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Honkanen EA, Rönkä J, Pekkonen E, Aaltonen J, Koivu M, Eskola O, Eldebakey H, Volkmann J, Kaasinen V, Reich MM, Joutsa J. GPi-DBS-induced brain metabolic activation in cervical dystonia. J Neurol Neurosurg Psychiatry 2024; 95:300-308. [PMID: 37758453 DOI: 10.1136/jnnp-2023-331668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/06/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the globus pallidus interna (GPi) is a highly efficacious treatment for cervical dystonia, but its mechanism of action is not fully understood. Here, we investigate the brain metabolic effects of GPi-DBS in cervical dystonia. METHODS Eleven patients with GPi-DBS underwent brain 18F-fluorodeoxyglucose positron emission tomography imaging during stimulation on and off. Changes in regional brain glucose metabolism were investigated at the active contact location and across the whole brain. Changes in motor symptom severity were quantified using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), executive function using trail making test (TMT) and parkinsonism using Unified Parkinson's Disease Rating Scale (UPDRS). RESULTS The mean (SD) best therapeutic response to DBS during the treatment was 81 (22)%. The TWSTRS score was 3.2 (3.9) points lower DBS on compared with off (p=0.02). At the stimulation site, stimulation was associated with increased metabolism, which correlated with DBS stimulation amplitude (r=0.70, p=0.03) but not with changes in motor symptom severity (p>0.9). In the whole brain analysis, stimulation increased metabolism in the GPi, subthalamic nucleus, putamen, primary sensorimotor cortex (PFDR<0.05). Acute improvement in TWSTRS correlated with metabolic activation in the sensorimotor cortex and overall treatment response in the supplementary motor area. Worsening of TMT-B score was associated with activation of the anterior cingulate cortex and parkinsonism with activation in the putamen. CONCLUSIONS GPi-DBS increases metabolic activity at the stimulation site and sensorimotor network. The clinical benefit and adverse effects are mediated by modulation of specific networks.
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Affiliation(s)
- Emma A Honkanen
- Neurocenter, Turku University Hospital, Turku, Finland
- Turku Brain and Mind Center, Clinical Neurosciences, University of Turku, Turku, Finland
- Department of Neurology, Satasairaala Central Hospital, Pori, Finland
- Turku PET Centre, Turku University Hospital, Turku, Finland
| | - Jaana Rönkä
- Neurocenter, Turku University Hospital, Turku, Finland
- Clinical Neurosciences, University of Turku, Turku, Finland
| | - Eero Pekkonen
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Juho Aaltonen
- Turku Brain and Mind Center, Clinical Neurosciences, University of Turku, Turku, Finland
| | - Maija Koivu
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Olli Eskola
- Turku PET Centre, Turku University Hospital, Turku, Finland
| | - Hazem Eldebakey
- Department of Neurology, University Hospital Wurzburg, Wurzburg, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital Wurzburg, Wurzburg, Germany
| | - Valtteri Kaasinen
- Neurocenter, Turku University Hospital, Turku, Finland
- Clinical Neurosciences, University of Turku, Turku, Finland
| | - Martin M Reich
- Department of Neurology, University Hospital Wurzburg, Wurzburg, Germany
| | - Juho Joutsa
- Neurocenter, Turku University Hospital, Turku, Finland
- Turku Brain and Mind Center, Clinical Neurosciences, University of Turku, Turku, Finland
- Turku PET Centre, Turku University Hospital, Turku, Finland
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Lange F, Soares C, Roothans J, Raimundo R, Eldebakey H, Weigl B, Peach R, Daniels C, Musacchio T, Volkmann J, Rosas MJ, Reich MM. Machine versus physician-based programming of deep brain stimulation in isolated dystonia: A feasibility study. Brain Stimul 2023; 16:1105-1111. [PMID: 37422109 DOI: 10.1016/j.brs.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Deep brain stimulation of the internal globus pallidus effectively alleviates dystonia motor symptoms. However, delayed symptom control and a lack of therapeutic biomarkers and a single pallidal sweetspot region complicates optimal programming. Postoperative management is complex, typically requiring multiple, lengthy follow-ups with an experienced physician - an important barrier to widespread adoption in medication-refractory dystonia patients. OBJECTIVE Here we prospectively tested the best machine-predicted programming settings in a dystonia cohort treated with GPi-DBS against the settings derived from clinical long-term care in a specialised DBS centre. METHODS Previously, we reconstructed an anatomical map of motor improvement probability across the pallidal region using individual stimulation volumes and clinical outcomes in dystonia patients. We used this to develop an algorithm that tests in silico thousands of putative stimulation settings in de novo patients after reconstructing an individual, image-based anatomical model of electrode positions, and suggests stimulation parameters with the highest likelihood of optimal symptom control. To test real-life application, our prospective study compared results in 10 patients against programming settings derived from long-term care. RESULTS In this cohort, dystonia symptom reduction was observed at 74.9 ± 15.3% with C-SURF programming as compared to 66.3 ± 16.3% with clinical programming (p < 0.012). The average total electrical energy delivered (TEED) was similar for both the clinical and C-SURF programming (262.0 μJ/s vs. 306.1 μJ/s respectively). CONCLUSION Our findings highlight the clinical potential of machine-based programming in dystonia, which could markedly reduce the programming burden in postoperative management.
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Affiliation(s)
- Florian Lange
- Department of Neurology, University Hospital and Julius Maximilian University, 97080, Wuerzburg, Germany.
| | - Carolina Soares
- Department of Neurology, Centro Hospitalar Universitário de São João, EPE, 4200-319, Porto, Portugal; Department of Clinic Neurosciences and Mental Health, Faculty of Medicine of University of Porto, 4200-319, Porto, Portugal
| | - Jonas Roothans
- Department of Neurology, University Hospital and Julius Maximilian University, 97080, Wuerzburg, Germany
| | - Rita Raimundo
- Department of Neurology, Centro Hospitalar Trás-os-Montes e Alto Douro, EPE, Unidade Hospitalar de Vila Real, 5000-508, Vila Real, Portugal
| | - Hazem Eldebakey
- Department of Neurology, University Hospital and Julius Maximilian University, 97080, Wuerzburg, Germany
| | - Benedikt Weigl
- Department of Neurology, University Hospital and Julius Maximilian University, 97080, Wuerzburg, Germany
| | - Robert Peach
- Department of Neurology, University Hospital and Julius Maximilian University, 97080, Wuerzburg, Germany; Department of Brain Sciences, Imperial College London, London, SW7 2AZ, UK
| | - Christine Daniels
- Department of Neurology, University Hospital and Julius Maximilian University, 97080, Wuerzburg, Germany
| | - Thomas Musacchio
- Department of Neurology, University Hospital and Julius Maximilian University, 97080, Wuerzburg, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital and Julius Maximilian University, 97080, Wuerzburg, Germany
| | - Maria José Rosas
- Department of Neurology, Centro Hospitalar Universitário de São João, EPE, 4200-319, Porto, Portugal
| | - Martin M Reich
- Department of Neurology, University Hospital and Julius Maximilian University, 97080, Wuerzburg, Germany
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Gelineau-Morel R, Kruer MC, Garris JF, Libdeh AA, Barbosa DAN, Coffman KA, Moon D, Barton C, Vera AZ, Bruce AB, Larsh T, Wu SW, Gilbert DL, O’Malley JA. Deep Brain Stimulation for Pediatric Dystonia: A Review of the Literature and Suggested Programming Algorithm. J Child Neurol 2022; 37:813-824. [PMID: 36053123 PMCID: PMC9912476 DOI: 10.1177/08830738221115248] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Deep brain stimulation (DBS) is an established intervention for use in pediatric movement disorders, especially dystonia. Although multiple publications have provided guidelines for deep brain stimulation patient selection and programming in adults, there are no evidence-based or consensus statements published for pediatrics. The result is lack of standardized care and underutilization of this effective treatment. To this end, we assembled a focus group of 13 pediatric movement disorder specialists and 1 neurosurgeon experienced in pediatric deep brain stimulation to review recent literature and current practices and propose a standardized approach to candidate selection, implantation target site selection, and programming algorithms. For pediatric dystonia, we provide algorithms for (1) programming for initial session and follow-up sessions, and (2) troubleshooting side effects encountered during programming. We discuss common side effects, how they present, and recommendations for management. This topical review serves as a resource for movement disorders specialists interested in using deep brain stimulation for pediatric dystonia.
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Affiliation(s)
- Rose Gelineau-Morel
- Division of Neurology, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, Missouri, 64108
| | - Michael C Kruer
- Pediatric Movement Disorders Program, Barrow Neurological Institute, Phoenix Children’s Hospital & University of Arizona College of Medicine - Phoenix, Phoenix, AZ, 85016
| | - Jordan F Garris
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, PO Box 800394, Charlottesville, VA, 22908−0394
| | - Amal Abu Libdeh
- Division of Pediatric Neurology, Department of Neurology, University of Virginia, PO Box 800394, Charlottesville, VA, 22908−0394
| | - Daniel A N Barbosa
- Department of Neurosurgery, Stanford University School of Medicine, 300 Pasteur Drive, Edwards Bldg, Stanford, CA, 94305
| | - Keith A Coffman
- Division of Neurology, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road, Kansas City, Missouri, 64108
| | - David Moon
- Department of Child Neurology, Division of Neurosciences, Helen DeVos Children’s Hospital, 100 Michigan St NE, Grand Rapids, MI 49503
| | - Christopher Barton
- Department of Neurology, University of Louisville School of Medicine, Louisville, Kentucky; Division of Child Neurology, Norton Children’s Medical Group, 231 E Chestnut St, Louisville, KY 40202
| | - Alonso Zea Vera
- Department of Neurology, Children’s National Hospital, 111 Michigan Ave NW, Washington, DC, 20010
| | - Adrienne B Bruce
- Division of Pediatric Neurology, Department of Pediatrics, Prisma Health, 200 Patewood Drive A350, Greenville, SC, USA 29615; University of South Carolina School of Medicine Greenville, 607 Grove Road, Greenville, SC, 29605
| | - Travis Larsh
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Location E4, Suite 110, Cincinnati, OH 45229
| | - Steve W Wu
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Location E4, Suite 110, Cincinnati, OH 45229
| | - Donald L Gilbert
- Division of Neurology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, 3333 Burnet Ave, Location E4, Suite 110, Cincinnati, OH 45229
| | - Jennifer A O’Malley
- Department of Neurology, Division of Child Neurology, Stanford University School of Medicine, 750 Welch Road, Suite 317, Palo Alto, California, 94304
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Lange F, Roothans J, Wichmann T, Gelbrich G, Röser C, Volkmann J, Reich M. DIPS (Dystonia Image-based Programming of Stimulation: a prospective, randomized, double-blind crossover trial). Neurol Res Pract 2021; 3:65. [PMID: 34924027 PMCID: PMC8686267 DOI: 10.1186/s42466-021-00165-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Deep brain stimulation of the internal globus pallidus is an effective treatment for dystonia. However, there is a large variability in clinical outcome with up to 25% non-responders even in highly selected primary dystonia patients. In a large cohort of patients we recently demonstrated that the variable clinical outcomes of pallidal DBS for dystonia may result to a large degree by the exact location and stimulation volume within the pallidal region. Here we test a novel approach of programing based on these insights: we first defined probabilistic maps of anti-dystonic effects by aggregating individual electrode locations and volumes of tissue activated of > 80 patients collected in a multicentre effort. We subsequently modified the algorithms to be able to test all possible stimulation settings of de novo patients in silico based on the expected clinical outcome and thus potentially predict the best possible stimulation parameters for the individual patients. Methods Within the framework of a BMBF-funded study, this concept of a computer-based prediction of optimal stimulation parameters for patients with dystonia will be tested in a randomized, controlled crossover study. The main parameter for clinical efficacy and primary endpoint is based on the blinded physician rating of dystonia severity reflected by Clinical Dystonia Rating Scales for both interventions (best clinical settings and model predicted settings) after 4 weeks of continuous stimulation. The primary endpoint is defined as “successful treatment with model predicted settings” (yes or no). The value is “yes” if the motor symptoms with model predicted settings are equal or better (tolerance 5% of absolute difference in percentages) to clinical settings. Secondary endpoints will include measures of quality of life, calculated energy consumption of the neurostimulation system and physician time for programming. Perspective We envision, that computer-guided deep brain stimulation programming in silico might provide optimal stimulation settings for patients with dystonia without the burden of months of programming sessions. The study protocol is designed to evaluate which programming method is more effective in controlling motor symptom severity and improving quality of life in dystonia (best clinical settings and model predicted settings). Trial registration Registered with ClinicalTrials.gov on Oct 27, 2021 (NCT05097001).
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Affiliation(s)
- Florian Lange
- Department of Neurology, University Hospital and Julius Maximilian University, Josef-Schneider-Straße 11, 97080, Würzburg, Germany.
| | - Jonas Roothans
- Department of Neurology, University Hospital and Julius Maximilian University, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Tim Wichmann
- Department of Neurology, University Hospital and Julius Maximilian University, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Götz Gelbrich
- Institute for Clinical Epidemiology and Biometry (ICE-B) at the University of Würzburg, Josef-Schneider-Straße 2, 97080, Würzburg, Germany.,Clinical Trial Center (CTC) at the University of Würzburg, Josef-Schneider-Straße 2, 97080, Würzburg, Germany
| | - Christoph Röser
- Clinical Trial Center (CTC) at the University of Würzburg, Josef-Schneider-Straße 2, 97080, Würzburg, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital and Julius Maximilian University, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
| | - Martin Reich
- Department of Neurology, University Hospital and Julius Maximilian University, Josef-Schneider-Straße 11, 97080, Würzburg, Germany
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Mulroy E, Vijiaratnam N, De Roquemaurel A, Bhatia KP, Zrinzo L, Foltynie T, Limousin P. A practical guide to troubleshooting pallidal deep brain stimulation issues in patients with dystonia. Parkinsonism Relat Disord 2021; 87:142-154. [PMID: 34074583 DOI: 10.1016/j.parkreldis.2021.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/18/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022]
Abstract
High frequency deep brain stimulation (DBS) of the internal portion of the globus pallidus has, in the last two decades, become a mainstream therapy for the management of medically-refractory dystonia syndromes. Such increasing uptake places an onus on movement disorder physicians to become familiar with this treatment modality, in particular optimal patient selection for the procedure and how to troubleshoot problems relating to sub-optimal efficacy and therapy-related side effects. Deep brain stimulation for dystonic conditions presents some unique challenges. For example, the frequent lack of immediate change in clinical status following stimulation alterations means that programming often relies on personal experience and local practice rather than real-time indicators of efficacy. Further, dystonia is a highly heterogeneous disorder, making the development of unifying guidelines and programming algorithms for DBS in this population difficult. Consequently, physicians may feel less confident in managing DBS for dystonia as compared to other indications e.g. Parkinson's disease. In this review, we integrate our years of personal experience of the programming of DBS systems for dystonia with a critical appraisal of the literature to produce a practical guide for troubleshooting common issues encountered in patients with dystonia treated with DBS, in the hope of improving the care for these patients.
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Affiliation(s)
- Eoin Mulroy
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK.
| | - Nirosen Vijiaratnam
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Alexis De Roquemaurel
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Ludvic Zrinzo
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Thomas Foltynie
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Patricia Limousin
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
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