ferreira Felloni Borges
- Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, University of Toronto, Toronto, ON, Canada
| | - Cletus Cheyuo
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, University of Toronto, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
- Department of Parkinson's Disease & Movement Disorders Rehabilitation, Moriggia-Pelascini Hospital, Gravedona Ed Uniti, Como, Italy
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10
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Pourahmad R, Saleki K, Esmaili M, Abdollahi A, Alijanizadeh P, Gholinejad MZ, Banazadeh M, Ahmadi M. Deep brain stimulation (DBS) as a therapeutic approach in gait disorders: What does it bring to the table? IBRO Neurosci Rep 2023; 14:507-513. [PMID: 37304345 PMCID: PMC10248795 DOI: 10.1016/j.ibneur.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 06/13/2023] Open
Abstract
Gait deficits are found in various degenerative central nervous system conditions, and are particularly a hallmark of Parkinson's disease (PD). While there is no cure for such neurodegenerative disorders, Levodopa is considered as the standard medication in PD patients. Often times, the therapy of severe PD consists of deep brain stimulation (DBS) of the subthalamic nucleus. Earlier research exploring the effect of gait have reported contradictory results or insufficient efficacy. A change in gait includes various parameters, such as step length, cadence, Double-stance phase duration which may be positively affected by DBS. DBS could also be effective in correcting the levodopa-induced postural sway abnormalities. Moreover, during normal walking, interaction among the subthalamic nucleus and cortex -essential regions which exert a role in locomotion- are coupled. However, during the freezing of gait, the activity is desynchronized. The mechanisms underlying DBS-induced neurobehavioral improvements in such scenarios requires further study. The present review discusses DBS in the context of gait, the benefits associated with DBS compared to standard pharmacotherapy options, and provides insights into future research.
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Affiliation(s)
- Ramtin Pourahmad
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Tehran, Iran
| | - Kiarash Saleki
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
- Department of e-Learning, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences(SBMU), Tehran, Iran
- USERN Office, Babol University of Medical Sciences, Babol, Iran
| | | | - Arian Abdollahi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Parsa Alijanizadeh
- Student Research Committee, Babol University of Medical Sciences, Babol, Iran
- USERN Office, Babol University of Medical Sciences, Babol, Iran
| | | | - Mohammad Banazadeh
- Pharmaceutical Sciences and Cosmetic Products Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Mona Ahmadi
- Department of Neurology, School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran
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Senevirathne DKL, Mahboob A, Zhai K, Paul P, Kammen A, Lee DJ, Yousef MS, Chaari A. Deep Brain Stimulation beyond the Clinic: Navigating the Future of Parkinson's and Alzheimer's Disease Therapy. Cells 2023; 12:1478. [PMID: 37296599 PMCID: PMC10252401 DOI: 10.3390/cells12111478] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/30/2023] [Accepted: 05/16/2023] [Indexed: 06/12/2023] Open
Abstract
Deep brain stimulation (DBS) is a surgical procedure that uses electrical neuromodulation to target specific regions of the brain, showing potential in the treatment of neurodegenerative disorders such as Parkinson's disease (PD) and Alzheimer's disease (AD). Despite similarities in disease pathology, DBS is currently only approved for use in PD patients, with limited literature on its effectiveness in AD. While DBS has shown promise in ameliorating brain circuits in PD, further research is needed to determine the optimal parameters for DBS and address any potential side effects. This review emphasizes the need for foundational and clinical research on DBS in different brain regions to treat AD and recommends the development of a classification system for adverse effects. Furthermore, this review suggests the use of either a low-frequency system (LFS) or high-frequency system (HFS) depending on the specific symptoms of the patient for both PD and AD.
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Affiliation(s)
| | - Anns Mahboob
- Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, Doha 24144, Qatar
| | - Kevin Zhai
- Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, Doha 24144, Qatar
| | - Pradipta Paul
- Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, Doha 24144, Qatar
| | - Alexandra Kammen
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
| | - Darrin Jason Lee
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- USC Neurorestoration Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Mohammad S. Yousef
- Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, Doha 24144, Qatar
| | - Ali Chaari
- Weill Cornell Medicine-Qatar, Education City, Qatar Foundation, Doha 24144, Qatar
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12
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Bahadori-Jahromi F, Salehi S, Madadi Asl M, Valizadeh A. Efficient suppression of parkinsonian beta oscillations in a closed-loop model of deep brain stimulation with amplitude modulation. Front Hum Neurosci 2023; 16:1013155. [PMID: 36776221 PMCID: PMC9908610 DOI: 10.3389/fnhum.2022.1013155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Accepted: 12/09/2022] [Indexed: 01/27/2023] Open
Abstract
Introduction Parkinson's disease (PD) is a movement disorder characterized by the pathological beta band (15-30 Hz) neural oscillations within the basal ganglia (BG). It is shown that the suppression of abnormal beta oscillations is correlated with the improvement of PD motor symptoms, which is a goal of standard therapies including deep brain stimulation (DBS). To overcome the stimulation-induced side effects and inefficiencies of conventional DBS (cDBS) and to reduce the administered stimulation current, closed-loop adaptive DBS (aDBS) techniques were developed. In this method, the frequency and/or amplitude of stimulation are modulated based on various disease biomarkers. Methods Here, by computational modeling of a cortico-BG-thalamic network in normal and PD conditions, we show that closed-loop aDBS of the subthalamic nucleus (STN) with amplitude modulation leads to a more effective suppression of pathological beta oscillations within the parkinsonian BG. Results Our results show that beta band neural oscillations are restored to their normal range and the reliability of the response of the thalamic neurons to motor cortex commands is retained due to aDBS with amplitude modulation. Furthermore, notably less stimulation current is administered during aDBS compared with cDBS due to a closed-loop control of stimulation amplitude based on the STN local field potential (LFP) beta activity. Discussion Efficient models of closed-loop stimulation may contribute to the clinical development of optimized aDBS techniques designed to reduce potential stimulation-induced side effects of cDBS in PD patients while leading to a better therapeutic outcome.
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Affiliation(s)
| | - Sina Salehi
- Shiraz Neuroscience Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mojtaba Madadi Asl
- School of Biological Sciences, Institute for Research in Fundamental Sciences (IPM), Tehran, Iran
- Pasargad Institute for Advanced Innovative Solutions (PIAIS), Tehran, Iran
| | - Alireza Valizadeh
- Department of Physics, Institute for Advanced Studies in Basic Sciences (IASBS), Zanjan, Iran
- Pasargad Institute for Advanced Innovative Solutions (PIAIS), Tehran, Iran
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13
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Pirker W, Katzenschlager R, Hallett M, Poewe W. Pharmacological Treatment of Tremor in Parkinson's Disease Revisited. JOURNAL OF PARKINSON'S DISEASE 2023; 13:127-144. [PMID: 36847017 PMCID: PMC10041452 DOI: 10.3233/jpd-225060] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
The pathophysiology of Parkinson's disease (PD) tremor remains incompletely understood and there is a lack of clinical trials specifically addressing its pharmacological treatment. Levodopa is the most efficacious drug for most patients and should be used as primary approach to control troublesome tremor. While the efficacy of oral dopamine agonists on PD tremor has been demonstrated in controlled trials, there is no evidence of greater antitremor efficacy compared to levodopa. The magnitude of the antitremor effect of anticholinergics is generally lower than that of levodopa. Due to their adverse effects, anticholinergics have a limited role in selected young and cognitively intact patients. Propranolol may improve resting and action tremor and may be considered as an adjunct in patients with insufficient tremor response to levodopa and this also applies to clozapine, despite its unfavorable adverse effect profile. Treating motor fluctuations with MAO-B and COMT inhibitors, dopamine agonists, amantadine, or on-demand treatments such as subcutaneous or sublingual apomorphine and inhaled levodopa as well as with continuous infusions of levodopa or apomorphine will improve off period tremor episodes. For patients with drug-refractory PD tremor despite levodopa optimization deep brain stimulation and focused ultrasound are first-line considerations. Surgery can also be highly effective for the treatment medication-refractory tremor in selected patients without motor fluctuations. The present review highlights the clinical essentials of parkinsonian tremor, critically examines available trial data on the effects of medication and surgical approaches and provides guidance for the choice of treatments to control PD tremor in clinical practice.
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Affiliation(s)
- Walter Pirker
- Department of Neurology, Klinik Ottakring, Vienna, Austria
| | - Regina Katzenschlager
- Department of Neurology and Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Klinik Donaustadt, Vienna, Austria
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, Maryland, USA
| | - Werner Poewe
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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14
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Prakash P, Deuschl G, Ozinga S, Mitchell KT, Cheeran B, Larson PS, Merola A, Groppa S, Tomlinson T, Ostrem JL. Benefits and Risks of a Staged‐Bilateral VIM versus Unilateral VIM DBS for Essential Tremor. Mov Disord Clin Pract 2022; 9:775-784. [PMID: 35937489 PMCID: PMC9346253 DOI: 10.1002/mdc3.13490] [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: 01/19/2022] [Revised: 04/23/2022] [Accepted: 05/11/2022] [Indexed: 11/16/2022] Open
Abstract
Background Despite over 30 years of clinical experience, high‐quality studies on the efficacy of bilateral versus unilateral deep brain stimulation (DBS) of the ventral intermediate (VIM) nucleus of the thalamus for medically refractory essential tremor (ET) remain limited. Objectives To compare benefits and risks of bilateral versus unilateral VIM DBS using the largest ET DBS clinical trial dataset available to date. Methods Participants from the US St. Jude/Abbott pivotal ET DBS trial who underwent staged‐bilateral VIM implantation constituted the primary cohort in this sub‐analysis. Their assessments “on” DBS at six months after second‐side VIM DBS implantation were compared to the assessments six months after unilateral implantation. Two control cohorts of participants with unilateral implantation only were also used for between‐group comparisons. Results The primary cohort consisted of n = 38 ET patients (22M/16F; age of 65.3 ± 9.5 years). The second side VIM‐DBS resulted in a 29.6% additional improvement in the total motor CRST score (P < 0.001), with a 64.1% CRST improvement in the contralateral side (P < 0.001). An added improvement was observed in the axial tremor score (21.4%, P = 0.005), and CRST part B (24.8%, P < 0.001) score. Rate of adverse events was slightly higher after bilateral stimulation. Conclusions In the largest ET DBS study to date, staged‐bilateral VIM DBS was a highly effective treatment for ET with bilateral implantation resulting in greater reduction in total motor tremor scores when compared to unilateral stimulation alone.
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Affiliation(s)
- Prarthana Prakash
- Department of Neurology, UCSF Weill Institute for Neurosciences, Movement Disorder and Neuromodulation Center University of California San Francisco CA United States
| | - Guenther Deuschl
- Department of Neurology, Universitatsklinikum Schleswig‐Holstein, Kiel Campus Christian Albrechts University Kiel Kiel Germany
| | - Sarah Ozinga
- Abbott, Clinical Research Department 6901 Preston Road Plano TX 75024 USA
| | | | - Binith Cheeran
- Abbott, Clinical Research Department 6901 Preston Road Plano TX 75024 USA
| | - Paul S. Larson
- Department of Neurosurgery University of Arizona Tuscon AZ
| | - Aristide Merola
- Department of Neurology, Madden Center for Parkinson Disease and other Movement Disorders Ohio State University Wexner Medical Center Columbus OH United States
| | - Sergiu Groppa
- Department of Neurology, Focus Program Translational Neuroscience University Medical Center of the Johannes Gutenberg‐University Mainz Mainz Germany
| | - Tucker Tomlinson
- Abbott, Clinical Research Department 6901 Preston Road Plano TX 75024 USA
| | - Jill L. Ostrem
- Department of Neurology, UCSF Weill Institute for Neurosciences, Movement Disorder and Neuromodulation Center University of California San Francisco CA United States
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15
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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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16
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Surgical and Hardware-Related Adverse Events of Deep Brain Stimulation: A Ten-Year Single-Center Experience. Neuromodulation 2022; 25:296-304. [PMID: 35125149 DOI: 10.1016/j.neurom.2021.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/16/2021] [Accepted: 12/08/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Although deep brain stimulation (DBS) is effective for treating a number of neurological and psychiatric indications, surgical and hardware-related adverse events (AEs) can occur that affect quality of life. This study aimed to give an overview of the nature and frequency of those AEs in our center and to describe the way they were managed. Furthermore, an attempt was made at identifying possible risk factors for AEs to inform possible future preventive measures. MATERIALS AND METHODS Patients undergoing DBS-related procedures between January 2011 and July 2020 were retrospectively analyzed to inventory AEs. The mean follow-up time was 43 ± 31 months. Univariate logistic regression analysis was used to assess the predictive value of selected demographic and clinical variables. RESULTS From January 2011 to July 2020, 508 DBS-related procedures were performed including 201 implantations of brain electrodes in 200 patients and 307 implantable pulse generator (IPG) replacements in 142 patients. Surgical or hardware-related AEs following initial implantation affected 40 of 200 patients (20%) and resolved without permanent sequelae in all instances. The most frequent AEs were surgical site infections (SSIs) (9.95%, 20/201) and wire tethering (2.49%, 5/201), followed by hardware failure (1.99%, 4/201), skin erosion (1.0%, 2/201), pain (0.5%, 1/201), lead migration (0.52%, 2/386 electrode sites), and hematoma (0.52%, 2/386 electrode sites). The overall rate of AEs for IPG replacement was 5.6% (17/305). No surgical, ie, staged or nonstaged, electrode fixation, or patient-related risk factors were identified for SSI or wire tethering. CONCLUSIONS Major AEs including intracranial surgery-related AEs or AEs requiring surgical removal or revision of hardware are rare. In particular, aggressive treatment is required in SSIs involving multiple sites or when Staphylococcus aureus is identified. For future benchmarking, the development of a uniform reporting system for surgical and hardware-related AEs in DBS surgery would be useful.
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Marceglia S, Guidetti M, Harmsen IE, Loh A, Meoni S, Foffani G, Lozano AM, Volkmann J, Moro E, Priori A. Deep brain stimulation: is it time to change gears by closing the loop? J Neural Eng 2021; 18. [PMID: 34678794 DOI: 10.1088/1741-2552/ac3267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 10/22/2021] [Indexed: 11/12/2022]
Abstract
Objective.Adaptive deep brain stimulation (aDBS) is a form of invasive stimulation that was conceived to overcome the technical limitations of traditional DBS, which delivers continuous stimulation of the target structure without considering patients' symptoms or status in real-time. Instead, aDBS delivers on-demand, contingency-based stimulation. So far, aDBS has been tested in several neurological conditions, and will be soon extensively studied to translate it into clinical practice. However, an exhaustive description of technical aspects is still missing.Approach.in this topical review, we summarize the knowledge about the current (and future) aDBS approach and control algorithms to deliver the stimulation, as reference for a deeper undestending of aDBS model.Main results.We discuss the conceptual and functional model of aDBS, which is based on the sensing module (that assesses the feedback variable), the control module (which interpretes the variable and elaborates the new stimulation parameters), and the stimulation module (that controls the delivery of stimulation), considering both the historical perspective and the state-of-the-art of available biomarkers.Significance.aDBS modulates neuronal circuits based on clinically relevant biofeedback signals in real-time. First developed in the mid-2000s, many groups have worked on improving closed-loop DBS technology. The field is now at a point in conducting large-scale randomized clinical trials to translate aDBS into clinical practice. As we move towards implanting brain-computer interfaces in patients, it will be important to understand the technical aspects of aDBS.
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Affiliation(s)
- Sara Marceglia
- Department of Engineering and Architecture, University of Trieste, 34127 Trieste, Italy
| | - Matteo Guidetti
- Aldo Ravelli Research Center for Neurotechnology and Experimental Neurotherapeutics, Department of Health Sciences, University of Milan, 20142 Milan, Italy.,Department of Electronics, Information and Bioengineering, Politecnico di Milano, 20133 Milan, Italy
| | - Irene E Harmsen
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Sara Meoni
- Aldo Ravelli Research Center for Neurotechnology and Experimental Neurotherapeutics, Department of Health Sciences, University of Milan, 20142 Milan, Italy.,Movement Disorders Unit, Division of Neurology, CHU Grenoble Alpes, Grenoble, France.,Grenoble Institute of Neurosciences, INSERM U1216, University Grenoble Alpes, Grenoble, France
| | - Guglielmo Foffani
- HM CINAC (Centro Integral de Neurociencias Abarca Campal), Hospital Universitario HM Puerta del Sur, HM Hospitales, Madrid, Spain.,Hospital Nacional de Parapléjicos, SESCAM, Toledo, Spain
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Jens Volkmann
- Department of Neurology, University of Wurzburg, Wurzburg, Germany
| | - Elena Moro
- Movement Disorders Unit, Division of Neurology, CHU Grenoble Alpes, Grenoble, France.,Grenoble Institute of Neurosciences, INSERM U1216, University Grenoble Alpes, Grenoble, France
| | - Alberto Priori
- Aldo Ravelli Research Center for Neurotechnology and Experimental Neurotherapeutics, Department of Health Sciences, University of Milan, 20142 Milan, Italy.,ASST Santi Paolo e Carlo, 20142 Milan, Italy
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18
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Zali A, Khoshnood RJ, Motavaf M, Salimi A, Akhlaghdoust M, Safari S, Ghajarzadeh M, Mirmosayyeb O. Deep brain stimulation for multiple sclerosis tremor: A systematic review and meta-analysis. Mult Scler Relat Disord 2021; 56:103256. [PMID: 34517191 DOI: 10.1016/j.msard.2021.103256] [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: 05/11/2021] [Revised: 09/01/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This systematic review and meta-analysis aims to evaluate efficacy of deep brain stimulation (DBS) in treating MS-related tremor. METHODS We systematically searched PubMed, Web of Science, Embase, Scopus, Google Scholar, and gray literature using a search strategy including the MeSH and text words as (((Brain Stimulations) OR (Deep Brain Stimulations) OR (Deep Brain Stimulations) OR (Deep Brain Brain Stimulation) OR (Deep Electrical Stimulation of the Brain)) AND (Multiple Sclerosis OR Sclerosis, Multiple) OR Sclerosis, Disseminated) OR Disseminated Sclerosis) OR MS (Multiple Sclerosis)) OR Multiple Sclerosis, Acute Fulminating). RESULTS The literature search revealed 1663 articles, 1027 of which remained after removing duplicates. Seventeen articles, published between 1999-2018, were included for the meta-analysis, including overall 168 patients. Follow-up time ranged between 6-62 months. The pooled frequency of tremor improvement among the enrolled patients was 73%, (95% CI:64-83%) (I2=84.1%, p<0.001). The pooled standardized mean difference (SMD) (after -before) was -2.9, (95% CI:-4.8, -0.98) (I2=89.8%, p<0.001). CONCLUSION The results of this systematic review and meta-analysis demonstrate MS-related tremor improvement after DBS.
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Affiliation(s)
- Alireza Zali
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Comprehensive Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reza Jalili Khoshnood
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Comprehensive Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahsa Motavaf
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Comprehensive Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Salimi
- Department of Anesthesiology and Critical Care, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Meisam Akhlaghdoust
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Comprehensive Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Saeid Safari
- Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Comprehensive Center of Excellence, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Mahsa Ghajarzadeh
- Multiple Sclerosis Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran. Universal Council of Epidemiology (UCE), Universal Scientific Education and Research Network (USERN), Tehran University of Medical Sciences, Tehran, Iran
| | - Omid Mirmosayyeb
- Department of Neurology, School of medicine, Isfahan University of medical sciences, Isfahan, Iran, Isfahan Neurosciences Research Center, Isfahan University of medical sciences, Isfahan, Iran
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Kremer NI, Pauwels RWJ, Pozzi NG, Lange F, Roothans J, Volkmann J, Reich MM. Deep Brain Stimulation for Tremor: Update on Long-Term Outcomes, Target Considerations and Future Directions. J Clin Med 2021; 10:3468. [PMID: 34441763 PMCID: PMC8397098 DOI: 10.3390/jcm10163468] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 01/11/2023] Open
Abstract
Deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus is one of the main advanced neurosurgical treatments for drug-resistant tremor. However, not every patient may be eligible for this procedure. Nowadays, various other functional neurosurgical procedures are available. In particular cases, radiofrequency thalamotomy, focused ultrasound and radiosurgery are proven alternatives to DBS. Besides, other DBS targets, such as the posterior subthalamic area (PSA) or the dentato-rubro-thalamic tract (DRT), may be appraised as well. In this review, the clinical characteristics and pathophysiology of tremor syndromes, as well as long-term outcomes of DBS in different targets, will be summarized. The effectiveness and safety of lesioning procedures will be discussed, and an evidence-based clinical treatment approach for patients with drug-resistant tremor will be presented. Lastly, the future directions in the treatment of severe tremor syndromes will be elaborated.
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Affiliation(s)
- Naomi I. Kremer
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (N.I.K.); (R.W.J.P.)
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Rik W. J. Pauwels
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (N.I.K.); (R.W.J.P.)
| | - Nicolò G. Pozzi
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Florian Lange
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Jonas Roothans
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Jens Volkmann
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Martin M. Reich
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
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Peters J, Tisch S. Habituation After Deep Brain Stimulation in Tremor Syndromes: Prevalence, Risk Factors and Long-Term Outcomes. Front Neurol 2021; 12:696950. [PMID: 34413826 PMCID: PMC8368435 DOI: 10.3389/fneur.2021.696950] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/02/2021] [Indexed: 12/12/2022] Open
Abstract
Deep brain stimulation (DBS) of the thalamus is an effective treatment for medically refractory essential, dystonic and Parkinson's tremor. It may also provide benefit in less common tremor syndromes including, post-traumatic, cerebellar, Holmes, neuropathic and orthostatic tremor. The long-term benefit of DBS in essential and dystonic tremor (ET/DT) often wanes over time, a phenomena referred to as stimulation "tolerance" or "habituation". While habituation is generally accepted to exist, it remains controversial. Attempts to quantify habituation have revealed conflicting reports. Placebo effects, loss of micro-lesional effect, disease related progression, suboptimal stimulation and stimulation related side-effects may all contribute to the loss of sustained long-term therapeutic effect. Habituation often presents as substantial loss of initial DBS benefit occurring as early as a few months after initial stimulation; a complex and feared issue when faced in the setting of optimal electrode placement. Simply increasing stimulation current tends only to propagate tremor severity and induce stimulation related side effects. The report by Paschen and colleagues of worsening tremor scores in the "On" vs. "Off" stimulation state over time, even after accounting for "rebound" tremor, supports the concept of habituation. However, these findings have not been consistent across all studies. Chronic high intensity stimulation has been hypothesized to induce detrimental plastic effects on tremor networks, with some lines of evidence that DT and ET may be more susceptible than Parkinson's tremor to habituation. However, Tsuboi and colleague's recent longitudinal follow-up in dystonic and "pure" essential tremor suggests otherwise. Alternatively, post-mortem findings support a biological adaption to stimulation. The prevalence and etiology of habituation is still not fully understood and management remains difficult. A recent study reported that alternating thalamic stimulation parameters at weekly intervals provided improved stability of tremor control consistent with reduced habituation. In this article the available evidence for habituation after DBS for tremor syndromes is reviewed; including its prevalence, time-course, possible mechanisms; along with expected long-term outcomes for tremor and factors that may assist in predicting, preventing and managing habituation.
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Affiliation(s)
- James Peters
- Department of Neurology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Stephen Tisch
- Department of Neurology, St Vincent's Hospital, Sydney, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
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21
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Schnitzler A, Mir P, Brodsky MA, Verhagen L, Groppa S, Alvarez R, Evans A, Blazquez M, Nagel S, Pilitsis JG, Pötter-Nerger M, Tse W, Almeida L, Tomycz N, Jimenez-Shahed J, Libionka W, Carrillo F, Hartmann CJ, Groiss SJ, Glaser M, Defresne F, Karst E, Cheeran B, Vesper J. Directional Deep Brain Stimulation for Parkinson's Disease: Results of an International Crossover Study With Randomized, Double-Blind Primary Endpoint. Neuromodulation 2021; 25:817-828. [PMID: 34047410 DOI: 10.1111/ner.13407] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/11/2021] [Accepted: 03/23/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Published reports on directional deep brain stimulation (DBS) have been limited to small, single-center investigations. Therapeutic window (TW) is used to describe the range of stimulation amplitudes achieving symptom relief without side effects. This crossover study performed a randomized double-blind assessment of TW for directional and omnidirectional DBS in a large cohort of patients implanted with a DBS system in the subthalamic nucleus for Parkinson's disease. MATERIALS AND METHODS Participants received omnidirectional stimulation for the first three months after initial study programming, followed by directional DBS for the following three months. The primary endpoint was a double-blind, randomized evaluation of TW for directional vs. omnidirectional stimulation at three months after initial study programming. Additional data recorded at three- and six-month follow-ups included stimulation preference, therapeutic current strength, Unified Parkinson's Disease Rating Scale (UPDRS) part III motor score, and quality of life. RESULTS The study enrolled 234 subjects (62 ± 8 years, 33% female). TW was wider using directional stimulation in 183 of 202 subjects (90.6%). The mean increase in TW with directional stimulation was 41% (2.98 ± 1.38 mA, compared to 2.11 ± 1.33 mA for omnidirectional). UPDRS part III motor score on medication improved 42.4% at three months (after three months of omnidirectional stimulation) and 43.3% at six months (after three months of directional stimulation) with stimulation on, compared to stimulation off. After six months, 52.8% of subjects blinded to stimulation type (102/193) preferred the period with directional stimulation, and 25.9% (50/193) preferred the omnidirectional period. The directional period was preferred by 58.5% of clinicians (113/193) vs. 21.2% (41/193) who preferred the omnidirectional period. CONCLUSION Directional stimulation yielded a wider TW compared to omnidirectional stimulation and was preferred by blinded subjects and clinicians.
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Affiliation(s)
- Alfons Schnitzler
- Department of Neurology, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Pablo Mir
- Clinical Neurology and Neurophysiology Department, Movement Disorders Unit, Institute of Biomedicine of Seville, Virgen del Rocío University Hospital, CSIC/University of Seville, Seville, Spain.,Network Center for Biomedical Research in Neurodegenerative Diseases (CIBERNED), Seville, Spain
| | - Matthew A Brodsky
- Department of Neurology, Oregon Health and Science University, Portland, OR, USA
| | - Leonard Verhagen
- Department of Neurological Sciences, Rush University, Chicago, IL, USA
| | - Sergiu Groppa
- Johannes Gutenberg University of Mainz, Clinic of Neurology, Mainz, Germany
| | - Ramiro Alvarez
- Department of Neurology, Hospital Trias i Pujol, Badalona, Spain
| | - Andrew Evans
- Department of Neurology, Royal Melbourne Hospital, Melbourne, Australia
| | - Marta Blazquez
- Department of Neurology, Hospital Universitario Central de Asturias, Spain
| | - Sean Nagel
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Julie G Pilitsis
- Department of Neurosurgery, Albany Medical Center, New York, NY, USA
| | | | - Winona Tse
- Department of Neurology, Mount Sinai Hospital, New York, NY, USA
| | - Leonardo Almeida
- Department of Neurology, Shands at University of Florida, Gainesville, FL, USA
| | - Nestor Tomycz
- Department of Neurosurgery, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | - Witold Libionka
- Department of Neurology, Copernicus Hospital, Gdansk, Poland
| | - Fatima Carrillo
- Clinical Neurology and Neurophysiology Department, Movement Disorders Unit, Institute of Biomedicine of Seville, Virgen del Rocío University Hospital, CSIC/University of Seville, Seville, Spain
| | - Christian J Hartmann
- Department of Neurology, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Stefan Jun Groiss
- Department of Neurology, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Martin Glaser
- Department of Neurosurgery, Johannes Gutenberg University of Mainz, Mainz, Germany
| | | | - Edward Karst
- Abbott, Medical and Clinical Affairs, Plano, TX, USA
| | | | - Jan Vesper
- Department of Neurosurgery, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
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22
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Philipson J, Blomstedt P, Hariz M, Jahanshahi M. Deep brain stimulation in the caudal zona incerta in patients with essential tremor: effects on cognition 1 year after surgery. J Neurosurg 2021; 134:208-215. [PMID: 31860827 DOI: 10.3171/2019.9.jns191646] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 09/23/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The ventral intermediate nucleus (VIM) of the thalamus is currently the established target in the use of deep brain stimulation (DBS) to treat essential tremor (ET). In recent years, the caudal zona incerta (cZi), a brain target commonly used during the lesional era, has been revived as the primary target in a number of DBS studies that show evidence of the efficacy of cZi targeting in DBS treatment for controlling the symptoms of ET. The authors sought to obtain comprehensive neuropsychological data and thoroughly investigate the cognitive effects of cZi targeting in patients with ET treated with DBS. METHODS Twenty-six consecutive patients with ET who received DBS with cZi as the target at our department from December 2012 to February 2017 were included in this study. All patients were assessed using a comprehensive neuropsychological test battery covering the major cognitive domains both preoperatively and 12 months postoperatively. RESULTS The results show no major adverse effects on patient performance on the tests of cognitive function other than a slight decline of semantic verbal fluency. CONCLUSIONS This study indicates that the cZi is a safe target from a cognitive perspective in the treatment of ET with DBS.
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Affiliation(s)
- Johanna Philipson
- 1Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Patric Blomstedt
- 1Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Marwan Hariz
- 1Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
- 2Unit of Functional Neurosurgery, UCL Institute of Neurology, London, United Kingdom; and
| | - Marjan Jahanshahi
- 2Unit of Functional Neurosurgery, UCL Institute of Neurology, London, United Kingdom; and
- 3The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China
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23
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Dissociative Tremor Response with Pallidal Deep Brain Stimulation in Parkinson's Disease. Tremor Other Hyperkinet Mov (N Y) 2020; 10:53. [PMID: 33362947 PMCID: PMC7747761 DOI: 10.5334/tohm.568] [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] [Indexed: 11/20/2022] Open
Abstract
Background: Pallidal and subthalamic targets are commonly used for deep brain stimulation in Parkinson’s disease (PD), with similar efficacy for resting tremor control. However, neuromodulatory effects on kinetic and postural tremor in PD is less clear. Case Report: We present a 67-year-old PD patient with marked dissociative tremor response following pallidal neuromodulation. We observed excellent resting tremor suppression, but postural and kinetic tremors remained severe, requiring additional thalamic VIM stimulation for management. Discussion: Our findings illustrate the phenotypical differences in PD and differential response to diverse tremor characteristics with distinctive stimulation targets. Additional studies are necessary to understand these differences.
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Guridi J, Gonzalez-Quarante LH. Revisiting Forel Field Surgery. World Neurosurg 2020; 147:11-22. [PMID: 33276174 DOI: 10.1016/j.wneu.2020.11.143] [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: 07/16/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Lesioning the Forel field or the subthalamic region is considered a possible treatment for tremoric patients with Parkinson disease, essential tremor, and other diseases. This surgical treatment was performed in the 1960s to 1970s and was an alternative to thalamotomy. Recently, there has been increasing interest in the reappraisal of stimulating and/or lesioning these targets, partly as a result of innovations in imaging and noninvasive ablative technologies, such as magnetic resonance-guided focused ultrasonography. OBJECTIVE We wanted to perform a thorough review of the subthalamic region, both from an anatomic and a surgical standpoint, to offer a comprehensive and updated analysis of the techniques and results reported for patients with tremor treated with different techniques. METHODS We performed a systematic review of the literature, gathering articles that included patients who underwent ablative or stimulation surgical techniques, targeting the pallidothalamic pathways (pallidothalamic tractotomy), cerebellothalamic pathway (cerebellothalamic tractotomy), or subthalamic area. RESULTS Pallidothalamic tractotomy consists of a reduced area that includes pallidofugal pathways. It may be considered an interesting target, given the benefit/risk ratio and the clinical effect, which, compared with pallidotomy, involves a lower risk of injury or involvement of vital structures such as the internal capsule or optic tract. Cerebellothalamic tractotomy and/or posterior subthalamic area are other alternative targets to thalamic stimulation or ablative surgery. CONCLUSIONS Based on the significant breakthrough that magnetic resonance-guided focused ultrasonography has meant in the neurosurgical world, some classic targets such as the pallidothalamic tract, Forel field, and posterior subthalamic area may be reconsidered as surgical alternatives for patients with movement disorders.
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Affiliation(s)
- Jorge Guridi
- Department of Neurosurgery, Clínica Universidad de Navarra, Navarra University, Pamplona, Spain
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25
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Giordano M, Caccavella VM, Zaed I, Foglia Manzillo L, Montano N, Olivi A, Polli FM. Comparison between deep brain stimulation and magnetic resonance-guided focused ultrasound in the treatment of essential tremor: a systematic review and pooled analysis of functional outcomes. J Neurol Neurosurg Psychiatry 2020; 91:1270-1278. [PMID: 33055140 DOI: 10.1136/jnnp-2020-323216] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 08/22/2020] [Accepted: 09/09/2020] [Indexed: 01/01/2023]
Abstract
The current gold standard surgical treatment for medication-resistant essential tremor (ET) is deep brain stimulation (DBS). However, recent advances in technologies have led to the development of incisionless techniques, such as magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy. The authors perform a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to compare unilateral MRgFUS thalamotomy to unilateral and bilateral DBS in the treatment of ET in terms of tremor severity and quality of life improvement. PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and SCOPUS databases were searched. 45 eligible articles, published between 1990 and 2019, were retrieved. 1202 patients were treated with DBS and 477 were treated with MRgFUS thalamotomy. Postoperative tremor improvement was greater following DBS than MRgFUS thalamotomy (p<0.001). A subgroup analysis was carried out stratifying by treatment laterality: bilateral DBS was significantly superior to both MRgFUS and unilateral DBS (p<0.001), but no significant difference was recorded between MRgFUS and unilateral DBS (p<0.198). Postoperative quality of life improvement was significantly greater following MRgFUS thalamotomy than DBS (p<0.001). Complications were differently distributed among the two groups (p<0.001). Persistent complications were significantly more common in the MRgFUS group (p=0.042). While bilateral DBS proves superior to unilateral MRgFUS thalamotomy in the treatment of ET, a subgroup analysis suggests that treatment laterality is the most significant determinant of tremor improvement, thus highlighting the importance of future investigations on bilateral staged MRgFUS thalamotomy.
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Affiliation(s)
- Martina Giordano
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | | | - Ismail Zaed
- Department of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | | | - Nicola Montano
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | - Filippo Maria Polli
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
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Structure-function relationship of the posterior subthalamic area with directional deep brain stimulation for essential tremor. NEUROIMAGE-CLINICAL 2020; 28:102486. [PMID: 33395977 PMCID: PMC7674616 DOI: 10.1016/j.nicl.2020.102486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 10/10/2020] [Accepted: 10/25/2020] [Indexed: 11/21/2022]
Abstract
Directional DBS of the DRTT and the zona incerta is correlated with tremor suppression. Activation patterns for tremor suppression and side effects involve mostly the dentato-rubro-thalamic tract and the zona incerta. Concomitant side effects often limit the therapeutic window of directional deep brain stimulation.
Deep Brain Stimulation of the posterior subthalamic area is an emergent target for the treatment of Essential Tremor. Due to the heterogeneous and complex anatomy of the posterior subthalamic area, it remains unclear which specific structures mediate tremor suppression and different side effects. The objective of the current work was to yield a better understanding of what anatomical structures mediate the different clinical effects observed during directional deep brain stimulation of that area. We analysed a consecutive series of 12 essential tremor patients. Imaging analysis and systematic clinical testing performed 4–6 months postoperatively yielded location, clinical efficacy and corresponding therapeutic windows for 160 directional contacts. Overlap ratios between individual activation volumes and neighbouring thalamic and subthalamic nuclei as well as individual fiber tracts were calculated. Further, we generated stimulation heatmaps to assess the area of activity and structures stimulated during tremor suppression and occurrence of side effects. Stimulation of the dentato-rubro-thalamic tract and the zona incerta was most consistently correlated with tremor suppression. Both individual and group analysis demonstrated a similar pattern of activation for tremor suppression and different sorts of side-effects. Unlike current clinical concepts, induction of spasms and paresthesia were not correlated with stimulation of the corticospinal tract and the medial lemniscus. Furthermore, we noticed a significant difference in the therapeutic window between the best and worst directional contacts. The best directional contacts did not provide significantly larger therapeutic windows than omnidirectional stimulation at the same level. Deep brain stimulation of the posterior subthalamic area effectively suppresses all aspects of ET but can be associated with concomitant side effects limiting the therapeutic window. Activation patterns for tremor suppression and side effects were similar and predominantly involved the dentato-rubro-thalamic tract and the zona incerta. We found no different activation patterns between different types of side effects and no clear correlation between structure and function. Future studies with use of more sophisticated modelling of activation volumes taking into account fiber heterogeneity and orientation may eventually better delineate these different clusters, which may allow for a refined targeting and programming within this area.
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Wang KL, Ren Q, Chiu S, Patel B, Meng FG, Hu W, Shukla AW. Deep brain stimulation and other surgical modalities for the management of essential tremor. Expert Rev Med Devices 2020; 17:817-833. [PMID: 33081571 DOI: 10.1080/17434440.2020.1806709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Surgical treatments are considered for essential tremor (ET) when patients do not respond to oral pharmacological therapies. These treatments mainly comprise radiofrequency (RF) thalamotomy, gamma knife radiosurgery (GKRS), deep brain stimulation (DBS), and focused ultrasound (FUS) procedures. AREAS COVERED We reviewed the strengths and weaknesses of each procedure and clinical outcomes for 7 RF studies (n = 85), 11 GKRS (n = 477), 33 DBS (n = 1061), and 13 FUS studies (n = 368). A formal comparison was not possible given the heterogeneity in studies. Improvements were about 42%-90% RF, 10%-79% GKRS, 45%-83% DBS, 42%-83% FUS at short-term follow-up (<12 months) and were about 54%-82% RF, 11%-84% GKRS, 18%-92% DBS, and 42%-80% FUS at long-term follow-up (>12 months). EXPERT OPINION We found DBS with inherent advantages of being an adjustable and reversible procedure as the most frequently employed surgical procedure for control of ET symptoms. FUS is a promising procedure but has limited applicability for unilateral control of symptoms. RF is invasive, and GKRS has unpredictable delayed effects. Each of these surgical modalities has advantages and limitations that need consideration when selecting a treatment for the ET patients.
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Affiliation(s)
- Kai-Liang Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University , Beijing, China.,Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Qianwei Ren
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Shannon Chiu
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Bhavana Patel
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Fan-Gang Meng
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Wei Hu
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Aparna Wagle Shukla
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
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28
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Outcomes and Adverse Effects of Deep Brain Stimulation on the Ventral Intermediate Nucleus in Patients with Essential Tremor. Neural Plast 2020; 2020:2486065. [PMID: 32802034 PMCID: PMC7416257 DOI: 10.1155/2020/2486065] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 06/24/2020] [Accepted: 07/03/2020] [Indexed: 01/17/2023] Open
Abstract
Objective This study was aimed at identifying the potential outcome predictors, comparing the efficacy in patients with different tremor characteristics, and summarizing the adverse effect rates (AERs) of deep brain stimulation on the ventral intermediate nucleus (VIM-DBS) for essential tremor (ET). Methods An extensive search of articles published to date in 2019 was conducted, and two main aspects were analyzed. Improvement was calculated as a percentage of change in any objective tremor rating scale (TRS) and analyzed by subgroup analyses of patients' tremor characteristics, laterality, and stimulation parameters. Furthermore, the AERs were analyzed as follows: the adverse effects (AEs) were classified as stimulation-related, surgical-related, or device-related effects. A simple regression analysis was used to identify the potential prognostic factors, and a two-sample mean-comparison test was used to verify the statistical significance of the subgroup analyses. Results Forty-six articles involving 1714 patients were included in the meta-analysis. The pooled improvement in any objective TRS score was 61.3% (95% CI: 0.564-0.660) at the mean follow-up visit (20.0 ± 17.3 months). The midline and extremity symptoms showed consistent improvement (P = 0.440), and the results of the comparison of postural and kinetic tremor were the same (P = 0.219). In addition, the improvement in rest tremor was similar to that in action tremor (OR = 2.759, P = 0.120). In the simple regression analysis, the preoperative Fahn-Tolosa-Marin Tremor Rating Scale (FTM-TRS) scores and follow-up time were negatively correlated with the percentage change in any objective TRS score (P < 0.05). The most common adverse event was dysarthria (10.5%), which is a stimulation-related AE (23.6%), while the rates of the surgical-related and device-related AEs were 6.4% and 11.5%, respectively. Conclusion VIM-DBS is an efficient and safe surgical method in ET, and the efficacy was not affected by the body distribution of tremor, age at surgery, and disease duration. Lower preoperative FTM-TRS scores likely indicate greater improvement, and the effect of VIM-DBS declines over time.
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29
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Bruno S, Nikolov P, Hartmann CJ, Trenado C, Slotty PJ, Vesper J, Schnitzler A, Groiss SJ. Directional Deep Brain Stimulation of the Thalamic Ventral Intermediate Area for Essential Tremor Increases Therapeutic Window. Neuromodulation 2020; 24:343-352. [PMID: 32666569 DOI: 10.1111/ner.13234] [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: 03/04/2020] [Revised: 05/16/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Deep brain stimulation (DBS) of the posterior subthalamic area (PSA) and the ventral intermediate thalamic nucleus (VIM) is a well-established therapy for essential tremor (ET), but it is frequently associated with side effects like dysarthria or gait ataxia. Directional DBS (dDBS) may be a way to activate fiber tracts more selectively. Is dDBS for ET superior to omnidirectional DBS (oDBS) regarding therapeutic window and clinically as effective as oDBS? MATERIALS AND METHODS Ten patients with ET treated with PSA/VIM-DBS were recruited. Therapeutic window served as primary outcome parameter; clinical efficacy, volume of neuronal activation, and total electrical energy delivered (TEED) served as secondary outcome parameters. Therapeutic window was calculated for all three dDBS directions and for oDBS by determining therapeutic thresholds and side effect thresholds. Clinical efficacy was assessed by comparing the effect of best dDBS and oDBS on tremor and ataxia rating scales, and accelerometry. Volume of neural activation and TEED were also calculated for both paradigms. RESULTS For best dDBS, therapeutic window was wider and therapeutic threshold was lower compared to oDBS. While side effect threshold did not differ, volume of neural activation was larger for dDBS. In terms of clinical efficacy, dDBS was as effective as oDBS. CONCLUSIONS dDBS for ET widens therapeutic window due to reduction of therapeutic threshold. Larger volume of neural activation for dDBS at side effect threshold supports the notion of persistent directionality even at higher intensities. dDBS may compensate for slightly misplaced leads and should be considered first line for PSA/VIM-DBS.
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Affiliation(s)
- Sabine Bruno
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Petyo Nikolov
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian J Hartmann
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Carlos Trenado
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Functional Neurosurgery and Stereotaxy, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefan J Groiss
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Guzick A, Hunt PJ, Bijanki KR, Schneider SC, Sheth SA, Goodman WK, Storch EA. Improving long term patient outcomes from deep brain stimulation for treatment-refractory obsessive-compulsive disorder. Expert Rev Neurother 2019; 20:95-107. [PMID: 31730752 DOI: 10.1080/14737175.2020.1694409] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Deep brain stimulation (DBS) has emerged as an effective treatment for patients with severe treatment-refractory obsessive-compulsive disorder (OCD). Over the past two decades, several clinical trials with multiple years of follow-up have shown that DBS offers long-term symptom relief for individuals with severe OCD, though a portion of patients do not achieve an adequate response.Areas covered: This review sought to summarize the literature on the efficacy and long-term effectiveness of DBS for OCD, and to identify strategies that have the potential to improve treatment outcomes.Expert opinion: Although this literature is just emerging, a small number of DBS enhancement strategies have shown promising initial results. More posterior targets along the striatal axis and at the bed nucleus of the stria terminalis appear to offer greater symptom relief than more anterior targets. Research is also beginning to demonstrate the feasibility of maximizing treatment outcomes with target selection based on neural activation patterns during symptom provocation and clinical presentation. Finally, integrating DBS with post-surgery exposure and response prevention therapy appears to be another promising approach. Definitive conclusions about these strategies are limited by a low number of studies with small sample sizes that will require multi-site replication.
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Affiliation(s)
- Andrew Guzick
- Departments of Psychiatry & Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Section of Psychology, Texas Children's Hospital, Houston, TX, USA.,Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USA
| | - Patrick J Hunt
- Departments of Psychiatry & Pediatrics, Baylor College of Medicine, Houston, TX, USA.,Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, USA
| | - Kelly R Bijanki
- Departments of Psychiatry & Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Sophie C Schneider
- Departments of Psychiatry & Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Sameer A Sheth
- Departments of Psychiatry & Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Wayne K Goodman
- Departments of Psychiatry & Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Eric A Storch
- Departments of Psychiatry & Pediatrics, Baylor College of Medicine, Houston, TX, USA
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Bullard AJ, Hutchison BC, Lee J, Chestek CA, Patil PG. Estimating Risk for Future Intracranial, Fully Implanted, Modular Neuroprosthetic Systems: A Systematic Review of Hardware Complications in Clinical Deep Brain Stimulation and Experimental Human Intracortical Arrays. Neuromodulation 2019; 23:411-426. [DOI: 10.1111/ner.13069] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 08/05/2019] [Accepted: 09/10/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Autumn J. Bullard
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
| | | | - Jiseon Lee
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
| | - Cynthia A. Chestek
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
- Department of Electrical Engineering and Computer Science University of Michigan Ann Arbor MI USA
| | - Parag G. Patil
- Department of Biomedical Engineering University of Michigan Ann Arbor MI USA
- Department of Neurosurgery University of Michigan Medical School Ann Arbor MI USA
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Cordeiro JG, Diaz A, Davis JK, Di Luca DG, Farooq G, Luca CC, Jagid JR. Safety of Noncontrast Imaging-Guided Deep Brain Stimulation Electrode Placement in Parkinson Disease. World Neurosurg 2019; 134:e1008-e1014. [PMID: 31756502 DOI: 10.1016/j.wneu.2019.11.071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 01/30/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) is considered standard of care for the treatment of medically refractory Parkinson disease (PD). The placement of brain electrodes is performed using contrast imaging to enhance blood vessel identification during stereotactic planning. We present our experience with a series of patients implanted using noncontrast imaging. METHODS All cases of DBS surgery for PD performed between 2012 and 2018 with noncontrast imaging were retrospectively reviewed. Clinical features, postoperative imaging, and complications were analyzed. RESULTS A total of 287 deep-seated electrodes were implanted in 152 patients. Leads were placed at the subthalamic nucleus and globus pallidus internus in 258 and 29 hemispheres, respectively. We identified 2 cases of intracranial hemorrhage (0.7%). CONCLUSIONS DBS lead placement can be performed without the use of intravenous contrast with a postoperative intracranial hemorrhage rate comparable with other reported series.
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Affiliation(s)
| | - Anthony Diaz
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jenna Kylene Davis
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Daniel Garbin Di Luca
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Ghulam Farooq
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Corneliu C Luca
- Department of Neurology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Jonathan Russell Jagid
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA.
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Bot M, van Rootselaar F, Contarino MF, Odekerken V, Dijk J, de Bie R, Schuurman R, van den Munckhof P. Deep Brain Stimulation for Essential Tremor: Aligning Thalamic and Posterior Subthalamic Targets in 1 Surgical Trajectory. Oper Neurosurg (Hagerstown) 2019; 15:144-152. [PMID: 29281074 DOI: 10.1093/ons/opx232] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 10/04/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ventral intermediate nucleus (VIM) deep brain stimulation (DBS) and posterior subthalamic area (PSA) DBS suppress tremor in essential tremor (ET) patients, but it is not clear which target is optimal. Aligning both targets in 1 surgical trajectory would facilitate exploring stimulation of either target in a single patient. OBJECTIVE To evaluate aligning VIM and PSA in 1 surgical trajectory for DBS in ET. METHODS Technical aspects of trajectories, intraoperative stimulation findings, final electrode placement, target used for chronic stimulation, and adverse and beneficial effects were evaluated. RESULTS In 17 patients representing 33 trajectories, we successfully aligned VIM and PSA targets in 26 trajectories. Trajectory distance between targets averaged 7.2 (range 6-10) mm. In all but 4 aligned trajectories, optimal intraoperative tremor suppression was obtained in the PSA. During follow-up, active electrode contacts were located in PSA in the majority of cases. Overall, successful tremor control was achieved in 69% of patients. Stimulation-induced dysarthria or gait ataxia occurred in, respectively, 56% and 44% of patients. Neither difference in tremor suppression or side effects was noted between aligned and nonaligned leads nor between the different locations of chronic stimulation. CONCLUSION Alignment of VIM and PSA for DBS in ET is feasible and enables intraoperative exploration of both targets in 1 trajectory. This facilitates positioning of electrode contacts in both areas, where multiple effective points of stimulation can be found. In the majority of aligned leads, optimal intraoperative and chronic stimulation were located in the PSA.
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Affiliation(s)
- Maarten Bot
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Nether-lands
| | - Fleur van Rootselaar
- Department of Neurology and Clinical Neurophysiology, Academic Med-ical Center, Amsterdam, The Netherlands
| | - Maria Fiorella Contarino
- Department of Neurology, Haga Teach-ing Hospital, The Hague, The Netherlands.,Department of Neurology, Leiden Uni-versity Medical Center, Leiden, The Netherlands
| | - Vincent Odekerken
- Department of Neurology and Clinical Neurophysiology, Academic Med-ical Center, Amsterdam, The Netherlands
| | - Joke Dijk
- Department of Neurology and Clinical Neurophysiology, Academic Med-ical Center, Amsterdam, The Netherlands
| | - Rob de Bie
- Department of Neurology and Clinical Neurophysiology, Academic Med-ical Center, Amsterdam, The Netherlands
| | - Richard Schuurman
- Department of Neurosurgery, Academic Medical Center, Amsterdam, The Nether-lands
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Nowacki A, Bogdanovic M, Sarangmat N, Fitzgerald J, Green A, Aziz TZ. Revisiting the rules for anatomical targeting of ventralis intermediate nucleus. J Clin Neurosci 2019; 68:97-100. [DOI: 10.1016/j.jocn.2019.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/23/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022]
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Palakurthi B, Burugupally SP. Postural Instability in Parkinson's Disease: A Review. Brain Sci 2019; 9:brainsci9090239. [PMID: 31540441 PMCID: PMC6770017 DOI: 10.3390/brainsci9090239] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 09/14/2019] [Accepted: 09/16/2019] [Indexed: 12/13/2022] Open
Abstract
Parkinson’s disease (PD) is a heterogeneous progressive neurodegenerative disorder, which typically affects older adults; it is predicted that by 2030 about 3% of the world population above 65 years of age is likely to be affected. At present, the diagnosis of PD is clinical, subjective, nonspecific, and often inadequate. There is a need to quantify the PD factors for an objective disease assessment. Among the various factors, postural instability (PI) is unresponsive to the existing treatment strategies resulting in morbidity. In this work, we review the physiology and pathophysiology of postural balance that is essential to treat PI among PD patients. Specifically, we discuss some of the reported factors for an early PI diagnosis, including age, nervous system lesions, genetic mutations, abnormal proprioception, impaired reflexes, and altered biomechanics. Though the contributing factors to PI have been identified, how their quantification to grade PI severity in a patient can help in treatment is not fully understood. By contextualizing the contributing factors, we aim to assist the future research efforts that underpin posturographical and histopathological studies to measure PI in PD. Once the pathology of PI is established, effective diagnostic tools and treatment strategies could be developed to curtail patient falls.
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Affiliation(s)
- Bhavana Palakurthi
- Department of Biological Sciences, University of Notre Dame, Notre Dame, IN 46556, USA.
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36
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Nowacki A, Debove I, Rossi F, Schlaeppi JA, Petermann K, Wiest R, Schüpbach M, Pollo C. Targeting the posterior subthalamic area for essential tremor: proposal for MRI-based anatomical landmarks. J Neurosurg 2019; 131:820-827. [PMID: 30497206 DOI: 10.3171/2018.4.jns18373] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/12/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) of the posterior subthalamic area (PSA) is an alternative to thalamic DBS for the treatment of essential tremor (ET). The dentato-rubro-thalamic tract (DRTT) has recently been proposed as the anatomical substrate underlying effective stimulation. For clinical purposes, depiction of the DRTT mainly depends on diffusion tensor imaging (DTI)-based tractography, which has some drawbacks. The objective of this study was to present an accurate targeting strategy for DBS of the PSA based on anatomical landmarks visible on MRI and to evaluate clinical effectiveness. METHODS The authors performed a retrospective cohort study of a prospective series of 11 ET patients undergoing bilateral DBS of the PSA. The subthalamic nucleus and red nucleus served as anatomical landmarks to define the target point within the adjacent PSA on 3-T T2-weighted MRI. Stimulating contact (SC) positions with reference to the midcommissural point were analyzed and projected onto the stereotactic atlas of Morel. Postoperative outcome assessment after 6 and 12 months was based on change in Tremor Rating Scale (TRS) scores. RESULTS Actual target position corresponded to the intended target based on anatomical landmarks depicted on MRI. The total TRS score was reduced (improved) from 47.2 ± 15.7 to 21.3 ± 10.7 (p < 0.001). No severe complication occurred. The mean SC position projected onto the PSA at the margin of the cerebellothalamic fascicle and the zona incerta. CONCLUSIONS Targeting of the PSA based on anatomical landmarks representable on MRI is reliable and leads to accurate lead placement as well as good long-term clinical outcome.
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Affiliation(s)
| | | | | | | | | | - Roland Wiest
- 3Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, and University of Bern, Bern, Switzerland
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Fasano A, Helmich RC. Tremor habituation to deep brain stimulation: Underlying mechanisms and solutions. Mov Disord 2019; 34:1761-1773. [PMID: 31433906 DOI: 10.1002/mds.27821] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 07/01/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022] Open
Abstract
DBS of the ventral intermediate nucleus is an extremely effective treatment for essential tremor, although a waning benefit is observed after a variable time in a variable proportion of patients (ranging from 0% to 73%), a concept historically defined as "tolerance." Tolerance is currently an established concept in the medical community, although there is debate on its real existence. In fact, very few publications have actually addressed the problem, thus making tolerance a typical example of science based on "eminence rather than evidence." The underpinnings of the phenomena associated with the progressive loss of DBS benefit are not fully elucidated, although the interplay of different-not mutually exclusive-factors has been advocated. In this viewpoint, we gathered the evidence explaining the progressive loss of benefit observed after DBS. We grouped these factors in three categories: disease-related factors (tremor etiology and progression); surgery-related factors (electrode location, microlesional effect and placebo); and stimulation-related factors (not optimized stimulation, stimulation-induced side effects, habituation, and tremor rebound). We also propose possible pathophysiological explanations for the phenomenon and define a nomenclature of the associated features: early versus late DBS failure; tremor rebound versus habituation (to be preferred over tolerance). Finally, we provide a practical approach for preventing and treating this loss of DBS benefit, and we draft a possible roadmap for the research to come. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada; Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Rick C Helmich
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Nijmegen, The Netherlands
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The onset mechanism of Parkinson's beta oscillations: A theoretical analysis. J Theor Biol 2019; 470:1-16. [PMID: 30858065 DOI: 10.1016/j.jtbi.2019.03.008] [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: 08/24/2018] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 11/20/2022]
Abstract
In this paper, we build a basal ganglia-cortex-thalamus model to study the oscillatory mechanisms and boundary conditions of the beta frequency band (13-30 Hz) that appears in the subthalamic nucleus. First, a theoretical oscillatory boundary formula is obtained in a simplified model by using the Laplace transform and linearization process of the system at fixed points. Second, we simulate the oscillatory boundary conditions through numerical calculations, which fit with our theoretical results very well, at least in the changing trend. We find that several critical coupling strengths in the model exert great effects on the oscillations, the mechanisms of which differ but can be explained in detail by our model and the oscillatory boundary formula. Specifically, we note that the relatively small or large sizes of the coupling strength from the fast-spiking interneurons to the medium spiny neurons and from the cortex to the fast-spiking interneurons both have obvious maintenance roles on the states. Similar phenomena have been reported in other neurological diseases, such as absence epilepsy. However, some of those interesting mutual regulation mechanisms in the model have rarely been considered in previous studies. In addition to the coupling weight in the pathway, in this work, we show that the delay is a key parameter that affects oscillations. On the one hand, the system needs a minimum delay to generate oscillations; on the other hand, in the appropriate range, a longer delay leads to a higher activation level of the subthalamic nucleus. In this paper, we study the oscillation activities that appear on the subthalamic nucleus. Moreover, all populations in the model show the dynamic behaviour of a synchronous resonance. Therefore, we infer that the mechanisms obtained can be expanded to explore the state of other populations, and that the model provides a unified framework for studying similar problems in the future. Moreover, the oscillatory boundary curves obtained are all critical conditions between the stable state and beta frequency oscillation. The method is also suitable for depicting other common frequency bands during brain oscillations, such as the alpha band (8-12 Hz), theta band (4-7 Hz) and delta band (1-3 Hz). Thus, the results of this work are expected to help us better understand the onset mechanism of parkinson's oscillations and can inspire related experimental research in this field.
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Koeglsperger T, Palleis C, Hell F, Mehrkens JH, Bötzel K. Deep Brain Stimulation Programming for Movement Disorders: Current Concepts and Evidence-Based Strategies. Front Neurol 2019; 10:410. [PMID: 31231293 PMCID: PMC6558426 DOI: 10.3389/fneur.2019.00410] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/04/2019] [Indexed: 11/16/2022] Open
Abstract
Deep brain stimulation (DBS) has become the treatment of choice for advanced stages of Parkinson's disease, medically intractable essential tremor, and complicated segmental and generalized dystonia. In addition to accurate electrode placement in the target area, effective programming of DBS devices is considered the most important factor for the individual outcome after DBS. Programming of the implanted pulse generator (IPG) is the only modifiable factor once DBS leads have been implanted and it becomes even more relevant in cases in which the electrodes are located at the border of the intended target structure and when side effects become challenging. At present, adjusting stimulation parameters depends to a large extent on personal experience. Based on a comprehensive literature search, we here summarize previous studies that examined the significance of distinct stimulation strategies for ameliorating disease signs and symptoms. We assess the effect of adjusting the stimulus amplitude (A), frequency (f), and pulse width (pw) on clinical symptoms and examine more recent techniques for modulating neuronal elements by electrical stimulation, such as interleaving (Medtronic®) or directional current steering (Boston Scientific®, Abbott®). We thus provide an evidence-based strategy for achieving the best clinical effect with different disorders and avoiding adverse effects in DBS of the subthalamic nucleus (STN), the ventro-intermedius nucleus (VIM), and the globus pallidus internus (GPi).
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Affiliation(s)
- Thomas Koeglsperger
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Carla Palleis
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Franz Hell
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität München, Martinsried, Germany
| | - Jan H Mehrkens
- Department of Neurosurgery, Ludwig Maximilians University, Munich, Germany
| | - Kai Bötzel
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
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Deep stimulation in neurosurgery. КЛИНИЧЕСКАЯ ПРАКТИКА 2019. [DOI: 10.17816/clinpract10163-71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The technique of deep brain stimulation is used to treat patients with various diseases of the central nervous system who are not amenable to conservative therapy, while open interventions in them are associated with a high risk of complications. In the review, we evaluate the efficiency of the deep stimulation of different regions of the brain in some pharmacoresistant forms of diseases.
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Harary M, Segar DJ, Hayes MT, Cosgrove GR. Unilateral Thalamic Deep Brain Stimulation Versus Focused Ultrasound Thalamotomy for Essential Tremor. World Neurosurg 2019; 126:e144-e152. [PMID: 30794976 DOI: 10.1016/j.wneu.2019.01.281] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 01/28/2019] [Accepted: 01/30/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The predominant neurosurgical approach to medication-refractory essential tremor is thalamic deep brain stimulation (DBS). The emergence of magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy has reawakened the debate surrounding the use of DBS versus thalamotomy for this indication. Herein, we aimed to provide a contemporary comparison between DBS and MRgFUS. METHODS Two controlled trials that evaluated DBS and MRgFUS for the unilateral treatment of refractory essential tremor were compared. Clinical outcomes extracted included postural tremor score in the treated upper extremity, quality of life (QoL), and incidence of adverse events (AE). RESULTS Baseline patient characteristics were comparable in the 2 studies, except that DBS patients were younger and had more severe baseline tremor. Both DBS- and MRgFUS-treated patients had significant tremor improvement that was sustained for 1-year posttreatment, and significant improvement in QoL. The MRgFUS cohort had higher rates of persistent neurologic AE, whereas the DBS group had higher rates of surgery- and hardware-related AEs, including intracranial hemorrhage. CONCLUSIONS In context of prior literature, both DBS and MRgFUS significantly improve tremor control and QoL. The 2 approaches are predominantly differentiated by their AE-profile. Additional head-to-head comparison on matched clinical populations are required to more accurately compare clinical efficacy and long-term outcomes.
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Affiliation(s)
- Maya Harary
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David J Segar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael T Hayes
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Barcia JA, Avecillas-Chasín JM, Nombela C, Arza R, García-Albea J, Pineda-Pardo JA, Reneses B, Strange BA. Personalized striatal targets for deep brain stimulation in obsessive-compulsive disorder. Brain Stimul 2018; 12:724-734. [PMID: 30670359 DOI: 10.1016/j.brs.2018.12.226] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 12/05/2018] [Accepted: 12/15/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Psychiatric conditions currently treated with deep brain stimulation (DBS), such as obsessive-compulsive disorder (OCD), are heterogeneous diseases with different symptomatic dimensions, indicating that fixed neuroanatomical DBS targets for all OCD cases may not be efficacious. OBJECTIVE/HYPOTHESIS We tested whether the optimal DBS target for OCD is fixed for all patients or whether it is individualized and related to each patient's symptomatic content. Further, we explored if the optimal target can be predicted by combining functional neuroimaging and structural connectivity. METHODS In a prospective, randomized, double-blinded study in 7 OCD patients, symptomatic content was characterized pre-operatively by clinical interview and OCD symptom-provocation during functional MRI. DBS electrode implantation followed a trajectory placing 4 contacts along a striatal axis (nucleus accumbens to caudate). Patients underwent three-month stimulation periods for each contact (and sham), followed by clinical evaluation. Probabilistic tractography, applied to diffusion-weighted images acquired pre-operatively, was used to study the overlap between projections from the prefrontal areas activated during symptom provocation and the volume of activated tissue of each electrode contact. RESULTS Six patients were classified responders, with median symptomatic reduction of 50% achieved from each patient's best contact. This was located at the caudate in 4 cases and at the accumbens in 2. Critically, the anatomical locus of the best contact (accumbens or caudate) was related to an index derived by combining functional MRI responses to prevailing symptom provocation and prefronto-cortico-striatal projections defined by probabilistic tractography. CONCLUSION Our results therefore represent a step towards personalized, content-specific DBS targets for OCD.
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Affiliation(s)
- Juan A Barcia
- Service of Neurosurgery, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain; Department of Surgery, Universidad Complutense de Madrid, Madrid, Spain.
| | - Josué M Avecillas-Chasín
- Service of Neurosurgery, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
| | - Cristina Nombela
- Service of Neurosurgery, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
| | - Rocío Arza
- Service of Neurosurgery, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
| | - Julia García-Albea
- Service of Psychiatry, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
| | - José A Pineda-Pardo
- CINAC, HM Puerta del Sur, Hospitales de Madrid, Mostoles, and CEU-San Pablo University, Madrid, Spain
| | - Blanca Reneses
- Service of Psychiatry, Hospital Clinico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos, Madrid, Spain
| | - Bryan A Strange
- Laboratory for Clinical Neuroscience, Centre for Biomedical Technology, Universidad Politecnica de Madrid, Spain; Department of Neuroimaging, Reina Sofia Centre for Alzheimer's Disease, Madrid, Spain
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Seier M, Hiller A, Quinn J, Murchison C, Brodsky M, Anderson S. Alternating Thalamic Deep Brain Stimulation for Essential Tremor: A Trial to Reduce Habituation. Mov Disord Clin Pract 2018; 5:620-626. [PMID: 30637283 DOI: 10.1002/mdc3.12685] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 09/03/2018] [Accepted: 09/09/2018] [Indexed: 11/08/2022] Open
Abstract
Background DBS in the ventral intermediate nucleus (VIM) of the thalamus has been a revolutionary treatment for patients with essential tremor (ET) by reducing tremor. Unfortunately, some patients develop habituation to DBS and thus experience reduced efficacy and loss of tremor control. There are no standardized methods of addressing habituation to DBS. We propose alternating stimulation patterns as a way to reduce habituation. Methods This was a randomized, placebo-controlled trial for patients with VIM DBS for ET. Patients were randomized to either experimental treatment arm of alternating stimulation patterns on a weekly basis or standard care arm of continuous stimulation settings for 12 weeks. Primary outcome was change in the performance subscale of The Essential Tremor Rating Assessment Scale (TETRAS), which was performed at initial visit and 12-week follow-up. Secondary outcome included change in the activities of daily living subscale of TETRAS. Results Twenty-two patients were enrolled in the trial, and 16 were analyzed at follow-up. Experimental treatment subjects displayed sustained tremor control compared to standard care, as measured by the change in TETRAS performance subscale (-0.6 vs. 6.7 point change, respectively) with a 7.3 difference between the arms (P = 0.006). Conclusion Alternating stimulation patterns on a weekly basis for ET patients with VIM DBS reduced habituation in this pilot study. This study suggests that exposure to different stimulation groups may maintain better tremor control compared to constant stimulation parameters.
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Affiliation(s)
- Mara Seier
- Department of Neurological Sciences University of Nebraska Medical Center Omaha Nebraska USA
| | - Amie Hiller
- Northwest Parkinson Disease Research Education and Clinical Center, Portland VA Medical Center Portland Oregon USA.,Department of Neurology Oregon Health Sciences University Portland Oregon USA
| | - Joseph Quinn
- Northwest Parkinson Disease Research Education and Clinical Center, Portland VA Medical Center Portland Oregon USA.,Department of Neurology Oregon Health Sciences University Portland Oregon USA
| | - Charles Murchison
- Department of Biostatistics, School of Public Health University of Alabama at Birmingham Birmingham Alabama USA
| | - Matthew Brodsky
- Department of Neurology Oregon Health Sciences University Portland Oregon USA
| | - Shannon Anderson
- Department of Neurology Oregon Health Sciences University Portland Oregon USA
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Witjas-Slucki T. Surgical treatments for tremors. Rev Neurol (Paris) 2018; 174:615-620. [PMID: 30224158 DOI: 10.1016/j.neurol.2018.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 07/20/2018] [Accepted: 07/24/2018] [Indexed: 10/28/2022]
Abstract
Stereotactic surgery is an increasingly popular option for disabling tremors whenever it is insufficiently improved by drug treatment. Surgical approaches are expanding. Thalamic deep brain stimulation is one of the most efficacious treatments. Its recent technological advances with adaptive stimulation and new electrodes configuration will allow a more physiological stimulation. However, a reappraisal of less invasive, new lesioning procedures is underway. Gamma Knife thalamotomy and magnetic resonance-guided focused ultrasounds encounter very few contraindications. Recent studies reported their efficacy on tremor control and safety profile. Besides the ventralis intermedius nucleus of the thalamus, alternative targets are also emerging. The effectiveness of surgical therapies on essential tremor and Parkinson's disease tremor is well established. For more uncommon tremors, preliminary studies are encouraging. All these surgical therapies can be proposed as treatment option for medically refractory tremors.
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Affiliation(s)
- T Witjas-Slucki
- Service de neurologie et pathologie du mouvement, UMR 7289 CNRS Aix-Marseille université, institut de neurosciences de la Timone, CHU Timone, Marseille, boulevard, Jean-Moulin, 13005 Marseille, France.
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Benefits and risks of unilateral and bilateral ventral intermediate nucleus deep brain stimulation for axial essential tremor symptoms. Parkinsonism Relat Disord 2018; 60:126-132. [PMID: 30220556 DOI: 10.1016/j.parkreldis.2018.09.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/09/2018] [Accepted: 09/04/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Many experts assume bilateral deep brain stimulation (DBS) is necessary to improve axial tremor in essential tremor (ET). In the largest clinical trial of DBS for ET to date evaluating a non-directional, constant current device, we studied the effects of unilateral and staged bilateral DBS on axial tremor. METHODS We included all participants from the original trial with unilateral ventral intermediate nucleus (VIM) DBS and 90-day follow up at minimum. Primary outcomes were changes in pooled axial subscores in the Clinical Rating Scale for Tremor (CRST) at 90 and 180 days after activation of unilateral VIM DBS compared to pre-operative baseline (n=119). Additionally, we performed within-subject analyses for unilateral versus bilateral DBS at 180 days in the cohort who underwent staged surgery to bilateral DBS (n=39). RESULTS Unilateral VIM DBS improved midline tremor by 58% at 90 days (median[IQR]) (3[3] to 1[2], p<0.001) and 65% at 180 days (3[3] to 1[2], p<0.001) versus pre-op baseline. In the staged to bilateral DBS cohort, midline tremor scores further improved after bilateral DBS at 180 days by 63% versus unilateral DBS (3[3] to 1[3], p=0.007). There were, however, 35 additional DBS and surgery-related adverse events, 14 related to incoordination, gait impairment, or speech impairment, versus 6 after unilateral DBS. CONCLUSION Unilateral VIM DBS for ET significantly improved associated axial tremor. Staged bilateral DBS was associated with additional axial tremor improvement but also additional adverse events. Unilateral VIM DBS may be sufficient to achieve a goal of contralateral limb and axial tremor attenuation.
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Choe CU, Hidding U, Schaper M, Gulberti A, Köppen J, Buhmann C, Gerloff C, Moll CKE, Hamel W, Pötter-Nerger M. Thalamic short pulse stimulation diminishes adverse effects in essential tremor patients. Neurology 2018; 91:e704-e713. [PMID: 30045955 DOI: 10.1212/wnl.0000000000006033] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/23/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the effect of directional current steering and short pulse stimulation in the ventral intermediate thalamic nucleus (VIM) on stimulation-induced side effects in patients with essential tremor. METHODS We recruited 8 patients with essential tremor in a stable postoperative condition (>3 months after electrode implantation of deep brain stimulation [DBS] electrodes) with segmented contacts implanted in the VIM. Tremor severity on acute stimulation was assessed by the Fahn-Tolosa-Marin Tremor Rating Scale. Cerebellar impairment was evaluated with the International Cooperative Ataxia Rating Scale. Patients rated paresthesia intensity with a visual analog scale. RESULTS In all patients, tremor was reduced to the same extent by VIM stimulation regardless of pulse width using energy dose-equivalent amplitudes. Short pulse stimulation diminished stimulation-induced ataxia of the upper extremities and paresthesia compared with conventional parameters. Directional steering with monopolar stimulation of single segments successfully suppressed tremor but also induced ataxia. No differences in adverse effects were found between single-segment stimulation conditions. CONCLUSION These proof-of-principle findings provide evidence that acute short pulse stimulation is superior to directional steering in the subthalamic area to decrease stimulation-induced side effects while preserving tremor suppression effects in patients with tremor. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with tremor with thalamic DBS, acute short pulse stimulation reduces adverse effects, while directional steering does not provide a generalizable benefit regarding adverse effects.
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Affiliation(s)
- Chi-Un Choe
- From the Departments of Neurology (C.-u.C., U.H., A.G., C.B., C.G., M.P.-N.), Neurosurgery (M.S., J.K., W.H.), and Neurophysiology and Pathophysiology (A.G., C.K.E.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Ute Hidding
- From the Departments of Neurology (C.-u.C., U.H., A.G., C.B., C.G., M.P.-N.), Neurosurgery (M.S., J.K., W.H.), and Neurophysiology and Pathophysiology (A.G., C.K.E.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miriam Schaper
- From the Departments of Neurology (C.-u.C., U.H., A.G., C.B., C.G., M.P.-N.), Neurosurgery (M.S., J.K., W.H.), and Neurophysiology and Pathophysiology (A.G., C.K.E.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandro Gulberti
- From the Departments of Neurology (C.-u.C., U.H., A.G., C.B., C.G., M.P.-N.), Neurosurgery (M.S., J.K., W.H.), and Neurophysiology and Pathophysiology (A.G., C.K.E.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Köppen
- From the Departments of Neurology (C.-u.C., U.H., A.G., C.B., C.G., M.P.-N.), Neurosurgery (M.S., J.K., W.H.), and Neurophysiology and Pathophysiology (A.G., C.K.E.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Buhmann
- From the Departments of Neurology (C.-u.C., U.H., A.G., C.B., C.G., M.P.-N.), Neurosurgery (M.S., J.K., W.H.), and Neurophysiology and Pathophysiology (A.G., C.K.E.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- From the Departments of Neurology (C.-u.C., U.H., A.G., C.B., C.G., M.P.-N.), Neurosurgery (M.S., J.K., W.H.), and Neurophysiology and Pathophysiology (A.G., C.K.E.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K E Moll
- From the Departments of Neurology (C.-u.C., U.H., A.G., C.B., C.G., M.P.-N.), Neurosurgery (M.S., J.K., W.H.), and Neurophysiology and Pathophysiology (A.G., C.K.E.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- From the Departments of Neurology (C.-u.C., U.H., A.G., C.B., C.G., M.P.-N.), Neurosurgery (M.S., J.K., W.H.), and Neurophysiology and Pathophysiology (A.G., C.K.E.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Pötter-Nerger
- From the Departments of Neurology (C.-u.C., U.H., A.G., C.B., C.G., M.P.-N.), Neurosurgery (M.S., J.K., W.H.), and Neurophysiology and Pathophysiology (A.G., C.K.E.M.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Abstract
INTRODUCTION Essential tremor is the most common form of pathologic tremor. Surgical therapies disrupt tremorogenic oscillation in the cerebellothalamocortical pathway and are capable of abolishing severe tremor that is refractory to available pharmacotherapies. Surgical methods are raspidly improving and are the subject of this review. Areas covered: A PubMed search on 18 January 2018 using the query essential tremor AND surgery produced 839 abstracts. 379 papers were selected for review of the methods, efficacy, safety and expense of stereotactic deep brain stimulation (DBS), stereotactic radiosurgery (SRS), focused ultrasound (FUS) ablation, and radiofrequency ablation of the cerebellothalamocortical pathway. Expert commentary: DBS and SRS, FUS and radiofrequency ablations are capable of reducing upper extremity tremor by more than 80% and are far more effective than any available drug. The main research questions at this time are: 1) the relative safety, efficacy, and expense of DBS, SRS, and FUS performed unilaterally and bilaterally; 2) the relative safety and efficacy of thalamic versus subthalamic targeting; 3) the relative safety and efficacy of atlas-based versus direct imaging tractography-based anatomical targeting; and 4) the need for intraoperative microelectrode recordings and macroelectrode stimulation in awake patients to identify the optimum anatomical target. Randomized controlled trials are needed.
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Affiliation(s)
- Rodger J Elble
- a Neuroscience Institute , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Ludy Shih
- b Department of Neurology , Beth Israel Deaconess Medical Center, Harvard Medical School , Boston , Massachusetts USA
| | - Jeffrey W Cozzens
- a Neuroscience Institute , Southern Illinois University School of Medicine , Springfield , Illinois , USA
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Tuleasca C, Régis J, Najdenovska E, Witjas T, Girard N, Champoudry J, Faouzi M, Thiran JP, Cuadra MB, Levivier M, Van De Ville D. Pretherapeutic Functional Imaging Allows Prediction of Head Tremor Arrest After Thalamotomy for Essential Tremor: The Role of Altered Interconnectivity Between Thalamolimbic and Supplementary Motor Circuits. World Neurosurg 2018; 112:e479-e488. [PMID: 29410136 DOI: 10.1016/j.wneu.2018.01.063] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To correlate pretherapeutic resting-state functional magnetic resonance imaging (rs-fMRI) measures with pretherapeutic head tremor presence and/or further improvement 1 year after stereotactic radiosurgical thalamotomy (SRS-T) for essential tremor (ET). METHODS We prospectively collected head tremor scores (range, 0-3) and rs-fMRI data for a cohort of 17 consecutive ET patients in pretherapeutic and 1 year after SRS-T states. We additionally acquired rs-fMRI data for a healthy control (HC) group (n = 12). Group-level independent component analysis (n = 17 for pretherapeutic rs-fMRI) was applied to decompose neuroimaging data into 20 large-scale brain networks using a standard approach. Through spatial regression, we projected 1 year after SRS-T and HC rs-fMRI time points, on the same 20 brain networks. RESULTS Pretherapeutic interconnectivity (IC) strength between the network including bilateral thalamus and limbic system with left supplementary motor area predicted head tremor improvement at 1 year after SRS-T (family-wise corrected P < 0.001, cluster size Kc = 146). For the statistically significant cluster, IC strength was strongest in HCs (mean, 4.6; median, 3.8) compared with pre- (mean, 0.1; median, 0.2) or posttherapeutic (mean, -0.2; median, 0.09) states. CONCLUSIONS Baseline measures of IC between bilateral thalamus and limbic system with left supplementary motor area may predict head tremor arrest after thalamotomy. However, procedures such as SRS-T, for this particular clinical feature, do not align patients to HCs in terms of functional brain connectivity. We postulate that supplementary motor area is modulating head tremor appearance, by abnormal connectivity with the thalamolimbic system.
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Affiliation(s)
- Constantin Tuleasca
- Centre Hospitalier Universitaire Vaudois, Neurosurgery Service and Gamma Knife Center, Lausanne, Switzerland; Signal Processing Laboratory (LTS5), Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.
| | - Jean Régis
- Stereotactic and Functional Neurosurgery Service and Gamma Knife Unit, CHU Timone, Marseille, France
| | - Elena Najdenovska
- Medical Image Analysis Laboratory and Department of Radiology-Center of Biomedical Imaging, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | - Nadine Girard
- Department of Diagnostic and Interventional Neuroradiology, AMU, CRMBM UMR CNRS 7339, Faculté de Médecine et APHM, Hopital Timone, Marseille, France
| | - Jérôme Champoudry
- Stereotactic and Functional Neurosurgery Service and Gamma Knife Unit, CHU Timone, Marseille, France
| | - Mohamed Faouzi
- Centre for Clinical Epidemiology, Institute of Social and Preventive Medicine, Lausanne, Switzerland
| | - Jean-Philippe Thiran
- Signal Processing Laboratory (LTS5), Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland; Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Meritxell Bach Cuadra
- Medical Image Analysis Laboratory and Department of Radiology-Center of Biomedical Imaging, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Signal Processing Laboratory (LTS5), Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
| | - Marc Levivier
- Centre Hospitalier Universitaire Vaudois, Neurosurgery Service and Gamma Knife Center, Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Dimitri Van De Ville
- Faculty of Medicine, University of Geneva, Geneva, Switzerland; Medical Image Processing Laboratory, Ecole Polytechnique Fédérale de Lausanne, Lausanne, Switzerland
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Reinacher PC, Amtage F, Rijntjes M, Piroth T, Prokop T, Jenkner C, Kätzler J, Coenen VA. One Pass Thalamic and Subthalamic Stimulation for Patients with Tremor-Dominant Idiopathic Parkinson Syndrome (OPINION): Protocol for a Randomized, Active-Controlled, Double-Blinded Pilot Trial. JMIR Res Protoc 2018; 7:e36. [PMID: 29382631 PMCID: PMC5811645 DOI: 10.2196/resprot.8341] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Revised: 12/13/2017] [Accepted: 12/16/2017] [Indexed: 01/15/2023] Open
Abstract
Background Besides fluctuations, therapy refractory tremor is one of the main indications of deep brain stimulation (DBS) in patients with idiopathic Parkinson syndrome (IPS). Although thalamic DBS (ventral intermediate nucleus [Vim] of thalamus) has been shown to reduce tremor in 85-95% of patients, bradykinesia and rigidity often are not well controlled. The dentato-rubro-thalamic tract (DRT) that can directly be targeted with special diffusion tensor magnetic resonance imaging sequences has been shown as an efficient target for thalamic DBS. The subthalamic nucleus (STN) is typically chosen in younger patients as the target for dopamine-responsive motor symptoms. This study investigates a one-path thalamic (Vim/DRT) and subthalamic implantation of DBS electrodes and possibly a combined stimulation strategy for both target regions. Objective This study investigates a one path thalamic (Vim/DRT) and subthalamic implantation of DBS electrodes and a possibly combined stimulation strategy for both target regions. Methods This is a randomized, active-controlled, double-blinded (patient- and observer-blinded), monocentric trial with three treatments, three periods and six treatment sequences allocated according to a Williams design. Eighteen patients will undergo one-path thalamic (Vim/DRT) and STN implantation of DBS electrodes. After one month, a double-blinded and randomly-assigned stimulation of the thalamic target (Vim/DRT), the STN and a combined stimulation of both target regions will be performed for a period of three months each. The primary objective is to assess the quality of life obtained by the Parkinson’s Disease Questionnaire (39 items) for each stimulation modality. Secondary objectives include tremor reduction (obtained by the Fahn-Tolosa-Marin tremor rating scale, video recordings, the Unified Parkinson’s disease rating scale, and by tremor analysis), psychiatric assessment of patients, and to assess the safety of intervention. Results At the moment, the recruitment is stopped and 12 patients have been randomized and treated. A futility analysis is being carried out by means of a conditional power analysis. Conclusions The approach of the OPINION trial planned to make, for the first time, a direct comparison of the different stimulation conditions (Vim/DRT, compared to STN, compared to Vim/DRT+STN) in a homogeneous patient population and, furthermore, will allow for intraindividual comparison of each condition with the “quality of life” outcome parameter. We hypothesize that the combined stimulation of the STN and the thalamic (Vim/DRT) target will be superior with respect to the patients’ quality of life as compared to the singular stimulation of the individual target regions. If this holds true, this work might change the standardized treatment described in the previous section. Trial Registration ClinicalTrials.gov: NCT02288468; https://clinicaltrials.gov/ct2/show/NCT02288468 (Archived by WebCite at http://www.webcitation.org/6wlKnt2pJ); and German Clinical Trials Register: DRKS00007526; https://www.drks.de/drks_ web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00007526 (Archived by WebCite at http://www.webcitation.org/6wlKyXZZL).
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Affiliation(s)
- Peter Christoph Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Florian Amtage
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Neurology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Michel Rijntjes
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Neurology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Tobias Piroth
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Neurology, Medical Center, University of Freiburg, Freiburg, Germany
| | - Thomas Prokop
- Department of Stereotactic and Functional Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Carolin Jenkner
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Clinical Trials Unit Freiburg, Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Kätzler
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Clinical Trials Unit Freiburg, Medical Center, University of Freiburg, Freiburg, Germany
| | - Volker Arnd Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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