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Liu X, Chou KL, Patil PG, Malaga KA. Effect of Anisotropic Brain Conductivity on Patient-Specific Volume of Tissue Activation in Deep Brain Stimulation for Parkinson Disease. IEEE Trans Biomed Eng 2024; 71:1993-2000. [PMID: 38277250 DOI: 10.1109/tbme.2024.3359119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2024]
Abstract
OBJECTIVE Deep brain stimulation (DBS) modeling can improve surgical targeting by quantifying the spatial extent of stimulation relative to subcortical structures of interest. A certain degree of model complexity is required to obtain accurate predictions, particularly complexity regarding electrical properties of the tissue around DBS electrodes. In this study, the effect of anisotropy on the volume of tissue activation (VTA) was evaluated in an individualized manner. METHODS Tissue activation models incorporating patient-specific tissue conductivity were built for 40 Parkinson disease patients who had received bilateral subthalamic nucleus (STN) DBS. To assess the impact of local changes in tissue anisotropy, one VTA was computed at each electrode contact using identical stimulation parameters. For comparison, VTAs were also computed assuming isotropic tissue conductivity. Stimulation location was considered by classifying the anisotropic VTAs relative to the STN. VTAs were characterized based on volume, spread in three directions, sphericity, and Dice coefficient. RESULTS Incorporating anisotropy generated significantly larger and less spherical VTAs overall. However, its effect on VTA size and shape was variable and more nuanced at the individual patient and implantation levels. Dorsal VTAs had significantly higher sphericity than ventral VTAs, suggesting more isotropic behavior. Contrastingly, lateral and posterior VTAs had significantly larger and smaller lateral-medial spreads, respectively. Volume and spread correlated negatively with sphericity. CONCLUSION The influence of anisotropy on VTA predictions is important to consider, and varies across patients and stimulation location. SIGNIFICANCE This study highlights the importance of considering individualized factors in DBS modeling to accurately characterize the VTA.
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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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Al Ali J, Lacy M, Padmanaban M, Abou Chaar W, Hagy H, Warnke PC, Xie T. Cognitive outcomes in patients with essential tremor treated with deep brain stimulation: a systematic review. Front Hum Neurosci 2024; 18:1319520. [PMID: 38371461 PMCID: PMC10869505 DOI: 10.3389/fnhum.2024.1319520] [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: 10/11/2023] [Accepted: 01/08/2024] [Indexed: 02/20/2024] Open
Abstract
Introduction Essential tremor (ET) is a common neurological disease. Deep brain stimulation (DBS) to the thalamic ventral intermediate nucleus (VIM) or the adjacent structures, such as caudal zona incerta/ posterior subthalamic area (cZi/PSA), can be effective in treating medication refractory tremor. However, it is not clear whether DBS can cause cognitive changes, in which domain, and to what extent if so. Methods We systematically searched PubMed and the Web of Science for available publications reporting on cognitive outcomes in patients with ET who underwent DBS following the PICO (population, intervention, comparators, and outcomes) concept. The PRISMA guideline for systematic reviews was applied. Results Twenty relevant articles were finally identified and included for review, thirteen of which were prospective (one also randomized) studies and seven were retrospective. Cognitive outcomes included attention, memory, executive function, language, visuospatial function, and mood-related variables. VIM and cZi/PSA DBS were generally well tolerated, although verbal fluency and language production were affected in some patients. Additionally, left-sided VIM DBS was associated with negative effects on verbal abstraction, word recall, and verbal memory performance in some patients. Conclusion Significant cognitive decline after VIM or cZi/PSA DBS in ET patients appears to be rare. Future prospective randomized controlled trials are needed to meticulously study the effect of the location, laterality, and stimulation parameters of the active contacts on cognitive outcomes while considering possible medication change post-DBS, timing, standard neuropsychological battery, practice effects, the timing of assessment, and effect size as potential confounders.
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Affiliation(s)
- Jamal Al Ali
- Department of Neurology, University of Chicago Medicine, Chicago, IL, United States
| | - Maureen Lacy
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, IL, United States
| | - Mahesh Padmanaban
- Department of Neurology, University of Chicago Medicine, Chicago, IL, United States
| | - Widad Abou Chaar
- Department of Neurology, University of Chicago Medicine, Chicago, IL, United States
| | - Hannah Hagy
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago Medicine, Chicago, IL, United States
| | - Peter C. Warnke
- Department of Neurological Surgery, University of Chicago Medicine, Chicago, IL, United States
| | - Tao Xie
- Department of Neurology, University of Chicago Medicine, Chicago, IL, United States
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Sun X, Shen R, Lin Z, Wang T, Wang L, Huang P, Feng T, Liu J, Ding J, Zhang C, Li D, Wu Y. Optimizing Deep Brain Stimulation in Essential Tremor: A Randomized Controlled Trial for Target Consideration. Neurosurgery 2024; 95:00006123-990000000-01032. [PMID: 38270451 PMCID: PMC11155559 DOI: 10.1227/neu.0000000000002839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/01/2023] [Indexed: 01/26/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The thalamic ventral intermediate nucleus (VIM) is a well-established target for deep brain stimulation (DBS) in the treatment of essential tremor (ET). Increasing data indicate that the posterior subthalamic area (PSA) may be superior, but high-level evidence is limited. We aimed at further comparing the intraindividual efficacy and side effect profile of PSA vs VIM DBS in ET. METHODS In this randomized, double-blind, crossover trial, 4-contact DBS leads were bilaterally implanted with single-trajectory covering the VIM and PSA. Patients were randomized postsurgery to 2 groups, receiving VIM stimulation (4-7 months) and then PSA stimulation (8-11 months) or vice versa. The primary end point was the difference in improvement from baseline to the end of the VIM vs PSA DBS period in the total score of the Fahn-Tolosa-Marin Tremor Rating Scale (FTM-TRS). RESULTS Ten patients with medically refractory ET were enrolled, and 9 completed the study. The difference between reduction of FTM-TRS total score in the PSA vs VIM DBS period was -7.4 (95% CI: -28.5 to 13.7, P = .328). Clinical benefit was achieved at significantly lower stimulation intensity under PSA DBS. Furthermore, PSA DBS provided greater improvement in head tremor subscore of FTM-TRS (PSA vs VIM: -2.2, P = .020) and disease-specific quality of life (PSA vs VIM: -13.8, P = .046) and induced fewer speech (Dysphonia Severity Index score: P = .043; diadochokinetic rate: P = .007; VDI score: P = .005) and gait disturbances compared with VIM DBS. Seven patients remained with PSA DBS after the crossover phase. CONCLUSION Our study confirms that PSA-DBS is comparable with VIM-DBS in suppressing tremors, superior in improving disease-specific quality of life, and possibly more effective in reducing head tremor.
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Affiliation(s)
- Xiaoyu Sun
- Department of Neurology & Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
| | - Ruinan Shen
- Department of Neurology & Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
| | - Zhengyu Lin
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
| | - Tao Wang
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
| | - Lingbing Wang
- Department of Neurology & Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
| | - Peng Huang
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
| | - Tienan Feng
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China;
| | - Jun Liu
- Department of Neurology & Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
| | - Jianqing Ding
- Department of Neurology & Institute of Neurology, Renji Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
| | - Chencheng Zhang
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
- Clinical Neuroscience Center, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dianyou Li
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
- Clinical Neuroscience Center, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiwen Wu
- Department of Neurology & Institute of Neurology, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China;
- Clinical Neuroscience Center, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Stenmark Persson R, Fytagoridis A, Ryzhkov M, Hariz M, Blomstedt P. Long-Term Follow-Up of Unilateral Deep Brain Stimulation Targeting the Caudal Zona Incerta in 13 Patients with Parkinsonian Tremor. Stereotact Funct Neurosurg 2023; 101:369-379. [PMID: 37879313 DOI: 10.1159/000533793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/22/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Deep brain stimulation (DBS) is an established treatment for Parkinson's disease (PD) and other movement disorders. The ventral intermediate nucleus of the thalamus is considered as the target of choice for tremor disorders, including tremor-dominant PD not suitable for DBS in the subthalamic nucleus (STN). In the last decade, several studies have shown promising results on tremor from DBS in the posterior subthalamic area (PSA), including the caudal zona incerta (cZi) located posteromedial to the STN. The aim of this study was to evaluate the long-term effect of unilateral cZi/PSA-DBS in patients with tremor-dominant PD. METHODS Thirteen patients with PD with medically refractory tremor were included. The patients were evaluated using the motor part of the Unified Parkinson Disease Rating Scale (UPDRS) off/on medication before surgery and off/on medication and stimulation 1-2 years (short-term) after surgery and at a minimum of 3 years after surgery (long-term). RESULTS At short-term follow-up, DBS improved contralateral tremor by 88% in the off-medication state. This improvement persisted after a mean of 62 months. Contralateral bradykinesia was improved by 40% at short-term and 20% at long-term follow-up, and the total UPDRS-III by 33% at short-term and by 22% at long-term follow-up with stimulation alone. CONCLUSIONS Unilateral cZi/PSA-DBS seems to remain an effective treatment for patients with severe Parkinsonian tremor several years after surgery. There was also a modest improvement on bradykinesia.
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Affiliation(s)
| | - Anders Fytagoridis
- Department of Clinical Neuroscience, Neurosurgery, Karolinska Institute, Stockholm, Sweden
| | - Maxim Ryzhkov
- Cranial and Spinal Technologies, Medtronic, Lafayette, Colorado, USA
| | - Marwan Hariz
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
- UCL Queen Square Institute of Neurology, London, UK
| | - Patric Blomstedt
- Department of Clinical Science, Neurosciences, Umeå University, Umeå, Sweden
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Holcomb JM, Chopra R, Feltrin FS, Elkurd M, El-Nazer R, McKenzie L, O’Suilleabhain P, Maldjian JA, Dauer W, Shah BR. Improving tremor response to focused ultrasound thalamotomy. Brain Commun 2023; 5:fcad165. [PMID: 37533544 PMCID: PMC10390385 DOI: 10.1093/braincomms/fcad165] [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: 11/03/2022] [Revised: 04/18/2023] [Accepted: 05/19/2023] [Indexed: 08/04/2023] Open
Abstract
MRI-guided high-intensity focused ultrasound thalamotomy is an incisionless therapy for essential tremor. To reduce adverse effects, the field has migrated to treating at 2 mm above the anterior commissure-posterior commissure plane. We perform MRI-guided high-intensity focused ultrasound with an advanced imaging targeting technique, four-tract tractography. Four-tract tractography uses diffusion tensor imaging to identify the critical white matter targets for tremor control, the decussating and non-decussating dentatorubrothalamic tracts, while the corticospinal tract and medial lemniscus are identified to be avoided. In some patients, four-tract tractography identified a risk of damaging the medial lemniscus or corticospinal tract if treated at 2 mm superior to the anterior commissure-posterior commissure plane. In these patients, we chose to target 1.2-1.5 mm superior to the anterior commissure-posterior commissure plane. In these patients, post-operative imaging revealed that the focused ultrasound lesion extended into the posterior subthalamic area. This study sought to determine if patients with focused ultrasound lesions that extend into the posterior subthalamic area have a differnce in tremor improvement than those without. Twenty essential tremor patients underwent MRI-guided high-intensity focused ultrasound and were retrospectively classified into two groups. Group 1 included patients with an extension of the thalamic-focused ultrasound lesion into the posterior subthalamic area. Group 2 included patients without extension of the thalamic-focused ultrasound lesion into the posterior subthalamic area. For each patient, the percent change in postural tremor, kinetic tremor and Archimedes spiral scores were calculated between baseline and a 3-month follow-up. Two-tailed Wilcoxon rank-sum tests were used to compare the improvement in tremor scores, the total number of sonications, thermal dose to achieve initial tremor response, and skull density ratio between groups. Group 1 had significantly greater postural, kinetic, and Archimedes spiral score percent improvement than Group 2 (P values: 5.41 × 10-5, 4.87 × 10-4, and 5.41 × 10-5, respectively). Group 1 also required significantly fewer total sonications to control the tremor and a significantly lower thermal dose to achieve tremor response (P values: 6.60 × 10-4 and 1.08 × 10-5, respectively). No significant group differences in skull density ratio were observed (P = 1.0). We do not advocate directly targeting the posterior subthalamic area with MRI-guided high-intensity focused ultrasound because the shape of the focused ultrasound lesion can result in a high risk of adverse effects. However, when focused ultrasound lesions naturally extend from the thalamus into the posterior subthalamic area, they provide greater tremor control than those that only involve the thalamus.
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Affiliation(s)
- James M Holcomb
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Rajiv Chopra
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Fabricio S Feltrin
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Mazen Elkurd
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Rasheda El-Nazer
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Lauren McKenzie
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | | | - Joseph A Maldjian
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - William Dauer
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
- O’Donnell Brain Institute, UTSW Medical Center, Dallas, TX 75235, USA
| | - Bhavya R Shah
- Correspondence to: Bhavya R. Shah Department of Radiology, UTSW Medical Center, 1801 Inwood Rd Dallas, TX 75235, USA E-mail:
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Hirt L, Thies KA, Ojemann S, Abosch A, Darwin ML, Thompson JA, Kern DS. Case series investigating the differences between stimulation of rostral zona incerta region in isolation or in conjunction with the subthalamic nucleus on acute clinical effects for Parkinson’s disease. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2022.101553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Baumgartner AJ, Thompson JA, Kern DS, Ojemann SG. Novel targets in deep brain stimulation for movement disorders. Neurosurg Rev 2022; 45:2593-2613. [PMID: 35511309 DOI: 10.1007/s10143-022-01770-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/01/2021] [Accepted: 03/08/2022] [Indexed: 12/26/2022]
Abstract
The neurosurgical treatment of movement disorders, primarily via deep brain stimulation (DBS), is a rapidly expanding and evolving field. Although conventional targets including the subthalamic nucleus (STN) and internal segment of the globus pallidus (GPi) for Parkinson's disease and ventral intermediate nucleus of the thalams (VIM) for tremor provide substantial benefit in terms of both motor symptoms and quality of life, other targets for DBS have been explored in an effort to maximize clinical benefit and also avoid undesired adverse effects associated with stimulation. These novel targets primarily include the rostral zona incerta (rZI), caudal zona incerta (cZI)/posterior subthalamic area (PSA), prelemniscal radiation (Raprl), pedunculopontine nucleus (PPN), substantia nigra pars reticulata (SNr), centromedian/parafascicular (CM/PF) nucleus of the thalamus, nucleus basalis of Meynert (NBM), dentato-rubro-thalamic tract (DRTT), dentate nucleus of the cerebellum, external segment of the globus pallidus (GPe), and ventral oralis (VO) complex of the thalamus. However, reports of outcomes utilizing these targets are scattered and disparate. In order to provide a comprehensive resource for researchers and clinicians alike, we have summarized the existing literature surrounding these novel targets, including rationale for their use, neurosurgical techniques where relevant, outcomes and adverse effects of stimulation, and future directions for research.
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Affiliation(s)
| | - John A Thompson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Hospital, 12631 East 17th Avenue, PO Box 6511, Aurora, CO, 80045, USA
| | - Drew S Kern
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
- University of Colorado Hospital, 12631 East 17th Avenue, PO Box 6511, Aurora, CO, 80045, USA
| | - Steven G Ojemann
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA.
- University of Colorado Hospital, 12631 East 17th Avenue, PO Box 6511, Aurora, CO, 80045, USA.
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Chandra V, Hilliard JD, Foote KD. Deep brain stimulation for the treatment of tremor. J Neurol Sci 2022; 435:120190. [DOI: 10.1016/j.jns.2022.120190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/07/2022] [Accepted: 02/17/2022] [Indexed: 01/15/2023]
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Páez-Nova M, Spiegelmann R, Korn-Israeli S, Zibly Z, Illera-Rivera D, Daza-Cordoba C, Alcazar-Daza JC, Garcia-Ballestas E. Targeting the vim by direct visualization of the cerebello-thalamo-cortical pathway in 3 T proton density MRI: correlation with focused ultrasound lesioning. Neurosurg Rev 2022; 45:2323-2332. [PMID: 35147798 DOI: 10.1007/s10143-022-01752-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 01/13/2022] [Accepted: 02/04/2022] [Indexed: 10/19/2022]
Abstract
Surgical targeting of the ventral intermediate nucleus of the thalamus (VIM) has been historically done using indirect strategies. Here we depict the cerebello-thalamo-cortical tract (CTCT) through 3 T proton density (PD) in a cohort of patients who underwent high-intensity focus ultrasound (HIFUS) thalamotomy. Forty-seven patients treated in our institution with MR-guided HIFUS VIM thalamotomy were included in this study. PD weighted 3 T MRI used for presurgical planning was compared with postoperative MRI obtained 1 month after surgery. Images were processed with ISTX software (Brain lab, Munich, Germany). The coordinates of the VIM lesion concerning the inter-commissural line (ICL) were annotated. Deterministic tractographies using three ROIs were used to verify the different tracts. The triangle seen in the 3 T PD sequence at the level of the mesencephalic-diencephalic junction was systematically recognized. The posterior angle of this triangle at the junction of the CTCT and the ZI was denominated as "point P." The area of this triangle corresponds to the posterior subthalamic area (PSA) harboring the Raprl fibers. The CTCT was visible from 1 to 2.5 mm below the ICL. The average center of the final HIFUS lesion (point F) was 11 mm from the medial thalamic border of the thalamus (14.9 mm from the midline), 6.4 mm anterior to PC, and 0.6 mm above the ICL. The FUS point was consistently 1-2 mm directly above point P. The anterior border of the external angle of this triangle (point P) can be used as an intraparenchymal point for targeting the ventral border of the VIM. Three ROIs placed in a single slice around this triangle are a fast way to originate tractography of the CTCT, lemniscus medialis, and pyramidal tract.
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Affiliation(s)
- Maximiliano Páez-Nova
- Functional Neurosurgery Unit, DepartmentofNeurosurgery, The Chaim Sheba Medical Center, Tel Hashomer, Israel.
| | - Roberto Spiegelmann
- Functional Neurosurgery Unit, DepartmentofNeurosurgery, The Chaim Sheba Medical Center, Tel Hashomer, Israel. .,The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Simon Korn-Israeli
- The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.,Abnormal Movements Unit, Department of Neurology, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Zion Zibly
- Functional Neurosurgery Unit, DepartmentofNeurosurgery, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Diego Illera-Rivera
- Social Medicine and Family Health Department, University of Cauca, Popayan, Colombia
| | - Carmen Daza-Cordoba
- Abnormal Movements Unit, Department of Neurology, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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Sugiyama J, Toda H. A Single DBS-Lead to Stimulate the Thalamus and Subthalamus: Two-Story Targets for Tremor Disorders. Front Hum Neurosci 2022; 16:790942. [PMID: 35140594 PMCID: PMC8820320 DOI: 10.3389/fnhum.2022.790942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 01/05/2022] [Indexed: 11/21/2022] Open
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Xie T, Padmanaban M, Javed A, Satzer D, Towle TE, Warnke P, Towle VL. Effect of Deep Brain Stimulation on Cerebellar Tremor Compared to Non-Cerebellar Tremor Using a Wearable Device in a Patient With Multiple Sclerosis: Case Report. Front Hum Neurosci 2022; 15:754091. [PMID: 35095448 PMCID: PMC8792598 DOI: 10.3389/fnhum.2021.754091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/24/2021] [Indexed: 12/02/2022] Open
Abstract
Tremor of the upper extremity is a significant cause of disability in some patients with multiple sclerosis (MS). The MS tremor is complex because it contains an ataxic intentional tremor component due to the involvement of the cerebellum and cerebellar outflow pathways by MS plaques, which makes the MS tremor, in general, less responsive to medications or deep brain stimulation (DBS) than those associated with essential tremor or Parkinson's disease. The cerebellar component has been thought to be the main reason for making DBS less effective, although it is not clear whether it is due to the lack of suppression of the ataxic tremor by DBS or else. The goal of this study was to clarify the effect of DBS on cerebellar tremor compared to non-cerebellar tremor in a patient with MS. By wearing an accelerometer on the index finger of each hand, we were able to quantitatively characterize kinetic tremor by frequency and amplitude, with cerebellar ataxia component on one hand and that without cerebellar component on the other hand, at the beginning and end of the hand movement approaching a target at DBS Off and On status. We found that cerebellar tremor surprisingly had as good a response to DBS as the tremor without a cerebellar component, but the function control on cerebellar tremor was not as good due to its distal oscillation, which made the amplitude of tremor increasingly greater as it approached the target. This explains why cerebellar tremor or MS tremor with cerebellar component has a poor functional transformation even with a good percentage of tremor control. This case study provides a better understanding of the effect of DBS on cerebellar tremor and MS tremor by using a wearable device, which could help future studies improve patient selection and outcome prediction for DBS treatment of this disabling tremor.
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Affiliation(s)
- Tao Xie
- Department of Neurology, University of Chicago Medicine, Chicago, IL, United States
- *Correspondence: Tao Xie
| | - Mahesh Padmanaban
- Department of Neurology, University of Chicago Medicine, Chicago, IL, United States
| | - Adil Javed
- Department of Neurology, University of Chicago Medicine, Chicago, IL, United States
| | - David Satzer
- Department of Neurosurgery, University of Chicago Medicine, Chicago, IL, United States
| | - Theresa E. Towle
- Department of Neurosurgery, University of Chicago Medicine, Chicago, IL, United States
| | - Peter Warnke
- Department of Neurosurgery, University of Chicago Medicine, Chicago, IL, United States
| | - Vernon L. Towle
- Department of Neurology, University of Chicago Medicine, Chicago, IL, United States
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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: 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: 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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14
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Thaker AA, Reddy KM, Thompson JA, Gerecht PD, Brown MS, Abosch A, Ojemann SG, Kern DS. Coronal Gradient Echo MRI to Visualize the Zona Incerta for Deep Brain Stimulation Targeting in Parkinson's Disease. Stereotact Funct Neurosurg 2021; 99:443-450. [PMID: 33902054 DOI: 10.1159/000515772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/10/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Deep brain stimulation of the zona incerta is effective at treating tremor and other forms of parkinsonism. However, the structure is not well visualized with standard MRI protocols making direct surgical targeting unfeasible and contributing to inconsistent clinical outcomes. In this study, we applied coronal gradient echo MRI to directly visualize the rostral zona incerta in Parkinson's disease patients to improve targeting for deep brain stimulation. METHODS We conducted a prospective study to optimize and evaluate an MRI sequence to visualize the rostral zona incerta in patients with Parkinson's disease (n = 31) and other movement disorders (n = 13). We performed a contrast-to-noise ratio analysis of specific regions of interest to quantitatively assess visual discrimination of relevant deep brain structures in the optimized MRI sequence. Regions of interest were independently assessed by 2 neuroradiologists, and interrater reliability was assessed. RESULTS Rostral zona incerta and subthalamic nucleus were well delineated in our 5.5-min MRI sequence, indicated by excellent interrater agreement between neuroradiologists for region-of-interest measurements (>0.90 intraclass coefficient). Mean contrast-to-noise ratio was high for both rostral zona incerta (6.39 ± 3.37) and subthalamic nucleus (17.27 ± 5.61) relative to adjacent white matter. There was no significant difference between mean signal intensities or contrast-to-noise ratio for Parkinson's and non-Parkinson's patients for either structure. DISCUSSION/CONCLUSION Our optimized coronal gradient echo MRI sequence delineates subcortical structures relevant to traditional and novel deep brain stimulation targets, including the zona incerta, with high contrast-to-noise. Future studies will prospectively apply this sequence to surgical planning and postimplantation outcomes.
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Affiliation(s)
- Ashesh A Thaker
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kartik M Reddy
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - John A Thompson
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Pamela David Gerecht
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mark S Brown
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Neurosurgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Steven G Ojemann
- Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Drew S Kern
- Department of Neurology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,Department of Neurosurgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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15
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Iorio-Morin C, Fomenko A, Kalia SK. Deep-Brain Stimulation for Essential Tremor and Other Tremor Syndromes: A Narrative Review of Current Targets and Clinical Outcomes. Brain Sci 2020; 10:E925. [PMID: 33271848 PMCID: PMC7761254 DOI: 10.3390/brainsci10120925] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 02/06/2023] Open
Abstract
Tremor is a prevalent symptom associated with multiple conditions, including essential tremor (ET), Parkinson's disease (PD), multiple sclerosis (MS), stroke and trauma. The surgical management of tremor evolved from stereotactic lesions to deep-brain stimulation (DBS), which allowed safe and reversible interference with specific neural networks. This paper reviews the current literature on DBS for tremor, starting with a detailed discussion of current tremor targets (ventral intermediate nucleus of the thalamus (Vim), prelemniscal radiations (Raprl), caudal zona incerta (Zi), thalamus (Vo) and subthalamic nucleus (STN)) and continuing with a discussion of results obtained when performing DBS in the various aforementioned tremor syndromes. Future directions for DBS research are then briefly discussed.
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Affiliation(s)
- Christian Iorio-Morin
- Christian Iorio-Morin, Division of Neurosurgery, Université de Sherbrooke, 3001, 12e Avenue Nord, Sherbrooke, QC J1H 5N4, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
| | - Anton Fomenko
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
| | - Suneil K. Kalia
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON M5T 2S8, Canada; (A.F.); (S.K.K.)
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16
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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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17
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Burns MR, Chiu SY, Patel B, Mitropanopoulos SG, Wong JK, Ramirez-Zamora A. Advances and Future Directions of Neuromodulation in Neurologic Disorders. Neurol Clin 2020; 39:71-85. [PMID: 33223090 DOI: 10.1016/j.ncl.2020.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
"Deep brain stimulation is a safe and effective therapy for the management of a variety of neurologic conditions with Food and Drug Administration or humanitarian exception approval for Parkinson disease, dystonia, tremor, and obsessive-compulsive disorder. Advances in neurophysiology, neuroimaging, and technology have driven increasing interest in the potential benefits of neurostimulation in other neuropsychiatric conditions including dementia, depression, pain, Tourette syndrome, and epilepsy, among others. New anatomic or combined targets are being investigated in these conditions to improve symptoms refractory to medications or standard stimulation."
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Affiliation(s)
- Matthew R Burns
- The Fixel Institute for Neurological Diseases, Department of Neurology, The University of Florida, 3009 Williston Road, Gainesville, FL 32608, USA
| | - Shannon Y Chiu
- The Fixel Institute for Neurological Diseases, Department of Neurology, The University of Florida, 3009 Williston Road, Gainesville, FL 32608, USA
| | - Bhavana Patel
- The Fixel Institute for Neurological Diseases, Department of Neurology, The University of Florida, 3009 Williston Road, Gainesville, FL 32608, USA
| | - Sotiris G Mitropanopoulos
- The Fixel Institute for Neurological Diseases, Department of Neurology, The University of Florida, 3009 Williston Road, Gainesville, FL 32608, USA
| | - Joshua K Wong
- The Fixel Institute for Neurological Diseases, Department of Neurology, The University of Florida, 3009 Williston Road, Gainesville, FL 32608, USA
| | - Adolfo Ramirez-Zamora
- The Fixel Institute for Neurological Diseases, Department of Neurology, The University of Florida, 3009 Williston Road, Gainesville, FL 32608, USA.
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18
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Yu H, Takahashi K, Bloom L, Quaynor SD, Xie T. Effect of Deep Brain Stimulation on Swallowing Function: A Systematic Review. Front Neurol 2020; 11:547. [PMID: 32765388 PMCID: PMC7380112 DOI: 10.3389/fneur.2020.00547] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 05/14/2020] [Indexed: 12/18/2022] Open
Abstract
The effect of deep brain stimulation (DBS) on swallowing function in movement disorders is unclear. Here, we systematically reviewed this topic by searching keywords following PICOS strategy of problem (swallowing or swallow or dysphagia or aspiration) and intervention (deep brain stimulation, or DBS) in the PubMed and Web of Science in English in April 2020, with comparators [subthalamic nucleus (STN), globus pallidus interna (GPi), ventralis intermedius, (ViM), post-subthalamic area, or caudal zona incerta (PSA/cZi); ON/OFF DBS state/settings, ON/OFF medication state, Parkinson's disease (PD), dystonia, tremor], outcomes (swallowing function measures, subjective/objective) and study types (good quality original studies) in mind. We found that STN DBS at usual high-frequency stimulation could have beneficial effect (more so on subjective measures and/or OFF medication), no effect, or detrimental effect (more so on objective measures and/or ON medication) on swallowing function in patients with PD, while low-frequency stimulation (LFS) could have beneficial effect on swallowing function in patients with freezing of gait. GPi DBS could have a beneficial effect (regardless of medication state and outcome measures) or no effect, but no detrimental effect, on swallowing function in PD. GPi DBS also has beneficial effects on swallowing function in majority of the studies on Meige syndrome but not in other diseases with dystonia. PSA/cZi DBS rarely has detrimental effect on swallowing functions in patients with PD or tremor. There is limited information on ViM to assess. Information on swallowing function by DBS remains limited. Well-designed studies and direct comparison of targets are further needed.
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Affiliation(s)
- Huiyan Yu
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Beijing, China.,Department of Neurology, The University of Chicago Medicine, Chicago, IL, United States
| | - Kazutaka Takahashi
- Department of Organismal Biology and Anatomy, The University of Chicago, Chicago, IL, United States
| | - Lisa Bloom
- Department of Neurology, The University of Chicago Medicine, Chicago, IL, United States.,Speech and Swallowing Service, The University of Chicago Medicine, Chicago, IL, United States
| | - Samuel D Quaynor
- Department of Neurology, The University of Chicago Medicine, Chicago, IL, United States
| | - Tao Xie
- Department of Neurology, The University of Chicago Medicine, Chicago, IL, United States
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19
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Macerollo A, Hammersley B, Bonello M, Somerset J, Bhargava D, Das K, Osman-Farah J, Eldridge PR, Alusi SH. Deep brain stimulation for post-thalamic stroke complex movement disorders. Neurol Sci 2020; 42:337-342. [PMID: 32654009 DOI: 10.1007/s10072-020-04572-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/02/2020] [Indexed: 11/30/2022]
Affiliation(s)
- A Macerollo
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK. .,Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK.
| | - B Hammersley
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - M Bonello
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - J Somerset
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - D Bhargava
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - K Das
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - J Osman-Farah
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - P R Eldridge
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - S H Alusi
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
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20
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Wang KL, Wong JK, Eisinger RS, Carbunaru S, Smith C, Hu W, Shukla AW, Hess CW, Okun MS, Ramirez-Zamora A. Therapeutic Advances in the Treatment of Holmes Tremor: Systematic Review. Neuromodulation 2020; 25:796-803. [PMID: 32578304 DOI: 10.1111/ner.13220] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 04/22/2020] [Accepted: 05/21/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We aimed to formulate a practical clinical treatment algorithm for Holmes's tremor (HT) by reviewing currently published clinical data. MATERIALS AND METHODS We performed a systematic review of articles discussing the management of HT published between January 1990 and December 2018. We examined data from 89 patients published across 58 studies detailing the effects of pharmacological or surgical interventions on HT severity. Clinical outcomes were measured by a continuous 1-10 ranked scale. The majority of studies addressing treatment response were case series or case reports. No randomized control studies were identified. RESULTS Our review included 24 studies focusing on pharmacologic treatments of 25 HT patients and 34 studies focusing on the effect of deep brain stimulation (DBS) in 64 patients. In the medical intervention group, the most commonly used drugs were levetiracetam, trihexyphenidyl, and levodopa. In the surgically treated group, the thalamic ventralis intermedius nucleus (VIM) and globus pallidus internus (GPi) were the most common brain targets for neuromodulation. The two targets accounted for 57.8% and 32.8% of total cases, respectively. Overall, compared to the medically treated group, DBS provided greater tremor suppression (p = 0.025) and was more effective for the management of postural tremor in HT. Moreover, GPi DBS displayed greater benefit in the resting tremor component (p = 0.042) and overall tremor reduction (p = 0.022). CONCLUSIONS There is a highly variable response to different medical treatments in HT without randomized clinical trials available to dictate treatment decisions. A variety of medical and surgical treatment options can be considered for the management of HT. Collaborative reseach between different institutions and researchers are warranted and needed to improve our understanding of the pathophysiology and management of this condition. In this review, we propose a practical treatment algorithm for HT based on currently available evidence.
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Affiliation(s)
- Kai-Liang Wang
- Department of Neurology, Program for Movement Disorders and Neurorestoration, Fixel Institute for Neurological Diseases at the University of Florida, Gainesville, FL, USA; Beijing Neurosurgical Institute, Capital Medical University, Beijing, China
| | - Joshua K Wong
- Department of Neurology, Program for Movement Disorders and Neurorestoration, Fixel Institute for Neurological Diseases at the University of Florida, Gainesville, FL, USA
| | - Robert S Eisinger
- Department of Neurology, Program for Movement Disorders and Neurorestoration, Fixel Institute for Neurological Diseases at the University of Florida, Gainesville, FL, USA
| | - Samuel Carbunaru
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Christine Smith
- Department of Neurology, Program for Movement Disorders and Neurorestoration, Fixel Institute for Neurological Diseases at the University of Florida, Gainesville, FL, USA
| | - Wei Hu
- Department of Neurology, Program for Movement Disorders and Neurorestoration, Fixel Institute for Neurological Diseases at the University of Florida, Gainesville, FL, USA
| | - Aparna Wagle Shukla
- Department of Neurology, Program for Movement Disorders and Neurorestoration, Fixel Institute for Neurological Diseases at the University of Florida, Gainesville, FL, USA
| | - Christopher W Hess
- Department of Neurology, Program for Movement Disorders and Neurorestoration, Fixel Institute for Neurological Diseases at the University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Department of Neurology, Program for Movement Disorders and Neurorestoration, Fixel Institute for Neurological Diseases at the University of Florida, Gainesville, FL, USA
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Program for Movement Disorders and Neurorestoration, Fixel Institute for Neurological Diseases at the University of Florida, Gainesville, FL, USA.
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21
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Diaz A, Cajigas I, Cordeiro JG, Mahavadi A, Sur S, Di Luca DG, Shpiner DS, Luca CC, Jagid JR. Individualized Anatomy-Based Targeting for VIM-cZI DBS in Essential Tremor. World Neurosurg 2020; 140:e225-e233. [PMID: 32438003 DOI: 10.1016/j.wneu.2020.04.240] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND Deep brain stimulation of the ventral intermediate nucleus (VIM) or caudal zona incerta (cZI) is effective for refractory essential tremor (ET). To refine stereotactic planning for lead placement, we developed a unique individualized anatomy-based planning protocol that targets both the VIM and the cZI in patients with ET. METHODS 33 patients with ET underwent VIM-cZI lead implantation with targeting based on our protocol. Indirect targeting was adjusted based on anatomic landmarks as reference lines bisecting the red nuclei and ipsilateral subthalamus. Outcomes were evaluated through the follow-up of 31.1 ± 18.4 months. Active contact coordinates were obtained from reconstructed electrodes in the Montreal Neurological Institute space using the MATLAB Lead-DBS toolbox. RESULTS Mean tremor improvement was 79.7% ± 22.4% and remained stable throughout the follow-up period. Active contacts at last postoperative visit had mean Montreal Neurological Institute coordinates of 15.5 ± 1.6 mm lateral to the intercommissural line, 15.3 ± 1.8 mm posterior to the anterior commissure, and 1.4 ± 2.9 mm below the intercommissural plane. No hemorrhagic complications were observed in the analyzed group. CONCLUSIONS Individualized anatomy-based VIM-cZI targeting is feasible and safe and is associated with favorable tremor outcomes.
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Affiliation(s)
- Anthony Diaz
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Iahn Cajigas
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Joacir G Cordeiro
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Anil Mahavadi
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Samir Sur
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | | | | | - Corneliu C Luca
- Department of Neurology, University of Miami, Miami, Florida, USA
| | - Jonathan R Jagid
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA.
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22
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Gravbrot N, Saranathan M, Pouratian N, Kasoff W. Advanced Imaging and Direct Targeting of the Motor Thalamus and Dentato-Rubro-Thalamic Tract for Tremor: A Systematic Review. Stereotact Funct Neurosurg 2020; 98:220-240. [DOI: 10.1159/000507030] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 02/27/2020] [Indexed: 11/19/2022]
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23
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De Marco R, Bhargava D, Macerollo A, Osman-Farah J. Could ZI have a role in DBS for Parkinson's Disease? An observational study to optimize DBS target localization. J Clin Neurosci 2020; 77:89-93. [PMID: 32402608 DOI: 10.1016/j.jocn.2020.05.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/03/2020] [Indexed: 11/29/2022]
Abstract
Deep Brain Stimulation (DBS) of the subthalamic nucleus (STN) is a well-recognized intervention for Parkinson's Disease (PD). We used LEAD-DBS, a toolbox facilitating DBS electrode reconstructions and computer simulations based on postoperative MRI and CT imaging, to investigate the interaction and followed benefits of electrical field generated by STN-DBS and surrounding areas, such as caudal Zona Incerta (cZI). Thirty-two PD patients, treated with directional STN-DBS in the period 2016-2018 at the Walton Center NHS Foundation Trust, were retrospectively recruited. Their MRI and CT imaging were analyzed with LEAD-DBS to measure the volume of tissue activated (VTA). Considering the clinical outcome based on the UPDRS III score improvement of 62.65% at 6 months follow up, we found a VTA intersection of 21.5% with motor STN and 61.7% with cZI. These observations may support the contribution of cZI deep stimulation to improve clinical outcome of PD patients treated with DBS, promoting the intriguing path of dual targeting.
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Affiliation(s)
- Raffaele De Marco
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK; Department of Neuroscience "Rita Levi Montalcini", Neurosurgery Unit, University of Turin, Italy.
| | - Deepti Bhargava
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Antonella Macerollo
- The Walton Centre for Neurology and Neurosurgery, Liverpool, UK; Faculty of Brain Sciences, University of Liverpool, UK
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24
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Wu A, Halpern C. Essential Tremor: Deep Brain Stimulation. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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25
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Outcomes from deep brain stimulation targeting subthalamic nucleus and caudal zona incerta for Parkinson's disease. NPJ PARKINSONS DISEASE 2019; 5:17. [PMID: 31453317 PMCID: PMC6704060 DOI: 10.1038/s41531-019-0089-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 06/24/2019] [Indexed: 12/14/2022]
Abstract
Both subthalamic nucleus (STN) and caudal zona incerta (cZI) have been implicated as the optimal locus for deep brain stimulation (DBS) in Parkinson’s disease (PD). We present a retrospective clinico-anatomical analysis of outcomes from DBS targeting both STN and cZI. Forty patients underwent bilateral DBS using an image-verified implantable guide tube/stylette technique. Contacts on the same quadripolar lead were placed in both STN and cZI. After pulse generator programming, contacts yielding the best clinical effect were selected for chronic stimulation. OFF-medication unified PD rating scale (UPDRS) part III scores pre-operatively and ON-stimulation at 1–2 year follow up were compared. Active contacts at follow-up were anatomically localised from peri-operative imaging. Overall, mean UPDRS part III score improvement was 55 ± 9% (95% confidence interval), with improvement in subscores for rigidity (59 ± 13%), bradykinesia (58 ± 13%), tremor (71 ± 24%) and axial features (36 ± 19%). Active contacts were distributed in the following locations: (1) within posterior/dorsal STN (50%); (2) dorsal to STN (24%); (3) in cZI (21%); and (4) lateral to STN (5%). When contacts were grouped by location, no significant differences between groups were seen in baseline or post-operative improvement in contralateral UPDRS part III subscores. We conclude that when both STN and cZI are targeted, active contacts are distributed most commonly within and immediately dorsal to STN. In a subgroup of cases, cZI contacts were selected for chronic stimulation in preference. Dual targeting of STN and cZI is feasible and may provide extra benefit compared with conventional STN DBS is some patients.
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Gilmore G, Murgai A, Nazer A, Parrent A, Jog M. Zona incerta deep-brain stimulation in orthostatic tremor: efficacy and mechanism of improvement. J Neurol 2019; 266:2829-2837. [DOI: 10.1007/s00415-019-09505-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/03/2019] [Accepted: 08/08/2019] [Indexed: 10/26/2022]
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Comparison of posterior subthalamic area deep brain stimulation for tremor using conventional landmarks versus directly targeting the dentatorubrothalamic tract with tractography. Clin Neurol Neurosurg 2019; 185:105466. [PMID: 31466022 DOI: 10.1016/j.clineuro.2019.105466] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/19/2019] [Accepted: 08/06/2019] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To compare posterior subthalamic area deep brain stimulation (PSA-DBS) performed in the conventional manner against diffusion tensor imaging and tractography (DTIT)-guided lead implantation into the dentatorubrothalamic tract (DRTT). PATIENTS AND METHODS Double-blind, randomised study involving 34 patients with either tremor-dominant Parkinson's disease or essential tremor. Patients were randomised to Group A (DBS leads inserted using conventional landmarks) or Group B (leads guided into the DRTT using DTIT). Tremor (Fahn-Tolosa-Marin) and quality-of-life (PDQ-39) scores were evaluated 0-, 6-, 12-, 36- and 60-months after surgery. RESULTS PSA-DBS resulted in marked tremor reduction in both groups. However, Group B patients had significantly better arm tremor control (especially control of intention tremor), increased mobility and activities of daily living, reduced social stigma and need for social support as well as lower stimulation amplitudes and pulse widths compared to Group A patients. The better outcomes were sustained for up to 60-months from surgery. The active contacts of Group B patients were consistently closer to the centre of the DRTT than in Group A. Speech problems were more common in Group A patients. CONCLUSION DTIT-guided lead placement results in better and more stable tremor control and fewer adverse effects compared to lead placement in the conventional manner. This is because DTIT-guidance allows closer and more consistent placement of leads to the centre of the DRTT than conventional methods.
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Segato A, Pieri V, Favaro A, Riva M, Falini A, De Momi E, Castellano A. Automated Steerable Path Planning for Deep Brain Stimulation Safeguarding Fiber Tracts and Deep Gray Matter Nuclei. Front Robot AI 2019; 6:70. [PMID: 33501085 PMCID: PMC7806057 DOI: 10.3389/frobt.2019.00070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 07/18/2019] [Indexed: 12/20/2022] Open
Abstract
Deep Brain Stimulation (DBS) is a neurosurgical procedure consisting in the stereotactic implantation of stimulation electrodes to specific brain targets, such as deep gray matter nuclei. Current solutions to place the electrodes rely on rectilinear stereotactic trajectories (RTs) manually defined by surgeons, based on pre-operative images. An automatic path planner that accurately targets subthalamic nuclei (STN) and safeguards critical surrounding structures is still lacking. Also, robotically-driven curvilinear trajectories (CTs) computed on the basis of state-of-the-art neuroimaging would decrease DBS invasiveness, circumventing patient-specific obstacles. This work presents a new algorithm able to estimate a pool of DBS curvilinear trajectories for reaching a given deep target in the brain, in the context of the EU's Horizon EDEN2020 project. The prospect of automatically computing trajectory plans relying on sophisticated newly engineered steerable devices represents a breakthrough in the field of microsurgical robotics. By tailoring the paths according to single-patient anatomical constraints, as defined by advanced preoperative neuroimaging including diffusion MR tractography, this planner ensures a higher level of safety than the standard rectilinear approach. Ten healthy controls underwent Magnetic Resonance Imaging (MRI) on 3T scanner, including 3DT1-weighted sequences, 3Dhigh-resolution time-of-flight MR angiography (TOF-MRA) and high angular resolution diffusion MR sequences. A probabilistic q-ball residual-bootstrap MR tractography algorithm was used to reconstruct motor fibers, while the other deep gray matter nuclei surrounding STN and vessels were segmented on T1 and TOF-MRA images, respectively. These structures were labeled as obstacles. The reliability of the automated planner was evaluated; CTs were compared to RTs in terms of efficacy and safety. Targeting the anterior STN, CTs performed significantly better in maximizing the minimal distance from critical structures, by finding a tuned balance between all obstacles. Moreover, CTs resulted superior in reaching the center of mass (COM) of STN, as well as in optimizing the entry angle in STN and in the skull surface.
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Affiliation(s)
- Alice Segato
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Valentina Pieri
- Neuroradiology Unit and CERMAC, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Favaro
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Marco Riva
- Department of Medical Biotechnology and Translational Medicine, Università degli Studi di Milano, Milan, Italy.,Unit of Oncological Neurosurgery, Humanitas Research Hospital, Rozzano, Italy
| | - Andrea Falini
- Neuroradiology Unit and CERMAC, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
| | - Elena De Momi
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Antonella Castellano
- Neuroradiology Unit and CERMAC, IRCCS Ospedale San Raffaele, Vita-Salute San Raffaele University, Milan, Italy
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Sidiropoulos C. Reader response: DBS of the PSA and the VIM in essential tremor: A randomized, double-blind, crossover trial. Neurology 2019; 92:975. [PMID: 31085730 DOI: 10.1212/wnl.0000000000007522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Kern DS, Picillo M, Thompson JA, Sammartino F, di Biase L, Munhoz RP, Fasano A. Interleaving Stimulation in Parkinson's Disease, Tremor, and Dystonia. Stereotact Funct Neurosurg 2019; 96:379-391. [PMID: 30654368 DOI: 10.1159/000494983] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 10/24/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS Interleaving stimulation (ILS) in deep brain stimulation (DBS) provides individualized stimulation of 2 contacts delivered in alternating order. Currently, limited information on the utility of ILS exists. The aims of this study were to determine the practical applications and outcomes of ILS DBS in Parkinson's disease (PD), tremor, and dystonia. METHODS We performed a single-center, unblinded, retrospective chart review of all patients with DBS attempted on ILS at our referral center assessing for rationale and outcomes. RESULTS Fifty patients (PD, n = 27; tremor, n = 7; dystonia, n = 16 patients) tried ILS for 2 rationales: management of adverse effects (n = 29) and to improve clinical efficacy (n = 21). A total of 19 patients demonstrated improvement with ILS for adverse effect management predominately for the treatment of dyskinesias (n = 12). In the vast majority of dyskinetic patients, a contact added into the rostral zona incerta with ILS was performed. Nine out of 21 patients demonstrated improved clinical efficacy with ILS with all 6 PD patients who tried ILS for this rationale demonstrating benefit. CONCLUSIONS In PD, ILS provided benefits for dyskinesias and parkinsonism, with minimal improvement of other adverse effects. In tremor and dystonia, marginal effects in terms of mitigation of adverse effects and improvement of clinical outcomes were evident.
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Affiliation(s)
- Drew S Kern
- Movement Disorders Center, Department of Neurology, University of Colorado, Denver, Colorado, USA, .,Movement Disorders Center, Department of Neurosurgery, University of Colorado, Denver, Colorado, USA,
| | - Marina Picillo
- Center for Neurodegenerative Diseases (CEMAND), Department of Medicine and Surgery, Neuroscience Section, University of Salerno, Salerno, Italy
| | - John A Thompson
- Movement Disorders Center, Department of Neurosurgery, University of Colorado, Denver, Colorado, USA
| | - Francesco Sammartino
- Division of Neurosurgery, University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Lazzaro di Biase
- Neurology Unit, Campus Bio-Medico University, Rome, Italy.,Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Renato P Munhoz
- Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease and Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Research Institute, Toronto, Ontario, Canada
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Russo M, Santarelli DM, Smith U. Cervical spinal cord stimulation for the treatment of essential tremor. BMJ Case Rep 2018; 2018:bcr-2018-224347. [PMID: 30068576 PMCID: PMC6078261 DOI: 10.1136/bcr-2018-224347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2018] [Indexed: 12/26/2022] Open
Abstract
A patient with refractory essential tremor of the hands and head/neck refused deep brain stimulation and requested consideration for spinal cord stimulation (SCS). Trial of a cervical SCS system using a basic tonic waveform produced positive outcomes in hand tremor, head-nodding and daily functioning. The patient proceeded to implant and received regular programming sessions. Outcomes were recorded at follow-ups (1, 3, 6, 12, 23 months postimplant) and included patient self-reported changes, clinical observations, handwriting assessments and The Essential Tremor Rating Assessment Scale scores. Trial of a paraesthesia-free burst waveform programme produced a small improvement in head-nodding, without uncomfortable paraesthesias. With continued programming, the patient reported further improvements to tremor and functionality, with minimal tremor remaining at 12-23 months. No major side effects were reported.
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Affiliation(s)
- Marc Russo
- Hunter Pain Clinic, Broadmeadow, New South Wales, Australia
| | | | - Ushtana Smith
- Boston Scientific Neuromodulation, Mascot, New South Wales, Australia
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Abstract
Within the field of movement disorders, the conceptual understanding of dystonia has continued to evolve. Clinical advances have included improvements in recognition of certain features of dystonia, such as tremor, and understanding of phenotypic spectrums in the genetic dystonias and dystonia terminology and classification. Progress has also been made in the understanding of underlying biological processes which characterize dystonia from discoveries using approaches such as neurophysiology, functional imaging, genetics, and animal models. Important advances include the role of the cerebellum in dystonia, the concept of dystonia as an aberrant brain network disorder, additional evidence supporting the concept of dystonia endophenotypes, and new insights into psychogenic dystonia. These discoveries have begun to shape treatment approaches as, in parallel, important new treatment modalities, including magnetic resonance imaging-guided focused ultrasound, have emerged and existing interventions such as deep brain stimulation have been further refined. In this review, these topics are explored and discussed.
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Affiliation(s)
- Stephen Tisch
- Faculty of Medicine, University of New South Wales, Sydney, Australia.,Department of Neurology, St Vincent's Hospital, Sydney, Australia
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Falconer RA, Rogers SL, Shenai M. Using Directional Deep Brain Stimulation to Co-activate the Subthalamic Nucleus and Zona Incerta for Overlapping Essential Tremor/Parkinson's Disease Symptoms. Front Neurol 2018; 9:544. [PMID: 30026728 PMCID: PMC6041971 DOI: 10.3389/fneur.2018.00544] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/18/2018] [Indexed: 12/02/2022] Open
Abstract
This index case report describes a novel programming approach that utilizes the 8-contact directional Deep Brain Stimulation (DBS) lead to effectively control the akinesia, rigidity and tremor of Parkinson's Disease (PD), as well as a severe kinetic tremor of Essential Tremor (ET), in a patient with overlapping symptoms of both PD and ET. Through utilizing a bipolar directional montage on a single segmented contact, symptom control was attained via likely co-activation of the Subthalamic Nucleus (STN) and the adjacent Zona Incerta (ZI). The patient is a 67-year-old professional guitarist with a long-standing diagnosis of ET manifesting with bilateral kinetic tremor, who then developed right lateralizing symptoms indicative of PD. After optimal medical management did not confer sufficient control, he underwent left-sided unilateral DBS targeting the STN. Both intraoperatively and post-operatively, omnidirectional, and directional electrode review resulted in significant akinesia, rigidity, and as well as resting tremor control but failed to sufficiently improve the kinetic tremor. As electrode 2B was shown to be the most efficacious with the largest therapeutic window, a bipolar directional montage on a single segmented contact was tried with the idea of possibly further extending the axial asymmetry of the directional stimulation toward the adjacent ZI to impact the kinetic tremor. This montage resulted in full kinetic and resting tremor control as well as akinesia and rigidity response [2B cathode (–), 2A anode (+), 2C anode (+) (1.4 mA, rate 160 Hz, pulse width 60 μs)]. At 6 months post initial programming, no montage changes have been made, and the patient has experienced a reduction in Motor UPDRS scores from 23 to 3 (evaluated off medication), full resolution of kinetic tremor and normalization of handwriting, as well as significant reduction in his medication requirements. This patient's response to a single segment bipolar directional montage, and lack of response from monopolar directional stimulation in the same area, does suggest the possibility of further axial asymmetric tissue activation and thus co-activation of both the dorsal STN and adjacent ZI. Further modeling and study are warranted.
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Affiliation(s)
- Ramsey A Falconer
- Inova Parkinson's and Movement Disorders Center, Falls Church, VA, United States
| | - Sean L Rogers
- Inova Parkinson's and Movement Disorders Center, Falls Church, VA, United States
| | - Mahesh Shenai
- Inova Parkinson's and Movement Disorders Center, Falls Church, VA, United States
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Blomstedt P, Stenmark Persson R, Hariz GM, Linder J, Fredricks A, Häggström B, Philipsson J, Forsgren L, Hariz M. Deep brain stimulation in the caudal zona incerta versus best medical treatment in patients with Parkinson's disease: a randomised blinded evaluation. J Neurol Neurosurg Psychiatry 2018; 89:710-716. [PMID: 29386253 PMCID: PMC6031280 DOI: 10.1136/jnnp-2017-317219] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/29/2017] [Accepted: 01/09/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Several open-label studies have shown good effect of deep brain stimulation (DBS) in the caudal zona incerta (cZi) on tremor, including parkinsonian tremor, and in some cases also a benefit on akinesia and axial symptoms. The aim of this study was to evaluate objectively the effect of cZi DBS in patients with Parkinson's disease (PD). METHOD 25 patients with PD were randomised to either cZi DBS or best medical treatment. The primary outcomes were differences between the groups in the motor scores of the Unified Parkinson's Disease Rating Scale (UPDRS-III) rated single-blindly at 6 months and differences in the Parkinson's Disease Questionnaire 39 items (PDQ-39). 19 patients, 10 in the medical arm and 9 in the DBS arm, fulfilled the study. RESULTS The DBS group had 41% better UPDRS-III scores off-medication on-stimulation compared with baseline, whereas the scores of the non-surgical patients off-medication were unchanged. In the on-medication condition, there were no differences between the groups, neither at baseline nor at 6 months. Subitems of the UPDRS-III showed a robust effect of cZi DBS on tremor. The PDQ-39 domains 'stigma' and 'ADL' improved only in the DBS group. The PDQ-39 summary index improved in both groups. CONCLUSION This is the first randomised blinded evaluation of cZi DBS showing its efficacy on PD symptoms. The most striking effect was on tremor; however, the doses of dopaminergic medications could not be decreased. cZi DBS in PD may be an addition to existing established targets, enabling tailoring the surgery to the needs of the individual patient.
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Affiliation(s)
- Patric Blomstedt
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | | | - Gun-Marie Hariz
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.,Unit of Occupational Therapy, Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Jan Linder
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anna Fredricks
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Björn Häggström
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Johanna Philipsson
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Lars Forsgren
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Marwan Hariz
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.,Unit of Functional Neurosurgery, UCL Institute of Neurology, London, UK
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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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Dos Santos Ghilardi MG, Ibarra M, Alho EJL, Reis PR, Lopez Contreras WO, Hamani C, Fonoff ET. Double-target DBS for essential tremor: 8-contact lead for cZI and Vim aligned in the same trajectory. Neurology 2018; 90:476-478. [PMID: 29438045 DOI: 10.1212/wnl.0000000000005076] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 12/18/2017] [Indexed: 11/15/2022] Open
Affiliation(s)
- Maria Gabriela Dos Santos Ghilardi
- From Instituto Sírio-Libanes de Ensino e Pesquisa (M.G.D.S.G., M.I., E.J.L.A., P.R.R., W.O.L.C., E.T.F.), São Paulo, Brazil; and Sunnybrook Research Institute (C.H.), University of Toronto, Canada
| | - Melisa Ibarra
- From Instituto Sírio-Libanes de Ensino e Pesquisa (M.G.D.S.G., M.I., E.J.L.A., P.R.R., W.O.L.C., E.T.F.), São Paulo, Brazil; and Sunnybrook Research Institute (C.H.), University of Toronto, Canada
| | - Eduardo J L Alho
- From Instituto Sírio-Libanes de Ensino e Pesquisa (M.G.D.S.G., M.I., E.J.L.A., P.R.R., W.O.L.C., E.T.F.), São Paulo, Brazil; and Sunnybrook Research Institute (C.H.), University of Toronto, Canada
| | - Paul Rodrigo Reis
- From Instituto Sírio-Libanes de Ensino e Pesquisa (M.G.D.S.G., M.I., E.J.L.A., P.R.R., W.O.L.C., E.T.F.), São Paulo, Brazil; and Sunnybrook Research Institute (C.H.), University of Toronto, Canada
| | - William Omar Lopez Contreras
- From Instituto Sírio-Libanes de Ensino e Pesquisa (M.G.D.S.G., M.I., E.J.L.A., P.R.R., W.O.L.C., E.T.F.), São Paulo, Brazil; and Sunnybrook Research Institute (C.H.), University of Toronto, Canada
| | - Clement Hamani
- From Instituto Sírio-Libanes de Ensino e Pesquisa (M.G.D.S.G., M.I., E.J.L.A., P.R.R., W.O.L.C., E.T.F.), São Paulo, Brazil; and Sunnybrook Research Institute (C.H.), University of Toronto, Canada
| | - Erich Talamoni Fonoff
- From Instituto Sírio-Libanes de Ensino e Pesquisa (M.G.D.S.G., M.I., E.J.L.A., P.R.R., W.O.L.C., E.T.F.), São Paulo, Brazil; and Sunnybrook Research Institute (C.H.), University of Toronto, Canada.
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Deep Brain Stimulation for Tremor. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00075-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Eisinger RS, Wong J, Almeida L, Ramirez-Zamora A, Cagle JN, Giugni JC, Ahmed B, Bona AR, Monari E, Wagle Shukla A, Hess CW, Hilliard JD, Foote KD, Gunduz A, Okun MS, Martinez-Ramirez D. Ventral Intermediate Nucleus Versus Zona Incerta Region Deep Brain Stimulation in Essential Tremor. Mov Disord Clin Pract 2017; 5:75-82. [PMID: 30363386 DOI: 10.1002/mdc3.12565] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 09/22/2017] [Accepted: 09/28/2017] [Indexed: 11/12/2022] Open
Abstract
Background The ventral intermediate nucleus (VIM) is the target of choice for Essential Tremor (ET) deep brain stimulation (DBS). Renewed interest in caudal zona incerta (cZI) stimulation for tremor control has recently emerged and some groups believe this approach may address long-term reduction of benefit seen with VIM-DBS. Objectives To compare clinical outcomes and DBS programming in the long-term between VIM and cZI neurostimulation in ET-DBS patients. Materials and Methods A retrospective review of 53 DBS leads from 47 patients was performed. Patients were classified into VIM or cZI groups according to the location of the activated DBS contact. Demographics, DBS settings, and Tremor Rating Scale scores were compared between groups at baseline and yearly follow-up to 4 years after DBS. Student t-tests and analysis of variance (ANOVA) were used to compare variables between groups. Results Relative to baseline, an improvement in ON-DBS tremor scores was observed in both groups from 6 months to 4 years post-DBS (p < 0.05). Although improvement was still significant at 4 years, scores from month 6 to 2 years were comparable between groups but at 3 and 4 years post-DBS the outcome was better in the VIM group (p < 0.01). Stimulation settings were similar across groups, although we found a lower voltage in the VIM group at 3 years post-DBS. Conclusions More ventral DBS contacts in the cZI region do improve tremor, however, VIM-DBS provided better long-term outcomes. Randomized controlled trials comparing cZI vs VIM targets should confirm these results.
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Affiliation(s)
- Robert S Eisinger
- Department of Neuroscience Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA
| | - Joshua Wong
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA
| | - Leonardo Almeida
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA
| | - Adolfo Ramirez-Zamora
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA
| | - Jackson N Cagle
- J. Crayton Pruitt Family Department of Biomedical Engineering University of Florida College of Medicine Gainesville FL USA
| | - Juan C Giugni
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA
| | - Bilal Ahmed
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA
| | - Alberto R Bona
- Department of Neurosurgery University of Florida College of Medicine Gainesville FL USA
| | - Erin Monari
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA
| | - Aparna Wagle Shukla
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA
| | - Christopher W Hess
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA
| | - Justin D Hilliard
- Department of Neurosurgery University of Florida College of Medicine Gainesville FL USA
| | - Kelly D Foote
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA.,Department of Neurosurgery University of Florida College of Medicine Gainesville FL USA
| | - Aysegul Gunduz
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA.,J. Crayton Pruitt Family Department of Biomedical Engineering University of Florida College of Medicine Gainesville FL USA
| | - Michael S Okun
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA.,Department of Neurosurgery University of Florida College of Medicine Gainesville FL USA
| | - Daniel Martinez-Ramirez
- Department of Neurology Center for Movement Disorders and Neurorestoration University of Florida College of Medicine Gainesville FL USA
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In reply to: "Hyperhidrosis caused by deep brain stimulation in the posterior subthalamic area" by Patric Blomstedt MD, PhD. J Neurol Sci 2017; 380:280. [PMID: 28754236 DOI: 10.1016/j.jns.2017.07.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 07/17/2017] [Indexed: 11/20/2022]
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