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Zampogna A, Suppa A, Bove F, Cavallieri F, Castrioto A, Meoni S, Pelissier P, Schmitt E, Chabardes S, Fraix V, Moro E. Disentangling Bradykinesia and Rigidity in Parkinson's Disease: Evidence from Short- and Long-Term Subthalamic Nucleus Deep Brain Stimulation. Ann Neurol 2024; 96:234-246. [PMID: 38721781 DOI: 10.1002/ana.26961] [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: 11/28/2023] [Revised: 04/04/2024] [Accepted: 04/07/2024] [Indexed: 07/11/2024]
Abstract
OBJECTIVE Bradykinesia and rigidity are considered closely related motor signs in Parkinson disease (PD), but recent neurophysiological findings suggest distinct pathophysiological mechanisms. This study aims to examine and compare longitudinal changes in bradykinesia and rigidity in PD patients treated with bilateral subthalamic nucleus deep brain stimulation (STN-DBS). METHODS In this retrospective cohort study, the clinical progression of appendicular and axial bradykinesia and rigidity was assessed up to 15 years after STN-DBS in the best treatment conditions (ON medication and ON stimulation). The severity of bradykinesia and rigidity was examined using ad hoc composite scores from specific subitems of the Unified Parkinson's Disease Rating Scale motor part (UPDRS-III). Short- and long-term predictors of bradykinesia and rigidity were analyzed through linear regression analysis, considering various preoperative demographic and clinical data, including disease duration and severity, phenotype, motor and cognitive scores (eg, frontal score), and medication. RESULTS A total of 301 patients were examined before and 1 year after surgery. Among them, 101 and 56 individuals were also evaluated at 10-year and 15-year follow-ups, respectively. Bradykinesia significantly worsened after surgery, especially in appendicular segments (p < 0.001). Conversely, rigidity showed sustained benefit, with unchanged clinical scores compared to preoperative assessment (p > 0.05). Preoperative motor disability (eg, composite scores from the UPDRS-III) predicted short- and long-term outcomes for both bradykinesia and rigidity (p < 0.01). Executive dysfunction was specifically linked to bradykinesia but not to rigidity (p < 0.05). INTERPRETATION Bradykinesia and rigidity show long-term divergent progression in PD following STN-DBS and are associated with independent clinical factors, supporting the hypothesis of partially distinct pathophysiology. ANN NEUROL 2024;96:234-246.
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Affiliation(s)
- Alessandro Zampogna
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
- Grenoble Alpes University, Division of Neurology, Centre Hospitalier Universitaire de Grenoble, Grenoble Institute of Neuroscience, INSERM U1216, Grenoble, France
- IRCCS Neuromed Institute, Pozzilli, Italy
| | - Antonio Suppa
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
- IRCCS Neuromed Institute, Pozzilli, Italy
| | - Francesco Bove
- Neurology Unit, Department of Neuroscience, Sensory Organs and Chest, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Cavallieri
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Anna Castrioto
- Grenoble Alpes University, Division of Neurology, Centre Hospitalier Universitaire de Grenoble, Grenoble Institute of Neuroscience, INSERM U1216, Grenoble, France
| | - Sara Meoni
- Grenoble Alpes University, Division of Neurology, Centre Hospitalier Universitaire de Grenoble, Grenoble Institute of Neuroscience, INSERM U1216, Grenoble, France
| | - Pierre Pelissier
- Grenoble Alpes University, Division of Neurology, Centre Hospitalier Universitaire de Grenoble, Grenoble Institute of Neuroscience, INSERM U1216, Grenoble, France
| | - Emmanuelle Schmitt
- Grenoble Alpes University, Division of Neurology, Centre Hospitalier Universitaire de Grenoble, Grenoble Institute of Neuroscience, INSERM U1216, Grenoble, France
| | - Stephan Chabardes
- Division of Neurosurgery, Grenoble Alpes University, Centre Hospitalier Universitaire de Grenoble, Grenoble, France
| | - Valerie Fraix
- Grenoble Alpes University, Division of Neurology, Centre Hospitalier Universitaire de Grenoble, Grenoble Institute of Neuroscience, INSERM U1216, Grenoble, France
| | - Elena Moro
- Grenoble Alpes University, Division of Neurology, Centre Hospitalier Universitaire de Grenoble, Grenoble Institute of Neuroscience, INSERM U1216, Grenoble, France
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Wilkins KB, Melbourne JA, Akella P, Bronte-Stewart HM. Unraveling the complexities of programming neural adaptive deep brain stimulation in Parkinson's disease. Front Hum Neurosci 2023; 17:1310393. [PMID: 38094147 PMCID: PMC10716917 DOI: 10.3389/fnhum.2023.1310393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/09/2023] [Indexed: 02/01/2024] Open
Abstract
Over the past three decades, deep brain stimulation (DBS) for Parkinson's disease (PD) has been applied in a continuous open loop fashion, unresponsive to changes in a given patient's state or symptoms over the course of a day. Advances in recent neurostimulator technology enable the possibility for closed loop adaptive DBS (aDBS) for PD as a treatment option in the near future in which stimulation adjusts in a demand-based manner. Although aDBS offers great clinical potential for treatment of motor symptoms, it also brings with it the need for better understanding how to implement it in order to maximize its benefits. In this perspective, we outline considerations for programing several key parameters for aDBS based on our experience across several aDBS-capable research neurostimulators. At its core, aDBS hinges on successful identification of relevant biomarkers that can be measured reliably in real-time working in cohesion with a control policy that governs stimulation adaption. However, auxiliary parameters such as the window in which stimulation is allowed to adapt, as well as the rate it changes, can be just as impactful on performance and vary depending on the control policy and patient. A standardize protocol for programming aDBS will be crucial to ensuring its effective application in clinical practice.
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Affiliation(s)
- Kevin B. Wilkins
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Jillian A. Melbourne
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Pranav Akella
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
| | - Helen M. Bronte-Stewart
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, United States
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
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Ramdhani RA, Watts J, Kline M, Fitzpatrick T, Niethammer M, Khojandi A. Differential spatiotemporal gait effects with frequency and dopaminergic modulation in STN-DBS. Front Aging Neurosci 2023; 15:1206533. [PMID: 37842127 PMCID: PMC10570440 DOI: 10.3389/fnagi.2023.1206533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 09/01/2023] [Indexed: 10/17/2023] Open
Abstract
Objective The spatiotemporal gait changes in advanced Parkinson's disease (PD) remain a treatment challenge and have variable responses to L-dopa and subthalamic deep brain stimulation (STN-DBS). The purpose of this study was to determine whether low-frequency STN-DBS (LFS; 60 Hz) elicits a differential response to high-frequency STN-DBS (HFS; 180 Hz) in spatiotemporal gait kinematics. Methods Advanced PD subjects with chronic STN-DBS were evaluated in both the OFF and ON medication states with LFS and HFS stimulation. Randomization of electrode contact pairs and frequency conditions was conducted. Instrumented Stand and Walk assessments were carried out for every stimulation/medication condition. LM-ANOVA was employed for analysis. Results Twenty-two PD subjects participated in the study, with a mean age (SD) of 63.9 years. Significant interactions between frequency (both LFS and HFS) and electrode contact pairs (particularly ventrally located contacts) were observed for both spatial (foot elevation, toe-off angle, stride length) and temporal (foot speed, stance, single limb support (SLS) and foot swing) gait parameters. A synergistic effect was also demonstrated with L-dopa and both HFS and LFS for right SLS, left stance, left foot swing, right toe-off angle, and left arm range of motion. HFS produced significant improvement in trunk and lumbar range of motion compared to LFS. Conclusion The study provides evidence of synergism of L-dopa and STN-DBS on lower limb spatial and temporal measures in advanced PD. HFS and LFS STN-DBS produced equivalent effects among all other tested lower limb gait features. HFS produced significant trunk and lumbar kinematic improvements.
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Affiliation(s)
- Ritesh A. Ramdhani
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Jeremy Watts
- Department of Industrial and Systems Engineering, University of Tennessee, Knoxville, TN, United States
| | - Myriam Kline
- Center for Neurosciences, Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY, United States
| | - Toni Fitzpatrick
- Center for Neurosciences, Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY, United States
| | - Martin Niethammer
- Department of Neurology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Center for Neurosciences, Feinstein Institutes for Medical Research at Northwell Health, Manhasset, NY, United States
| | - Anahita Khojandi
- Department of Industrial and Systems Engineering, University of Tennessee, Knoxville, TN, United States
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de Roquemaurel A, Wirth T, Vijiaratnam N, Ferreira F, Zrinzo L, Akram H, Foltynie T, Limousin P. Stimulation Sweet Spot in Subthalamic Deep Brain Stimulation - Myth or Reality? A Critical Review of Literature. Stereotact Funct Neurosurg 2021; 99:425-442. [PMID: 34120117 DOI: 10.1159/000516098] [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: 12/02/2020] [Accepted: 03/23/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION While deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been extensively used for more than 20 years in Parkinson's disease (PD), the optimal area of stimulation to relieve motor symptoms remains elusive. OBJECTIVE We aimed at localizing the sweet spot within the subthalamic region by performing a systematic review of the literature. METHOD PubMed database was searched for published studies exploring optimal stimulation location for STN DBS in PD, published between 2000 and 2019. A standardized assessment procedure based on methodological features was applied to select high-quality publications. Studies conducted more than 3 months after the DBS procedure, employing lateralized scores and/or stimulation condition, and reporting the volume of tissue activated or the position of the stimulating contact within the subthalamic region were considered in the final analysis. RESULTS Out of 439 references, 24 were finally retained, including 21 studies based on contact location and 3 studies based on volume of tissue activated (VTA). Most studies (all VTA-based studies and 13 of the 21 contact-based studies) suggest the superior-lateral STN and the adjacent white matter as the optimal sites for stimulation. Remaining contact-based studies were either inconclusive (5/21), favoured the caudal zona incerta (1/21), or suggested a better outcome of STN stimulation than adjacent white matter stimulation (2/21). CONCLUSION Using a standardized methodological approach, our review supports the presence of a sweet spot located within the supero-lateral STN and extending to the adjacent white matter.
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Affiliation(s)
- Alexis de Roquemaurel
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Thomas Wirth
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Neurology department, Strasbourg University Hospital, Strasbourg, France.,INSERM-U964/CNRS-UMR7104/University of Strasbourg, Illkirch-Graffenstaden, France
| | - Nirosen Vijiaratnam
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Francisca Ferreira
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Ludvic Zrinzo
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Harith Akram
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Thomas Foltynie
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Patricia Limousin
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Louie KH, Petrucci MN, Grado LL, Lu C, Tuite PJ, Lamperski AG, MacKinnon CD, Cooper SE, Netoff TI. Semi-automated approaches to optimize deep brain stimulation parameters in Parkinson's disease. J Neuroeng Rehabil 2021; 18:83. [PMID: 34020662 PMCID: PMC8147513 DOI: 10.1186/s12984-021-00873-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 04/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is a treatment option for Parkinson's disease patients when medication does not sufficiently manage their symptoms. DBS can be a highly effect therapy, but only after a time-consuming trial-and-error stimulation parameter adjustment process that is susceptible to clinician bias. This trial-and-error process will be further prolonged with the introduction of segmented electrodes that are now commercially available. New approaches to optimizing a patient's stimulation parameters, that can also handle the increasing complexity of new electrode and stimulator designs, is needed. METHODS To improve DBS parameter programming, we explored two semi-automated optimization approaches: a Bayesian optimization (BayesOpt) algorithm to efficiently determine a patient's optimal stimulation parameter for minimizing rigidity, and a probit Gaussian process (pGP) to assess patient's preference. Quantified rigidity measurements were obtained using a robotic manipulandum in two participants over two visits. Rigidity was measured, in 5Hz increments, between 10-185Hz (total 30-36 frequencies) on the first visit and at eight BayesOpt algorithm-selected frequencies on the second visit. The participant was also asked their preference between the current and previous stimulation frequency. First, we compared the optimal frequency between visits with the participant's preferred frequency. Next, we evaluated the efficiency of the BayesOpt algorithm, comparing it to random and equal interval selection of frequency. RESULTS The BayesOpt algorithm estimated the optimal frequency to be the highest tolerable frequency, matching the optimal frequency found during the first visit. However, the participants' pGP models indicate a preference at frequencies between 70-110 Hz. Here the stimulation frequency is lowest that achieves nearly maximal suppression of rigidity. BayesOpt was efficient, estimating the rigidity response curve to stimulation that was almost indistinguishable when compared to the longer brute force method. CONCLUSIONS These results provide preliminary evidence of the feasibility to use BayesOpt for determining the optimal frequency, while pGP patient's preferences include more difficult to measure outcomes. Both novel approaches can shorten DBS programming and can be expanded to include multiple symptoms and parameters.
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Affiliation(s)
- Kenneth H. Louie
- Department of Biomedical Engineering, University of Minnesota, 312 Church St. SE, Minneapolis, MN 55455 US
| | - Matthew N. Petrucci
- Department of Neurology, University of Minnesota, 516 Delaware St. SE, 55455 Minneapoli, MN US
| | - Logan L. Grado
- Department of Biomedical Engineering, University of Minnesota, 312 Church St. SE, Minneapolis, MN 55455 US
| | - Chiahao Lu
- Department of Neurology, University of Minnesota, 516 Delaware St. SE, 55455 Minneapoli, MN US
| | - Paul J. Tuite
- Department of Neurology, University of Minnesota, 516 Delaware St. SE, 55455 Minneapoli, MN US
| | - Andrew G. Lamperski
- Department of Electrical and Computer Engineering, University of Minnesota, 200 Union St. SE, Minneapolis, MN 55455 US
| | - Colum D. MacKinnon
- Department of Neurology, University of Minnesota, 516 Delaware St. SE, 55455 Minneapoli, MN US
| | - Scott E. Cooper
- Department of Neurology, University of Minnesota, 516 Delaware St. SE, 55455 Minneapoli, MN US
| | - Theoden I. Netoff
- Department of Biomedical Engineering, University of Minnesota, 312 Church St. SE, Minneapolis, MN 55455 US
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Sasagawa A, Enatsu R, Kitagawa M, Mikami T, Nakayama-Kamada C, Kuribara T, Hirano T, Arihara M, Mikuni N. Target Selection of Directional Lead in Patients with Parkinson's Disease. Neurol Med Chir (Tokyo) 2020; 60:622-628. [PMID: 33162470 PMCID: PMC7803701 DOI: 10.2176/nmc.tn.2020-0210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Several structures including subthalamic nucleus (STN), the caudal zona incerta (cZI), the prelemniscal radiation (Raprl), and the thalamic ventral intermediate nucleus (Vim) have been reported to be useful for improving symptoms of Parkinson’s disease (PD). However, the effect of each target is still unclear. Therefore, we investigated each structure’s effects and adverse effects using a directional lead implanted in the posterior STN adjacent to the cZI and Raprl in two patients with tremor-dominant PD. In Case 1, maximal reduction of tremor was obtained by stimulation toward the Vim, and stimulation toward the thalamic reticular nucleus (TRN) reduced verbal fluency, but did not induce dysarthria. In Case 2, maximal reduction of tremor was obtained by stimulation toward the dorsal STN and Raprl. Maximal reduction of rigidity was achieved by stimulation toward the dorsal STN, Raprl, and cZI. Bradykiensia was improved by stimulation in all directions, but dyskinesia and dysarthria were evoked by stimulation toward the dorsal STN and cZI. The directional lead may elucidate the stimulation effect of each structure and broaden target selection depending on patients’ symptoms and adverse effects.
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Affiliation(s)
- Ayaka Sasagawa
- Department of Neurosurgery, Sapporo Medical University School of Medicine
| | - Rei Enatsu
- Department of Neurosurgery, Sapporo Medical University School of Medicine
| | | | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University School of Medicine
| | | | - Tomoyoshi Kuribara
- Department of Neurosurgery, Sapporo Medical University School of Medicine
| | - Tsukasa Hirano
- Department of Neurosurgery, Sapporo Medical University School of Medicine
| | - Masayasu Arihara
- Department of Neurosurgery, Sapporo Medical University School of Medicine
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University School of Medicine
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Lee EJ, Oh JS, Moon H, Kim MJ, Kim MS, Chung SJ, Kim JS, Jeon SR. Parkinson Disease-Related Pattern of Glucose Metabolism Associated With the Potential for Motor Improvement After Deep Brain Stimulation. Neurosurgery 2020; 86:492-499. [PMID: 31215629 DOI: 10.1093/neuros/nyz206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Accepted: 02/24/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Motor dysfunctions in Parkinson disease (PD) patients are not completely normalized by deep brain stimulation (DBS), and there is an obvious difference in the degree of symptom improvement after DBS for each patient. OBJECTIVE To test our hypothesis that each patient has their own restoration capacity for motor improvement after DBS, and to investigate whether regional cerebral glucose metabolism in 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) scans is associated with the capacity for off-medication motor improvement (MIoff) after DBS. METHODS The MIoff (%) was calculated using the Unified Parkinson's Disease Rating Scale part III in 27 PD patients undergoing DBS in the globus pallidus interna. The standardized uptake value ratios (SUVRs) on FDG-PET were quantitatively measured, and the areas where the SUVR correlated with the MIoff (%) were identified. Also, the areas where the SUVR was significantly different between the 2 MIoff groups (≥60% vs <60%) were determined. RESULTS Ten patients achieved MIoff > 60% at 12 mo after DBS. In general, the MIoff (%) was positively correlated with preoperative SUVR in the temporo-parieto-occipital lobes, while it was inversely correlated with the metabolism in the primary motor cortex. The patients in the MIoff < 60% group showed a significant decrease in SUVR in the parieto-occipital lobes, while parieto-occipital metabolism in those with MIoff ≥ 60% was relatively preserved (Mann-Whitney U test, P = .03). CONCLUSION Our findings suggest that the parieto-occipital lobes may be implicated more generally in the prognosis of motor improvement after DBS in advanced PD than other regions.
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Affiliation(s)
- Eun Jung Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jungsu S Oh
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hyojeong Moon
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.,System Medical Device Team, Advanced Technology Department, Medical Device Development Center, Daegu-Gyeongbuk Medical Innovation Foundation, Daegu, Republic of Korea
| | - Min-Ju Kim
- Department of Clinical Epidemiology and Biostatics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Mi Sun Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sun Ju Chung
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Seung Kim
- Department of Nuclear Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang Ryong Jeon
- Department of Neurological Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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David FJ, Munoz MJ, Corcos DM. The effect of STN DBS on modulating brain oscillations: consequences for motor and cognitive behavior. Exp Brain Res 2020; 238:1659-1676. [PMID: 32494849 PMCID: PMC7415701 DOI: 10.1007/s00221-020-05834-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/15/2020] [Indexed: 12/11/2022]
Abstract
In this review, we highlight Professor John Rothwell's contribution towards understanding basal ganglia function and dysfunction, as well as the effects of subthalamic nucleus deep brain stimulation (STN DBS). The first section summarizes the rate and oscillatory models of basal ganglia dysfunction with a focus on the oscillation model. The second section summarizes the motor, gait, and cognitive mechanisms of action of STN DBS. In the final section, we summarize the effects of STN DBS on motor and cognitive tasks. The studies reviewed in this section support the conclusion that high-frequency STN DBS improves the motor symptoms of Parkinson's disease. With respect to cognition, STN DBS can be detrimental to performance especially when the task is cognitively demanding. Consolidating findings from many studies, we find that while motor network oscillatory activity is primarily correlated to the beta-band, cognitive network oscillatory activity is not confined to one band but is subserved by activity in multiple frequency bands. Because of these findings, we propose a modified motor and associative/cognitive oscillatory model that can explain the consistent positive motor benefits and the negative and null cognitive effects of STN DBS. This is clinically relevant because STN DBS should enhance oscillatory activity that is related to both motor and cognitive networks to improve both motor and cognitive performance.
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Affiliation(s)
- Fabian J David
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, 645 North Michigan Avenue, Suite 1100, Chicago, IL, 60611, USA.
| | - Miranda J Munoz
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, 645 North Michigan Avenue, Suite 1100, Chicago, IL, 60611, USA
| | - Daniel M Corcos
- Department of Physical Therapy and Human Movement Sciences, Northwestern University, 645 North Michigan Avenue, Suite 1100, Chicago, IL, 60611, USA
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL, USA
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Avecillas-Chasin JM, Honey CR. Modulation of Nigrofugal and Pallidofugal Pathways in Deep Brain Stimulation for Parkinson Disease. Neurosurgery 2020; 86:E387-E397. [PMID: 31832650 DOI: 10.1093/neuros/nyz544] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 10/13/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a well-established surgical therapy for patients with Parkinson disease (PD). OBJECTIVE To define the role of adjacent white matter stimulation in the effectiveness of STN-DBS. METHODS We retrospectively evaluated 43 patients with PD who received bilateral STN-DBS. The volumes of activated tissue were analyzed to obtain significant stimulation clusters predictive of 4 clinical outcomes: improvements in bradykinesia, rigidity, tremor, and reduction of dopaminergic medication. Tractography of the nigrofugal and pallidofugal pathways was performed. The significant clusters were used to calculate the involvement of the nigrofugal and pallidofugal pathways and the STN. RESULTS The clusters predictive of rigidity and tremor improvement were dorsal to the STN with most of the clusters outside of the STN. These clusters preferentially involved the pallidofugal pathways. The cluster predictive of bradykinesia improvement was located in the central part of the STN with an extension outside of the STN. The cluster predictive of dopaminergic medication reduction was located ventrolateral and caudal to the STN. These clusters preferentially involved the nigrofugal pathways. CONCLUSION Improvements in rigidity and tremor mainly involved the pallidofugal pathways dorsal to the STN. Improvement in bradykinesia mainly involved the central part of the STN and the nigrofugal pathways ventrolateral to the STN. Maximal reduction in dopaminergic medication following STN-DBS was associated with an exclusive involvement of the nigrofugal pathways.
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Affiliation(s)
| | - Christopher R Honey
- Department of Surgery, Division of Neurosurgery, University of British Columbia, Vancouver, Canada
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Sasaki T, Kuwahara K, Kin I, Okazaki M, Sasada S, Shinko A, Kameda M, Yasuhara T, Agari T, Date I. Identification of Somatotopic Organization and Optimal Stimulation Site Within the Subthalamic Nucleus for Parkinson's Disease. Oper Neurosurg (Hagerstown) 2019; 17:239-246. [PMID: 30445556 DOI: 10.1093/ons/opy351] [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: 04/26/2018] [Accepted: 10/30/2018] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Details of the somatotopy within the subthalamic nucleus (STN) are still poorly understood; however, the STN is a common target of deep brain stimulation (DBS) for Parkinson disease. OBJECTIVE To examine somatotopic organization within the STN and identify optimal stimulation sites from 77 surgical cases with microelectrode recording. METHODS STN-DBS was performed for 77 patients with Parkinson disease between 2010 and 2014. We performed passive movements of each joint and captured single neuronal activities to identify movement-related cells (MRCs). The sites of MRCs and active contacts were determined by measuring their distances from the first contact of DBS electrode. Their positional correlations were directly and indirectly analyzed. RESULTS The number of obtained MRCs was 264, of which 151 responded to multiple joints. The average x-, y-, and z-coordinates of the cells of the upper and lower limbs from the midcommisural point were 13.1 ± 1.1 and 12.7 ± 1.2, 0.22 ± 1.3 and -0.45 ± 1.5, and -2.5 ± 1.1 and -3.0 ± 1.4 mm, respectively. Most MRCs were distributed in the upper third of the STN, in its superior, lateral, and posterior regions, along the DBS electrode routes. Active contacts were observed to lie slightly inferior, medial, and posterior to the average MRC position. CONCLUSION Somatotopic organization of the STN was easier to observe in the present study than in previous studies. Optimal stimulation sites were located inferior, medial, and posterior to the average MRC location. The sites may correspond to associative or motor parts through which fibers from the supplementary motor area pass.
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Affiliation(s)
- Tatsuya Sasaki
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ken Kuwahara
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ittetsu Kin
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mihoko Okazaki
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Susumu Sasada
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Aiko Shinko
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masahiro Kameda
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takao Yasuhara
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takashi Agari
- Department of Neurological Surgery, Kurashiki-Heisei Hospital, Okayama, Japan
| | - Isao Date
- Department of Neurological Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Milchenko M, Snyder AZ, Campbell MC, Dowling JL, Rich KM, Brier LM, Perlmutter JS, Norris SA. ESM-CT: a precise method for localization of DBS electrodes in CT images. J Neurosci Methods 2018; 308:366-376. [PMID: 30201271 PMCID: PMC6205293 DOI: 10.1016/j.jneumeth.2018.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus produces variable effects in Parkinson disease. Variation may result from different electrode positions relative to target. Thus, precise electrode localization is crucial when investigating DBS effects. NEW METHOD We developed a semi-automated method, Electrode Shaft Modeling in CT images (ESM-CT) to reconstruct DBS lead trajectories and contact locations. We evaluated methodological sensitivity to operator-dependent steps, robustness to image resampling, and test-retest replicability. ESM-CT was applied in 56 patients to study electrode position change (and relation to time between scans, postoperative subdural air volume, and head tilt during acquisition) between images acquired immediately post-implantation (DBS-CT) and months later (DEL-CT). RESULTS Electrode tip localization was robust to image resampling and replicable to within ∼ 0.2 mm on test-retest comparisons. Systematic electrode displacement occurred rostral-ventral-lateral between DBS-CT and DEL-CT scans. Head angle was a major explanatory factor (p < 0.001,Pearson's r = 0.46, both sides) and volume of subdural air weakly predicted electrode displacement (p = 0.02,r = 0.29:p = 0.1,r = 0.25 for left:right). Modeled shaft curvature was slightly greater in DEL-CT. Magnitude of displacement and degree of curvature were independent of elapsed time between scans. COMPARISON WITH EXISTING METHODS Comparison of ESM-CT against two existing methods revealed systematic differences in one coordinate (1 ± 0.3 mm,p < 0.001) for one method and in three coordinates for another method (x:0.1 ± 0.1 mm, y:0.4 ± 0.2 mm, z:0.4 ± 0.2 mm, p < 10-10). Within-method coordinate variability across participants is similar. CONCLUSION We describe a robust and precise method for CT DBS contact localization. Application revealed that acquisition head angle significantly impacts electrode position. DBS localization schemes should account for head angle.
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Affiliation(s)
- Mikhail Milchenko
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Abraham Z Snyder
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Meghan C Campbell
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Joshua L Dowling
- Department of Neurosurgical Surgery, Washington University School of Medicine, (CB 8057), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Keith M Rich
- Department of Neurosurgical Surgery, Washington University School of Medicine, (CB 8057), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Lindsey M Brier
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Joel S Perlmutter
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurosurgical Surgery, Washington University School of Medicine, (CB 8057), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neuroscience, Washington University School of Medicine, (CB 8108), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Occupational Therapy, CB 8505, 4444 Forest Park Ave, St. Louis, MO 63108, USA; Department of Physical Therapy, CB 8502, 4444 Forest Park Ave, St. Louis, MO, 63108, USA
| | - Scott A Norris
- Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA.
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12
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Gourisankar A, Eisenstein SA, Trapp NT, Koller JM, Campbell MC, Ushe M, Perlmutter JS, Hershey T, Black KJ. Mapping movement, mood, motivation and mentation in the subthalamic nucleus. ROYAL SOCIETY OPEN SCIENCE 2018; 5:171177. [PMID: 30109035 PMCID: PMC6083651 DOI: 10.1098/rsos.171177] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 06/14/2018] [Indexed: 05/26/2023]
Abstract
The anatomical connections of the subthalamic nucleus (STN) have driven hypotheses about its functional anatomy, including the hypothesis that the precise anatomical location of STN deep brain stimulation (DBS) contributes to the variability of motor and non-motor responses across patients with Parkinson's disease (PD). We previously tested the hypothesis using a three-dimensional (3D) statistical method to interpret the acute effects of unilateral DBS at each patient's clinically optimized DBS settings and active contact. Here, we report a similar analysis from a new study in which DBS parameters were standardized and DBS locations were chosen blind to clinical response. In 74 individuals with PD and STN DBS, STN contacts were selected near the dorsal and ventral borders of the STN contralateral to the more affected side of the body. Participants were tested off PD medications in each of three unilateral DBS conditions (ventral STN DBS, dorsal STN DBS and DBS off) for acute effects on mood, apathy, working memory, response inhibition and motor function. Voltage, frequency and pulse width were standardized, and participants and raters were blind to condition. In a categorical analysis, both dorsal and ventral STN DBS improved mean motor function without affecting cognitive measures. Ventral STN DBS induced greater improvement in rigidity and anxiety than dorsal STN DBS. In the 3D analysis, contact location was significant for body hypokinesia, rigidity and resting tremor, with the greatest improvement occurring with DBS in dorsal STN and zona incerta. The 3D results provide new, direct functional evidence for the anatomically derived model of STN, in which motor function is best represented in dorsal STN. However, our data suggest that functional segregation between motor and non-motor areas of the STN is limited, because locations that induced improvements in motor function and mood overlapped substantially.
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Affiliation(s)
- Amritha Gourisankar
- Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO 63130, USA
| | - Sarah A. Eisenstein
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Nicholas T. Trapp
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Jonathan M. Koller
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Meghan C. Campbell
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Mwiza Ushe
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Joel S. Perlmutter
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Neuroscience, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Occupational Therapy, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Physical Therapy, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Tamara Hershey
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Kevin J. Black
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Radiology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO 63110, USA
- Department of Neuroscience, Washington University School of Medicine, St. Louis, MO 63110, USA
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13
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Xu SH, Yang C, Xian WB, Gu J, Liu JL, Jiang LL, Ye J, Liu YM, Guo QY, Zheng YF, Wu L, Chen WR, Pei Z, Chen L. Voltage adjustment improves rigidity and tremor in Parkinson's disease patients receiving deep brain stimulation. Neural Regen Res 2018; 13:347-352. [PMID: 29557387 PMCID: PMC5879909 DOI: 10.4103/1673-5374.226406] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Deep brain stimulation of the subthalamic nucleus is recognized as the most effective treatment for moderate and advanced Parkinson's disease. Programming of the stimulation parameters is important for maintaining the efficacy of deep brain stimulation. Voltage is considered to be the most effective programming parameter. The present study is a retrospective analysis of six patients with Parkinson's disease (four men and two women, aged 37–65 years), who underwent bilateral deep brain stimulation of the subthalamic nucleus at the First Affiliated Hospital of Sun Yat-sen University, China, and who subsequently adjusted only the stimulation voltage. We evaluated motor symptom severity using the Unified Parkinson's Disease Rating Scale Part III, symptom progression using the Hoehn and Yahr scale, and the levodopa equivalent daily dose, before surgery and 1 and 2 years after surgery. The 2-year follow-up results show that rigidity and tremor improved, and clinical symptoms were reduced, while pulse width was maintained at 60 μs and frequency at 130 Hz. Voltage adjustment alone is particularly suitable for patients who cannot tolerate multiparameter program adjustment. Levodopa equivalent daily dose was markedly reduced 1 and 2 years after surgery compared with baseline. Our results confirm that rigidity, tremor and bradykinesia can be best alleviated by voltage adjustment. The trial was registered at ClinicalTrials.gov (identifier: NCT01934881).
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Affiliation(s)
- Shao-Hua Xu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Chao Yang
- Department of Neurosurgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Wen-Biao Xian
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jing Gu
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jin-Long Liu
- Department of Neurosurgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Lu-Lu Jiang
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Jing Ye
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province; Department of Neurology, Tangshan Worker's Hospital, Tangshan, Hebei Province, China
| | - Yan-Mei Liu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Qi-Yu Guo
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Yi-Fan Zheng
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Lei Wu
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Wan-Ru Chen
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Zhong Pei
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Ling Chen
- Department of Neurology, National Key Clinical Department and Key Discipline of Neurolory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
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14
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Parastarfeizabadi M, Kouzani AZ. Advances in closed-loop deep brain stimulation devices. J Neuroeng Rehabil 2017; 14:79. [PMID: 28800738 PMCID: PMC5553781 DOI: 10.1186/s12984-017-0295-1] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 08/04/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Millions of patients around the world are affected by neurological and psychiatric disorders. Deep brain stimulation (DBS) is a device-based therapy that could have fewer side-effects and higher efficiencies in drug-resistant patients compared to other therapeutic options such as pharmacological approaches. Thus far, several efforts have been made to incorporate a feedback loop into DBS devices to make them operate in a closed-loop manner. METHODS This paper presents a comprehensive investigation into the existing research-based and commercial closed-loop DBS devices. It describes a brief history of closed-loop DBS techniques, biomarkers and algorithms used for closing the feedback loop, components of the current research-based and commercial closed-loop DBS devices, and advancements and challenges in this field of research. This review also includes a comparison of the closed-loop DBS devices and provides the future directions of this area of research. RESULTS Although we are in the early stages of the closed-loop DBS approach, there have been fruitful efforts in design and development of closed-loop DBS devices. To date, only one commercial closed-loop DBS device has been manufactured. However, this system does not have an intelligent and patient dependent control algorithm. A closed-loop DBS device requires a control algorithm to learn and optimize the stimulation parameters according to the brain clinical state. CONCLUSIONS The promising clinical effects of open-loop DBS have been demonstrated, indicating DBS as a pioneer technology and treatment option to serve neurological patients. However, like other commercial devices, DBS needs to be automated and modernized.
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Affiliation(s)
| | - Abbas Z. Kouzani
- School of Engineering, Deakin University, Waurn Ponds, VIC 3216 Australia
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15
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Stefani A, Trendafilov V, Liguori C, Fedele E, Galati S. Subthalamic nucleus deep brain stimulation on motor-symptoms of Parkinson's disease: Focus on neurochemistry. Prog Neurobiol 2017; 151:157-174. [PMID: 28159574 DOI: 10.1016/j.pneurobio.2017.01.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 01/20/2017] [Accepted: 01/22/2017] [Indexed: 12/19/2022]
Abstract
Deep brain stimulation (DBS) has become a standard therapy for Parkinson's disease (PD) and it is also currently under investigation for other neurological and psychiatric disorders. Although many scientific, clinical and ethical issues are still unresolved, DBS delivered into the subthalamic nucleus (STN) has improved the quality of life of several thousands of patients. The mechanisms underlying STN-DBS have been debated extensively in several reviews; less investigated are the biochemical consequences, which are still under scrutiny. Crucial and only partially understood, for instance, are the complex interplays occurring between STN-DBS and levodopa (LD)-centred therapy in the post-surgery follow-up. The main goal of this review is to address the question of whether an improved motor control, based on STN-DBS therapy, is also achieved through the additional modulation of other neurotransmitters, such as noradrenaline (NA) and serotonin (5-HT). A critical issue is to understand not only acute DBS-mediated effects, but also chronic changes, such as those involving cyclic nucleotides, capable of modulating circuit plasticity. The present article will discuss the neurochemical changes promoted by STN-DBS and will document the main results obtained in microdialysis studies. Furthermore, we will also examine the preliminary achievements of voltammetry applied to humans, and discuss new hypothetical investigational routes, taking into account novel players such as glia, or subcortical regions such as the pedunculopontine (PPN) area. Our further understanding of specific changes in brain chemistry promoted by STN-DBS would further disseminate its utilisation, at any stage of disease, avoiding an irreversible lesioning approach.
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Affiliation(s)
- A Stefani
- Department of System Medicine, University of Rome "Tor Vergata", Via Montpellier 1, 00133 Rome, Italy
| | - V Trendafilov
- Laboratory for Biomedical Neurosciences (LBN), Neurocenter of Southern Switzerland (NSI), Lugano, Switzerland
| | - C Liguori
- Department of System Medicine, University of Rome "Tor Vergata", Via Montpellier 1, 00133 Rome, Italy
| | - E Fedele
- Department of Pharmacy, Pharmacology and Toxicology Unit and Center of Excellence for Biomedical Research, University of Genoa, 16148 Genoa, Italy
| | - S Galati
- Laboratory for Biomedical Neurosciences (LBN), Neurocenter of Southern Switzerland (NSI), Lugano, Switzerland.
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16
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Lemaire JJ, Pereira B, Derost P, Vassal F, Ulla M, Morand D, Coll G, Gabrillargues J, Marques A, Debilly B, Coste J, Durif F. Subthalamus stimulation in Parkinson disease: Accounting for the bilaterality of contacts. Surg Neurol Int 2016; 7:S837-S847. [PMID: 27990316 PMCID: PMC5134117 DOI: 10.4103/2152-7806.194066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 05/27/2016] [Indexed: 01/24/2023] Open
Abstract
Background: Deep brain stimulation (DBS) in Parkinson's disease uses bi-hemispheric high-frequency stimulation within the subthalamus, however, the specific impacts of bilaterality of DBS are still not clear. Thus, we aimed to study the individual-level clinical impact of locations of right-left contact pair-up accounting for each subthalamic nucleus (STN) anatomy. Methods: Contact locations and effects at 1 year were studied retrospectively in an unselected series of 53 patients operated between 2004 and 2010. Location of contacts was defined relatively to the main axis of STN used to map longitudinal and transversal positions, and STN membership (out meaning out-of-STN). Contact pairings were described via three methods: (i) Unified contact location (UCL) collapsing DBS into an all-in-one contact; (ii) balance of contact pair-up (BCPU), defined as symmetric or asymmetric regardless of laterality; (iii) hemisphere-wise most frequent contact pair-up (MFCP) regardless of BCPU. Clinical data were: mean levodopa equivalent dose, Unified Parkinson's Disease Rating Scale (UPDRS) motor score III without medication, UPDRS II and III speech sub-scores, UPDRS II freezing sub-score, 1 year versus preoperative values, with and without levodopa. Ad-hoc two-sided tests were used for statistical analysis. Results: Worsening speech, was more frequent for UCL_out patients and when the left MFCP contact was rear and/or superolateral, however, it less frequent for BCPU-asymmetric patients. Worsening freezing was more frequent when the right MFCP contact was rear and superolateral. Conclusions: These results point to strategies for minimizing dysarthria and freezing as adverse effects of DBS.
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Affiliation(s)
- Jean-Jacques Lemaire
- Service of Neurosurgery, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France; Image-Guided Clinical Neuroscience and Connectomics, Research Team, Auvergne University, Auvergne, France
| | - Bruno Pereira
- Image-Guided Clinical Neuroscience and Connectomics, Research Team, Auvergne University, Auvergne, France; Biostatistics, Clinical Research Direction, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Philippe Derost
- Service of Neurology, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - François Vassal
- Image-Guided Clinical Neuroscience and Connectomics, Research Team, Auvergne University, Auvergne, France
| | - Miguel Ulla
- Service of Neurology, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Dominique Morand
- Biostatistics, Clinical Research Direction, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Guillaume Coll
- Service of Neurosurgery, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France; Image-Guided Clinical Neuroscience and Connectomics, Research Team, Auvergne University, Auvergne, France
| | - Jean Gabrillargues
- Service of Neurosurgery, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France; Service of Radiology, Neuroradiology Unit, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Ana Marques
- Service of Neurology, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Bérangère Debilly
- Service of Neurology, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Jérôme Coste
- Service of Neurosurgery, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France; Image-Guided Clinical Neuroscience and Connectomics, Research Team, Auvergne University, Auvergne, France
| | - Franck Durif
- Service of Neurology, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
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Pourfar MH, Mogilner AY, Farris S, Giroux M, Gillego M, Zhao Y, Blum D, Bokil H, Pierre MC. Model-Based Deep Brain Stimulation Programming for Parkinson's Disease: The GUIDE Pilot Study. Stereotact Funct Neurosurg 2015; 93:231-9. [DOI: 10.1159/000375172] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 01/13/2015] [Indexed: 11/19/2022]
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18
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Satzer D, Maurer EW, Lanctin D, Guan W, Abosch A. Anatomic correlates of deep brain stimulation electrode impedance. J Neurol Neurosurg Psychiatry 2015; 86:398-403. [PMID: 24935985 DOI: 10.1136/jnnp-2013-307284] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND The location of the optimal target for deep brain stimulation (DBS) of the subthalamic nucleus (STN) remains controversial. Electrode impedance affects tissue activation by DBS and has been found to vary by contact number, but no studies have examined association between impedance and anatomic location. OBJECTIVES To evaluate the relationship between electrode impedance and anatomic contact location, and to assess the clinical significance of impedance. METHODS We gathered retrospective impedance data from 101 electrodes in 73 patients with Parkinson's disease. We determined contact location using microelectrode recording (MER) and high-field 7T MRI, and assessed the relationship between impedance and contact location. RESULTS For contact location as assessed via MER, impedance was significantly higher for contacts in STN, at baseline (111 Ω vs STN border, p=0.03; 169 Ω vs white matter, p<0.001) and over time (90 Ω vs STN border, p<0.001; 54 Ω vs white matter, p<0.001). Over time, impedance was lowest in contacts situated at STN border (p=0.03). Impedance did not vary by contact location as assessed via imaging. Location determination was 75% consistent between MER and imaging. Impedance was inversely related to absolute symptom reduction during stimulation (-2.5 motor portion of the Unified Parkinson's Disease Rating Scale (mUPDRS) points per 1000 Ω, p=0.01). CONCLUSIONS In the vicinity of DBS electrodes chronically implanted in STN, impedance is lower at the rostral STN border and in white matter, than in STN. This finding suggests that current reaches white matter fibres more readily than neuronal cell bodies in STN, which may help explain anatomic variation in stimulation efficacy.
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Affiliation(s)
- David Satzer
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Eric W Maurer
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - David Lanctin
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA
| | - Weihua Guan
- Department of Biostatistics, University of Minnesota, Minneapolis, Minnesota, USA
| | - Aviva Abosch
- Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA Department of Neurosurgery, University of Colorado, Denver, Colorado, USA
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Phibbs FT, Pallavaram S, Tolleson C, D'Haese PF, Dawant BM. Use of efficacy probability maps for the post-operative programming of deep brain stimulation in essential tremor. Parkinsonism Relat Disord 2014; 20:1341-4. [PMID: 25280760 DOI: 10.1016/j.parkreldis.2014.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 08/22/2014] [Accepted: 09/04/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Post-operative programming of deep brain stimulation for movement disorders can be both time consuming and difficult, which can delay the optimal symptom control for the patient. Probabilistic maps of stimulation response could improve programming efficiency and optimization. METHODS The clinically selected contacts of patients who had undergone ventral intermediate nucleus deep brain stimulation for the treatment of essential tremor at our institution were compared against contacts selected based on a probability map of symptom reduction built by populating data from a number of patients using non-rigid image registration. A subgroup of patients whose clinical contacts did not match the map-based selections prospectively underwent a tremor rating scale evaluation to compare the symptom relief achieved by the two options. Both the patient and video reviewer were blinded to the selection. RESULTS 54% of the map-based and clinical contacts were an exact match retrospectively and were within one contact 83% of the time. In 5 of the 8 mismatched leads that were evaluated prospectively in a double blind fashion, the map-based contact showed equivalent or better tremor improvement than the clinically active contact. CONCLUSIONS This study suggests that probability maps of stimulation responses can assist in selecting the clinically optimal contact and increase the efficiency of programming.
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Affiliation(s)
- Fenna T Phibbs
- Dept. of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Srivatsan Pallavaram
- Dept. of Electrical Eng. & Computer Science, Vanderbilt University, Nashville, TN, USA
| | | | | | - Benoit M Dawant
- Dept. of Electrical Eng. & Computer Science, Vanderbilt University, Nashville, TN, USA
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Cooper SE, Driesslein KG, Noecker AM, McIntyre CC, Machado AM, Butson CR. Anatomical targets associated with abrupt versus gradual washout of subthalamic deep brain stimulation effects on bradykinesia. PLoS One 2014; 9:e99663. [PMID: 25098453 PMCID: PMC4123847 DOI: 10.1371/journal.pone.0099663] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 05/19/2014] [Indexed: 11/18/2022] Open
Abstract
The subthalamic nucleus (STN) is a common anatomical target for deep brain stimulation (DBS) for the treatment of Parkinson’s disease. However, the effects of stimulation may spread beyond the STN. Ongoing research aims to identify nearby anatomical structures where DBS-induced effects could be associated with therapeutic improvement or side effects. We previously found that DBS lead location determines the rate – abrupt vs. gradual – with which therapeutic effect washes out after stimulation is stopped. Those results suggested that electrical current spreads from the electrodes to two spatially distinct stimulation targets associated with different washout rates. In order to identify these targets we used computational models to predict the volumes of tissue activated during DBS in 14 Parkinson’s patients from that study. We then coregistered each patient with a stereotaxic atlas and generated a probabilistic stimulation atlas to obtain a 3-dimensional representation of regions where stimulation was associated with abrupt vs. gradual washout. We found that the therapeutic effect which washed out gradually was associated with stimulation of the zona incerta and fields of Forel, whereas abruptly-disappearing therapeutic effect was associated with stimulation of STN itself. This supports the idea that multiple DBS targets exist and that current spread from one electrode may activate more than one of them in a given patient, producing a combination of effects which vary according to electrode location and stimulation settings.
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Affiliation(s)
- Scott E. Cooper
- Cleveland Clinic, Center for Neurological Restoration, Cleveland, Ohio, United States of America
- * E-mail:
| | - Klaus G. Driesslein
- Medical College of Wisconsin, Departments of Neurology & Neurosurgery, Biotechnology and Bioengineering Center, Milwaukee, Wisconsin, United States of America
| | - Angela M. Noecker
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio, United States of America
| | - Cameron C. McIntyre
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio, United States of America
| | - Andre M. Machado
- Cleveland Clinic, Center for Neurological Restoration, Cleveland, Ohio, United States of America
| | - Christopher R. Butson
- Medical College of Wisconsin, Departments of Neurology & Neurosurgery, Biotechnology and Bioengineering Center, Milwaukee, Wisconsin, United States of America
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Eisenstein SA, Koller JM, Black KD, Campbell MC, Lugar HM, Ushe M, Tabbal SD, Karimi M, Hershey T, Perlmutter JS, Black KJ. Functional anatomy of subthalamic nucleus stimulation in Parkinson disease. Ann Neurol 2014; 76:279-95. [PMID: 24953991 PMCID: PMC4172323 DOI: 10.1002/ana.24204] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Revised: 06/17/2014] [Accepted: 06/17/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We developed a novel method to map behavioral effects of deep brain stimulation (DBS) across a 3-dimensional brain region and to assign statistical significance after stringent type I error correction. This method was applied to behavioral changes in Parkinson disease (PD) induced by subthalamic nucleus (STN) DBS to determine whether these responses depended on anatomical location of DBS. METHODS Fifty-one PD participants with STN DBS were evaluated off medication, with DBS off and during unilateral STN DBS with clinically optimized settings. Dependent variables included DBS-induced changes in Unified Parkinson Disease Rating Scale (UPDRS) subscores, kinematic measures of bradykinesia and rigidity, working memory, response inhibition, mood, anxiety, and akathisia. Weighted t tests at each voxel produced p images showing where DBS most significantly affected each dependent variable based on outcomes of participants with nearby DBS. Finally, a permutation test computed the probability that this p image indicated significantly different responses based on stimulation site. RESULTS Most motor variables improved with DBS anywhere in the STN region, but several motor, cognitive, and affective responses significantly depended on precise location stimulated, with peak p values in superior STN/zona incerta (quantified bradykinesia), dorsal STN (mood, anxiety), and inferior STN/substantia nigra (UPDRS tremor, working memory). INTERPRETATION Our method identified DBS-induced behavioral changes that depended significantly on DBS site. These results do not support complete functional segregation within STN, because movement improved with DBS throughout, and mood improved with dorsal STN DBS. Rather, findings support functional convergence of motor, cognitive, and limbic information in STN.
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Affiliation(s)
- Sarah A Eisenstein
- Department of Psychiatry, Washington University in St Louis, St Louis, MO
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22
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Ebersbach G, Moreau C, Gandor F, Defebvre L, Devos D. Clinical syndromes: Parkinsonian gait. Mov Disord 2014; 28:1552-9. [PMID: 24132843 DOI: 10.1002/mds.25675] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Revised: 08/09/2013] [Accepted: 08/16/2013] [Indexed: 01/06/2023] Open
Abstract
Disturbances of gait manifest in almost all cases of Parkinson's disease (PD), often leading to loss of mobility and increased mortality. In this review a clinically oriented approach to gait disorders in different stages of PD is presented. In addition, interactions between motor behavior and mental processing will be discussed. Analyzing the clinical features of gait can be helpful to differentiate PD from atypical forms of parkinsonism. Bedside tests to distinguish parkinsonian gait disorders are reviewed. There is still an unmet need to effectively treat complex gait disturbances, which are frequently not responsive to dopamine replacement medication. We thus present current approaches for the management of dopa-refractory gait disorders.
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Welter ML, Schüpbach M, Czernecki V, Karachi C, Fernandez-Vidal S, Golmard JL, Serra G, Navarro S, Welaratne A, Hartmann A, Mesnage V, Pineau F, Cornu P, Pidoux B, Worbe Y, Zikos P, Grabli D, Galanaud D, Bonnet AM, Belaid H, Dormont D, Vidailhet M, Mallet L, Houeto JL, Bardinet E, Yelnik J, Agid Y. Optimal target localization for subthalamic stimulation in patients with Parkinson disease. Neurology 2014; 82:1352-61. [PMID: 24647024 PMCID: PMC4001189 DOI: 10.1212/wnl.0000000000000315] [Citation(s) in RCA: 118] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: To further determine the causes of variable outcome from deep brain stimulation of the subthalamic nucleus (DBS-STN) in patients with Parkinson disease (PD). Methods: Data were obtained from our cohort of 309 patients with PD who underwent DBS-STN between 1996 and 2009. We examined the relationship between the 1-year motor, cognitive, and psychiatric outcomes and (1) preoperative PD clinical features, (2) MRI measures, (3) surgical procedure, and (4) locations of therapeutic contacts. Results: Pre- and postoperative results were obtained in 262 patients with PD. The best motor outcome was obtained when stimulating contacts were located within the STN as compared with the zona incerta (64% vs 49% improvement). Eighteen percent of the patients presented a postoperative cognitive decline, which was found to be principally related to the surgical procedure. Other factors predictive of poor cognitive outcome were perioperative confusion and psychosis. Nineteen patients showed a stimulation-induced hypomania, which was related to both the form of the disease (younger age, shorter disease duration, higher levodopa responsiveness) and the ventral contact location. Postoperative depression was more frequent in patients already showing preoperative depressive and/or residual axial motor symptoms. Conclusion: In this homogeneous cohort of patients with PD, we showed that (1) the STN is the best target to improve motor symptoms, (2) postoperative cognitive deficit is mainly related to the surgery itself, and (3) stimulation-induced hypomania is related to a combination of both the disease characteristics and a more ventral STN location.
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Affiliation(s)
- Marie-Laure Welter
- From the Université Pierre et Marie Curie-Paris 6 (M.-L.W., M.S., V.C., C.K., S.F.-V., J.-L.G., A.H., V.M., F.P., Y.W., D. Grabli, D. Galanaud, D.D., M.V., L.M., E.B., J.Y., Y.A.), Centre de Recherche de l'Institut du Cerveau et de, la Moelle épinière, UMR-S975, Paris; Inserm (M.-L.W., M.S., V.C., C.K., S.F.-V., A.H., V.M., F.P., Y.W., D. Grabli, D. Galanaud, D.D., M.V., L.M., E.B., J.Y., Y.A.), U975, Paris; CNRS (M.-L.W., M.S., C.K., S.F.-V., A.H., V.M., F.P., Y.W., D. Grabli, D. Galanaud, D.D., M.V., L.M., E.B., J.Y., Y.A.), UMR 7225, Paris; Centre d'Investigation Clinique (M.-L.W., M.S., C.K., G.S., A.H., V.M., F.P., Y.W., P.Z., D. Grabli, A.-M.B., M.V., Y.A.), Département de Neurologie (M.-L.W., V.C., A.W., A.H., V.M., D. Grabli, A.-M.B., M.V., Y.A.), IM2A (V.C., F.P.), Service de Neurochirurgie (C.K., S.N., P.C., H.B.), Department of Clinical Neurophysiology (B.P.), and Service de Neuroradiologie Diagnostique et Fonctionnelle (D. Galanaud, D.D.), Hôpitaux Universitaires Pitié-Salpêtrière/Charles Foix, Assistance Publique-Hôpitaux de Paris, France; Department of Neurology (M.S.), University Hospital, Bern, Switzerland; Centre de Neuroimagerie de Recherche (S.F.-V., D. Galanaud, D.D.), Hôpitaux Universitaires Pitié-Salpêtrière/Charles Foix, Paris, France; Département de Biostatistiques et Information Médicale (J.-L.G.), Hôpitaux Universitaires Pitié-Salpêtrière/Charles Foix, Assistance Publique-Hôpitaux de Paris, ER4 (ex EA3974) Modélisation en Recherche Clinique, Paris, France; Department of Neurology (P.Z.), 251 Hellenic Air Force General Hospital, Athens, Greece; and Department of Neurology (J.-L.H.), CHU Poitiers, France
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Hebb AO, Zhang JJ, Mahoor MH, Tsiokos C, Matlack C, Chizeck HJ, Pouratian N. Creating the feedback loop: closed-loop neurostimulation. Neurosurg Clin N Am 2013; 25:187-204. [PMID: 24262909 DOI: 10.1016/j.nec.2013.08.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Current DBS therapy delivers a train of electrical pulses at set stimulation parameters. This open-loop design is effective for movement disorders, but therapy may be further optimized by a closed loop design. The technology to record biosignals has outpaced our understanding of their relationship to the clinical state of the whole person. Neuronal oscillations may represent or facilitate the cooperative functioning of brain ensembles, and may provide critical information to customize neuromodulation therapy. This review addresses advances to date, not of the technology per se, but of the strategies to apply neuronal signals to trigger or modulate stimulation systems.
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Affiliation(s)
- Adam O Hebb
- Colorado Neurological Institute, Department of Electrical and Computer Engineering, University of Denver, 499 E Hampden Ave Ste, 220 Englewood, CO 80113, USA.
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25
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Hill KK, Campbell MC, McNeely ME, Karimi M, Ushe M, Tabbal SD, Hershey T, Flores HP, Hartlein JM, Lugar HM, Revilla FJ, Videen TO, Earhart GM, Perlmutter JS. Cerebral blood flow responses to dorsal and ventral STN DBS correlate with gait and balance responses in Parkinson's disease. Exp Neurol 2013; 241:105-12. [PMID: 23262122 PMCID: PMC3570746 DOI: 10.1016/j.expneurol.2012.12.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 12/03/2012] [Accepted: 12/06/2012] [Indexed: 01/04/2023]
Abstract
OBJECTIVES The effects of subthalamic nucleus (STN) deep brain stimulation (DBS) on gait and balance vary and the underlying mechanisms remain unclear. DBS location may alter motor benefit due to anatomical heterogeneity in STN. The purposes of this study were to (1) compare the effects of DBS of dorsal (D-STN) versus ventral (V-STN) regions on gait, balance and regional cerebral blood flow (rCBF) and (2) examine the relationships between changes in rCBF and changes in gait and balance induced by D-STN or V-STN DBS. METHODS We used a validated atlas registration to locate and stimulate through electrode contacts in D-STN and V-STN regions of 37 people with Parkinson's disease. In a within-subjects, double-blind and counterbalanced design controlled for DBS settings, we measured PET rCBF responses in a priori regions of interest and quantified gait and balance during DBS Off, unilateral D-STN DBS and unilateral V-STN DBS. RESULTS DBS of either site increased stride length without producing significant group-level changes in gait velocity, cadence or balance. Both sites increased rCBF in subcortical regions and produced variable changes in cortical and cerebellar regions. DBS-induced changes in gait velocity are related to premotor cortex rCBF changes during V-STN DBS (r=-0.40, p=0.03) and to rCBF changes in the cerebellum anterior lobe during D-STN DBS (r=-0.43, p=0.02). CONCLUSIONS DBS-induced changes in gait corresponded to rCBF responses in selected cortical and cerebellar regions. These relationships differed during D-STN versus V-STN DBS, suggesting DBS acts through distinct neuronal pathways dependent on DBS location.
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Affiliation(s)
- K K Hill
- Department of Biomedical Engineering, Washington University School of Medicine, St. Louis, MO, USA
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Pouratian N, Thakkar S, Kim W, Bronstein JM. Deep brain stimulation for the treatment of Parkinson's disease: efficacy and safety. Degener Neurol Neuromuscul Dis 2012; 2012. [PMID: 24298202 DOI: 10.2147/dnnd.s25750] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Deep brain stimulation (DBS) surgery has become increasingly utilized in the treatment of advanced Parkinson's disease. Over the past decade, a number of studies have demonstrated that DBS is superior to best medical management in appropriately selected patients. The primary targets for DBS in Parkinson's disease include the subthalamic nucleus and the internal segment of the globus pallidus, both of which improve the cardinal motor features in Parkinson's disease. Recent randomized studies have revealed that both targets are similarly effective in treating the motor symptoms of Parkinson's disease, but emerging evidence suggests that the globus pallidus may be the preferred target in many patients, based on differences in nonmotor outcomes. Here, we review appropriate patient selection, and the efficacy and safety of DBS therapy in Parkinson's disease. Best outcomes are achieved if the problems of the individual patient are considered when evaluating surgical candidates and considering whether the subthalamic nucleus or the globus pallidus internus should be targeted.
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Affiliation(s)
- Nader Pouratian
- Departments of Neurosurgery, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles ; Bioengineering, David Geffen School of Medicine at UCLA (University of California, Los Angeles), Los Angeles
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27
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Whitmer D, de Solages C, Hill B, Yu H, Henderson JM, Bronte-Stewart H. High frequency deep brain stimulation attenuates subthalamic and cortical rhythms in Parkinson's disease. Front Hum Neurosci 2012; 6:155. [PMID: 22675296 PMCID: PMC3366347 DOI: 10.3389/fnhum.2012.00155] [Citation(s) in RCA: 180] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 05/16/2012] [Indexed: 12/31/2022] Open
Abstract
Parkinson's disease (PD) is marked by excessive synchronous activity in the beta (8–35 Hz) band throughout the cortico-basal ganglia network. The optimal location of high frequency deep brain stimulation (HF DBS) within the subthalamic nucleus (STN) region and the location of maximal beta hypersynchrony are currently matters of debate. Additionally, the effect of STN HF DBS on neural synchrony in functionally connected regions of motor cortex is unknown and is of great interest. Scalp EEG studies demonstrated that stimulation of the STN can activate motor cortex antidromically, but the spatial specificity of this effect has not been examined. The present study examined the effect of STN HF DBS on neural synchrony within the cortico-basal ganglia network in patients with PD. We measured local field potentials dorsal to and within the STN of PD patients, and additionally in the motor cortex in a subset of these patients. We used diffusion tensor imaging (DTI) to guide the placement of subdural cortical surface electrodes over the DTI-identified origin of the hyperdirect pathway (HDP) between motor cortex and the STN. The results demonstrated that local beta power was attenuated during HF DBS both dorsal to and within the STN. The degree of attenuation was monotonic with increased DBS voltages in both locations, but this voltage-dependent effect was greater in the central STN than dorsal to the STN (p < 0.05). Cortical signals over the estimated origin of the HDP also demonstrated attenuation of beta hypersynchrony during DBS dorsal to or within STN, whereas signals from non-specific regions of motor cortex were not attenuated. The spatially-specific suppression of beta synchrony in the motor cortex support the hypothesis that DBS may treat Parkinsonism by reducing excessive synchrony in the functionally connected sensorimotor network.
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Affiliation(s)
- Diane Whitmer
- Department of Neurology and Neurological Sciences, Stanford University, Stanford CA, USA
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