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Alamri A, Breitbart S, Warsi N, Rayco E, Ibrahim G, Fasano A, Gorodetsky C. Deep Brain Stimulation of the Globus Pallidus Internus in a Child with Refractory Dystonia due to L2-Hydroxyglutaric Aciduria. Stereotact Funct Neurosurg 2024:1-8. [PMID: 38714179 DOI: 10.1159/000538418] [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: 11/01/2023] [Accepted: 03/14/2024] [Indexed: 05/09/2024]
Abstract
INTRODUCTION L-2-hydroxyglutaric aciduria (L2HGA) is a rare neurometabolic disorder marked by progressive and debilitating psychomotor deficits. Here, we report the first patient with L2HGA-related refractory dystonia that was managed with deep brain stimulation to the bilateral globus pallidus internus (GPi-DBS). CASE PRESENTATION We present a 17-year-old female with progressive decline in cognitive function, motor skills, and language ability which significantly impaired activities of daily living. Neurological exam revealed generalized dystonia, significant choreic movements in the upper extremities, slurred speech, bilateral dysmetria, and a wide-based gait. Brisk deep tendon reflexes, clonus, and bilateral Babinski signs were present. Urine 2-OH-glutaric acid level was significantly elevated. Brain MRI showed extensive supratentorial subcortical white matter signal abnormalities predominantly involving the U fibers and bilateral basal ganglia. Genetic testing identified a homozygous pathogenic mutation in the L-2-hydroxyglutarate dehydrogenase gene c. 164G>A (p. Gly55Asp). Following minimal response to pharmacotherapy, GPi-DBS was performed. Significant increases in mobility and decrease in dystonia were observed at 3 weeks, 6 months, and 12 months postoperatively. CONCLUSION This is the first utilization of DBS as treatment for L2HGA-related dystonia. The resulting significant improvements indicate that pallidal neuromodulation may be a viable option for pharmaco-resistant cases, and possibly in other secondary metabolic dystonias.
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Affiliation(s)
- Abdullah Alamri
- Department of Pediatrics, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Sara Breitbart
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nebras Warsi
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Eriberto Rayco
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - George Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Department of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada
- Krembil Brain Institute, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Carolina Gorodetsky
- Division of Neurology, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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Ebden M, Elkaim LM, Breitbart S, Yan H, Warsi N, Huynh M, Mithani K, Venetucci Gouveia F, Fasano A, Ibrahim GM, Gorodetsky C. Chronic Pallidal Local Field Potentials Are Associated With Dystonic Symptoms in Children. Neuromodulation 2024; 27:551-556. [PMID: 37768258 DOI: 10.1016/j.neurom.2023.08.003] [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: 03/05/2023] [Revised: 08/07/2023] [Accepted: 08/18/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Novel deep brain stimulation devices can record local field potentials (LFPs), which represent the synchronous synaptic activity of neuronal populations. The clinical relevance of LFPs in patients with dystonia remains unclear. OBJECTIVES We sought to determine whether chronic LFPs recorded from the globus pallidus internus (GPi) were associated with symptoms of dystonia in children. MATERIALS AND METHODS Ten patients with heterogeneous forms of dystonia (genetic and acquired) were implanted with neurostimulators that recorded LFP spectral snapshots. Spectra were compared across parent-reported asymptomatic and symptomatic periods, with daily narrowband data superimposed in 24 one-hour bins. RESULTS Spectral power increased during periods of registered dystonic symptoms: mean increase = 102%, CI: (76.7, 132). Circadian rhythms within the LFP narrowband time series correlated with dystonic symptoms: for delta/theta-waves, correlation = 0.33, CI: (0.18, 0.47) and for alpha waves, correlation = 0.27, CI: (0.14, 0.40). CONCLUSIONS LFP spectra recorded in the GPi indicate a circadian pattern and are associated with the manifestation of dystonic symptoms.
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Affiliation(s)
- Mark Ebden
- Neurosciences and Mental Health Program, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Lior M Elkaim
- Division of Neurology and Neurosurgery, McGill University, McGill University Health Centre, Montreal, Quebec, Canada
| | - Sara Breitbart
- Division of Neurosurgery, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Han Yan
- Division of Neurosurgery, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nebras Warsi
- Division of Neurosurgery, the Hospital for Sick Children, Toronto, Ontario, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - MyLoi Huynh
- Neurosciences and Mental Health Program, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Karim Mithani
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Flavia Venetucci Gouveia
- Neurosciences and Mental Health Program, the Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada; Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Krembil Brain Institute, Toronto, Ontario, Canada; CenteR for Advancing Neurotechnological Innovation to Application, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, the Hospital for Sick Children, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Carolina Gorodetsky
- Division of Neurology, the Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada.
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Zhang B, Tian H, Yu Y, Zhen X, Zhang L, Yuan Y, Wang L. A localized pallidal physiomarker in Meige syndrome. Front Neurol 2023; 14:1286634. [PMID: 38178893 PMCID: PMC10764606 DOI: 10.3389/fneur.2023.1286634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/06/2023] [Indexed: 01/06/2024] Open
Abstract
Objectives Oscillatory patterns in local field potentials (LFPs) have been recognized as disease-specific physiomarkers, particularly in the context of Parkinson's disease and cervical dystonia. This characteristic oscillatory feature is currently employed in adaptive deep brain stimulation (aDBS). However, for other types of dystonia, especially Meige syndrome, a distinct physiomarker of this nature is yet to be identified. Methods Local field potentials were recorded during microelectrode-guided deep brain stimulation surgery from 28 patients with primary Meige syndrome. Before surgery, the severity of patients' motor syndrome were assessed using the Burke-Fahn-Marsden Dystonia Rating Scale-Motor (BFMDRS-M). An instantaneous oscillation detection method was employed to identify true narrowband oscillations. Subsequently, a linear mixed effects model was utilized to examine the relationship between oscillatory activities (including power amplitude and burst duration) and symptom severity. Results The focal peaks of "oscillatory activities" detected were predominantly concentrated in the narrow theta band (4-8 Hz), constituting 81.5% of the total detected oscillations in all recording sites near active DBS contacts in the globus pallidus internus (GPi). The linear mixed effects model revealed a positive correlation between the theta burst duration and the severity of preoperative motor impairment, but no correlation with postoperative motor scores. Additionally, there was no significant lateralization effect observed between the left and right GPi. Conclusion Our findings suggest that the exaggerated narrowband theta activity (mainly the burst duration) in the GPi is predictive of dystonia symptom severity and may be used as a physiomarker for optimized DBS target during surgery and adaptive DBS for the treatment of Meige syndrome.
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Affiliation(s)
- Bo Zhang
- Key Laboratory of Brain Science, Zunyi Medical University, Zunyi, China
- Guizhou Key Laboratory of Anesthesia and Organ Protection, Zunyi Medical University, Zunyi, China
| | - Hong Tian
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing, China
| | - Yanbing Yu
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing, China
| | - Xueke Zhen
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing, China
| | - Li Zhang
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing, China
| | - Yue Yuan
- Department of Neurosurgery, China-Japan Friendship Hospital, Beijing, China
| | - Liang Wang
- CAS Key Laboratory of Mental Health, Institute of Psychology, Beijing, China
- Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
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Lumsden DE. Spastic dystonia: Still a valid term. Dev Med Child Neurol 2023; 65:1308-1315. [PMID: 36940234 DOI: 10.1111/dmcn.15582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/15/2023] [Accepted: 02/17/2023] [Indexed: 03/21/2023]
Abstract
Hypertonia in childhood may arise because of a variable combination of neuronal and non-neuronal factors. Involuntary muscle contraction may be due to spasticity or dystonia, which represent disorders of the spinal reflex arch and of central motor output respectively. Whilst consensus definitions for dystonia have been established, definitions of spasticity vary, highlighting the lack of a single unifying nomenclature in the field of clinical movement science. The term spastic dystonia refers to involuntary tonic muscle contraction in the context of an upper motor neuron (UMN) lesion. This review considers the utility of the term spastic dystonia, exploring our understanding of the pathophysiology of dystonia and the UMN syndrome. An argument is advanced that spastic dystonia is a valid construct that warrants further exploration. WHAT THIS PAPER ADDS: There is no single universally accepted definitions for terms commonly used to describe motor disorders. Spasticity and dystonia are phenomenologically and pathophysiologically distinct entities. Spastic dystonia represents a subset of dystonia, but with pathophysiological mechanisms more in common with spasticity.
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Affiliation(s)
- Daniel E Lumsden
- Complex Motor Disorders Service, Children's Neurosciences, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Perinatal imaging, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
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Zhang R, Nie Y, Dai W, Wang S, Geng X. Balance between pallidal neural oscillations correlated with dystonic activity and severity. Neurobiol Dis 2023:106178. [PMID: 37268239 DOI: 10.1016/j.nbd.2023.106178] [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: 03/23/2023] [Revised: 05/14/2023] [Accepted: 05/28/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVE The balance between neural oscillations provides valuable insights into the organisation of neural oscillations related to brain states, which may play important roles in dystonia. We aim to investigate the relationship of the balance in the globus pallidus internus (GPi) with the dystonic severity under different muscular contraction conditions. METHODS Twenty-one patients with dystonia were recruited. All of them underwent bilateral GPi implantation, and local field potentials (LFPs) from the GPi were recorded via simultaneous surface electromyography. The power spectral ratio between neural oscillations was computed as the measure of neural balance. This ratio was calculated under high and low dystonic muscular contraction conditions, and its correlation with the dystonic severity was assessed using clinical scores. RESULTS The power spectral of the pallidal LFPs peaked in the theta and alpha bands. Within participant comparison showed that the power spectral of the theta oscillations significantly increased during high muscle contraction compared with that during low contraction. The power spectral ratios between the theta and alpha, theta and low beta, and theta and high gamma oscillations were significantly higher during high contraction than during low contraction. The total score and motor score were associated with the power spectral ratio between the low and high beta oscillations, which was correlated with the dystonic severity both during high and low contractions. The power spectral ratios between the low beta and low gamma and between the low beta and high gamma oscillations showed a significantly positive correlation with the total score during both high and low contractions; a correlation with the motor scale score was found only during high contraction. Meanwhile, the power spectral ratio between the theta and alpha oscillations during low contraction showed a significantly negative correlation with the total score. The power spectral ratios between the alpha and high beta, alpha and low gamma, and alpha and high gamma oscillations were significantly correlated with the dystonic severity only during low contraction. CONCLUSION The balance between neural oscillations, as quantified by the power ratio between specific frequency bands, differed between the high and low muscular contraction conditions and was correlated with the dystonic severity. The balance between the low and high beta oscillations was correlated with the dystonic severity during both conditions, making this parameter a new possible biomarker for closed-loop deep brain stimulation in patients with dystonia.
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Affiliation(s)
- Ruili Zhang
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China; Key Laboratory of Computational Neuroscience and Brain-Inspired Intelligence, Fudan University, Ministry of Education, China; MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China; Zhangjiang Fudan International Innovation Center, Shanghai, China
| | - Yingnan Nie
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China; Key Laboratory of Computational Neuroscience and Brain-Inspired Intelligence, Fudan University, Ministry of Education, China; MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China; Zhangjiang Fudan International Innovation Center, Shanghai, China
| | - Wen Dai
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China; Key Laboratory of Computational Neuroscience and Brain-Inspired Intelligence, Fudan University, Ministry of Education, China; MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China; Zhangjiang Fudan International Innovation Center, Shanghai, China
| | - Shouyan Wang
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China; Key Laboratory of Computational Neuroscience and Brain-Inspired Intelligence, Fudan University, Ministry of Education, China; MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China; Zhangjiang Fudan International Innovation Center, Shanghai, China; Shanghai Engineering Research Center of AI & Robotics, Fudan University, Shanghai, China; Engineering Research Center of AI & Robotics, Ministry of Education, Fudan University, Shanghai, China
| | - Xinyi Geng
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, China; Key Laboratory of Computational Neuroscience and Brain-Inspired Intelligence, Fudan University, Ministry of Education, China; MOE Frontiers Center for Brain Science, Fudan University, Shanghai, China; Zhangjiang Fudan International Innovation Center, Shanghai, China.
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Matar E, Bhatia K. Dystonia and Parkinson's disease: Do they have a shared biology? INTERNATIONAL REVIEW OF NEUROBIOLOGY 2023; 169:347-411. [PMID: 37482398 DOI: 10.1016/bs.irn.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
Parkinsonism and dystonia co-occur across many movement disorders and are most encountered in the setting of Parkinson's disease. Here we aim to explore the shared neurobiological underpinnings of dystonia and parkinsonism through the clinical lens of the conditions in which these movement disorders can be seen together. Foregrounding the discussion, we briefly review the circuits of the motor system and the neuroanatomical and neurophysiological aspects of motor control and highlight their relevance to the proposed pathophysiology of parkinsonism and dystonia. Insight into shared biology is then sought from dystonia occurring in PD and other forms of parkinsonism including those disorders in which both can be co-expressed simultaneously. We organize these within a biological schema along with important questions to be addressed in this space.
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Affiliation(s)
- Elie Matar
- UCL Queen Square Institute of Neurology Department of Clinical and Movement Neurosciences, Queen Square, London, United Kingdom; Central Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
| | - Kailash Bhatia
- UCL Queen Square Institute of Neurology Department of Clinical and Movement Neurosciences, Queen Square, London, United Kingdom
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Fischer P, Piña-Fuentes D, Kassavetis P, Sadnicka A. Physiology of dystonia: Human studies. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2023; 169:137-162. [PMID: 37482391 DOI: 10.1016/bs.irn.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
In this chapter, we discuss neurophysiological techniques that have been used in the study of dystonia. We examine traditional disease models such as inhibition and excessive plasticity and review the evidence that these play a causal role in pathophysiology. We then review the evidence for sensory and peripheral influences within pathophysiology and look at an emergent literature that tries to probe how oscillatory brain activity may be linked to dystonia pathophysiology.
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Affiliation(s)
- Petra Fischer
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Biomedical Sciences Building, University Walk, Bristol, United Kingdom
| | - Dan Piña-Fuentes
- Department of Neurology, Amsterdam UMC, University of Amsterdam, Amsterdam Neuroscience, Meibergdreef 9, Amsterdam, The Netherlands; Department of Neurology, OLVG, Amsterdam, The Netherlands
| | | | - Anna Sadnicka
- Motor Control and Movement Disorders Group, St George's University of London, London, United Kingdom; Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, United Kingdom.
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Del Vecchio Del Vecchio J, Hanafi I, Pozzi NG, Capetian P, Isaias IU, Haufe S, Palmisano C. Pallidal Recordings in Chronically Implanted Dystonic Patients: Mitigation of Tremor-Related Artifacts. Bioengineering (Basel) 2023; 10:bioengineering10040476. [PMID: 37106663 PMCID: PMC10135680 DOI: 10.3390/bioengineering10040476] [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: 03/13/2023] [Revised: 03/31/2023] [Accepted: 04/01/2023] [Indexed: 04/29/2023] Open
Abstract
Low-frequency oscillatory patterns of pallidal local field potentials (LFPs) have been proposed as a physiomarker for dystonia and hold the promise for personalized adaptive deep brain stimulation. Head tremor, a low-frequency involuntary rhythmic movement typical of cervical dystonia, may cause movement artifacts in LFP signals, compromising the reliability of low-frequency oscillations as biomarkers for adaptive neurostimulation. We investigated chronic pallidal LFPs with the PerceptTM PC (Medtronic PLC) device in eight subjects with dystonia (five with head tremors). We applied a multiple regression approach to pallidal LFPs in patients with head tremors using kinematic information measured with an inertial measurement unit (IMU) and an electromyographic signal (EMG). With IMU regression, we found tremor contamination in all subjects, whereas EMG regression identified it in only three out of five. IMU regression was also superior to EMG regression in removing tremor-related artifacts and resulted in a significant power reduction, especially in the theta-alpha band. Pallido-muscular coherence was affected by a head tremor and disappeared after IMU regression. Our results show that the Percept PC can record low-frequency oscillations but also reveal spectral contamination due to movement artifacts. IMU regression can identify such artifact contamination and be a suitable tool for its removal.
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Affiliation(s)
- Jasmin Del Vecchio Del Vecchio
- Department of Neurology, University Hospital of Würzburg and Julius-Maximilian-University Würzburg, 97080 Würzburg, Germany
| | - Ibrahem Hanafi
- Department of Neurology, University Hospital of Würzburg and Julius-Maximilian-University Würzburg, 97080 Würzburg, Germany
| | - Nicoló Gabriele Pozzi
- Department of Neurology, University Hospital of Würzburg and Julius-Maximilian-University Würzburg, 97080 Würzburg, Germany
| | - Philipp Capetian
- Department of Neurology, University Hospital of Würzburg and Julius-Maximilian-University Würzburg, 97080 Würzburg, Germany
| | - Ioannis U Isaias
- Department of Neurology, University Hospital of Würzburg and Julius-Maximilian-University Würzburg, 97080 Würzburg, Germany
- Centro Parkinson e Parkinsonismi, ASST G. Pini-CTO, 20122 Milano, Italy
| | - Stefan Haufe
- Uncertainty, Inverse Modeling and Machine Learning Group, Technische Universität Berlin, 10623 Berlin, Germany
- Physikalisch-Technische Bundesanstalt Braunschweig und Berlin, 10587 Berlin, Germany
- Berlin Center for Advanced Neuroimaging, Charité-Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Chiara Palmisano
- Department of Neurology, University Hospital of Würzburg and Julius-Maximilian-University Würzburg, 97080 Würzburg, Germany
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Wiest C, Morgante F, Torrecillos F, Pogosyan A, He S, Baig F, Bertaina I, Hart MG, Edwards MJ, Pereira EA, Tan H. Subthalamic Nucleus Stimulation-Induced Local Field Potential Changes in Dystonia. Mov Disord 2023; 38:423-434. [PMID: 36562479 PMCID: PMC7614354 DOI: 10.1002/mds.29302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/02/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Subthalamic nucleus (STN) stimulation is an effective treatment for Parkinson's disease and induced local field potential (LFP) changes that have been linked with clinical improvement. STN stimulation has also been used in dystonia although the internal globus pallidus is the standard target where theta power has been suggested as a physiomarker for adaptive stimulation. OBJECTIVE We aimed to explore if enhanced theta power was also present in STN and if stimulation-induced spectral changes that were previously reported for Parkinson's disease would occur in dystonia. METHODS We recorded LFPs from 7 patients (12 hemispheres) with isolated craniocervical dystonia whose electrodes were placed such that inferior, middle, and superior contacts covered STN, zona incerta, and thalamus. RESULTS We did not observe prominent theta power in STN at rest. STN stimulation induced similar spectral changes in dystonia as in Parkinson's disease, such as broadband power suppression, evoked resonant neural activity (ERNA), finely-tuned gamma oscillations, and an increase in aperiodic exponents in STN-LFPs. Both power suppression and ERNA localize to STN. Based on this, single-pulse STN stimulation elicits evoked neural activities with largest amplitudes in STN, which are relayed to the zona incerta and thalamus with changing characteristics as the distance from STN increases. CONCLUSIONS Our results show that STN stimulation-induced spectral changes are a nondisease-specific response to high-frequency stimulation, which can serve as placement markers for STN. This broadens the scope of STN stimulation and makes it an option for other disorders with excessive oscillatory peaks in STN. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Christoph Wiest
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesJohn Radcliffe Hospital, University of OxfordOxfordUnited Kingdom
| | - Francesca Morgante
- Neurosciences Research CentreMolecular and Clinical Sciences Institute, St. George's, University of LondonLondonUnited Kingdom
| | - Flavie Torrecillos
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesJohn Radcliffe Hospital, University of OxfordOxfordUnited Kingdom
| | - Alek Pogosyan
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesJohn Radcliffe Hospital, University of OxfordOxfordUnited Kingdom
| | - Shenghong He
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesJohn Radcliffe Hospital, University of OxfordOxfordUnited Kingdom
| | - Fahd Baig
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesJohn Radcliffe Hospital, University of OxfordOxfordUnited Kingdom
- Neurosciences Research CentreMolecular and Clinical Sciences Institute, St. George's, University of LondonLondonUnited Kingdom
| | - Ilaria Bertaina
- Neurosciences Research CentreMolecular and Clinical Sciences Institute, St. George's, University of LondonLondonUnited Kingdom
| | - Michael G. Hart
- Neurosciences Research CentreMolecular and Clinical Sciences Institute, St. George's, University of LondonLondonUnited Kingdom
| | - Mark J. Edwards
- Institute of Psychiatry, Psychology and NeurosciencesKing's College LondonLondonUnited Kingdom
| | - Erlick A. Pereira
- Neurosciences Research CentreMolecular and Clinical Sciences Institute, St. George's, University of LondonLondonUnited Kingdom
| | - Huiling Tan
- Medical Research Council Brain Network Dynamics Unit, Nuffield Department of Clinical NeurosciencesJohn Radcliffe Hospital, University of OxfordOxfordUnited Kingdom
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Deep brain stimulation in animal models of dystonia. Neurobiol Dis 2022; 175:105912. [DOI: 10.1016/j.nbd.2022.105912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 11/19/2022] Open
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Rauschenberger L, Güttler C, Volkmann J, Kühn AA, Ip CW, Lofredi R. A translational perspective on pathophysiological changes of oscillatory activity in dystonia and parkinsonism. Exp Neurol 2022; 355:114140. [PMID: 35690132 DOI: 10.1016/j.expneurol.2022.114140] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/14/2022] [Accepted: 06/03/2022] [Indexed: 11/19/2022]
Abstract
Intracerebral recordings from movement disorders patients undergoing deep brain stimulation have allowed the identification of pathophysiological patterns in oscillatory activity that correlate with symptom severity. Changes in oscillatory synchrony occur within and across brain areas, matching the classification of movement disorders as network disorders. However, the underlying mechanisms of oscillatory changes are difficult to assess in patients, as experimental interventions are technically limited and ethically problematic. This is why animal models play an important role in neurophysiological research of movement disorders. In this review, we highlight the contributions of translational research to the mechanistic understanding of pathological changes in oscillatory activity, with a focus on parkinsonism and dystonia, while addressing the limitations of current findings and proposing possible future directions.
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Affiliation(s)
- Lisa Rauschenberger
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider-Straße 11, 97080 Würzburg, Germany
| | - Christopher Güttler
- Department of Neurology, Movement Disorders and Neuromodulation Unit, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider-Straße 11, 97080 Würzburg, Germany
| | - Andrea A Kühn
- Department of Neurology, Movement Disorders and Neuromodulation Unit, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany; Bernstein Center for Computational Neuroscience, Humboldt-Universität, Berlin, Germany; NeuroCure, Exzellenzcluster, Charité-Universitätsmedizin Berlin, Berlin, Germany; DZNE, German Center for Neurodegenerative Diseases, Berlin, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Chi Wang Ip
- Department of Neurology, University Hospital of Würzburg, Josef-Schneider-Straße 11, 97080 Würzburg, Germany
| | - Roxanne Lofredi
- Department of Neurology, Movement Disorders and Neuromodulation Unit, Campus Charité Mitte, Charité-Universitätsmedizin Berlin, Berlin, Germany; Berlin Institute of Health (BIH), Berlin, Germany.
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Guerra A, Bologna M. Low-Intensity Transcranial Ultrasound Stimulation: Mechanisms of Action and Rationale for Future Applications in Movement Disorders. Brain Sci 2022; 12:brainsci12050611. [PMID: 35624998 PMCID: PMC9139935 DOI: 10.3390/brainsci12050611] [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: 04/04/2022] [Revised: 04/29/2022] [Accepted: 05/05/2022] [Indexed: 02/01/2023] Open
Abstract
Low-intensity transcranial ultrasound stimulation (TUS) is a novel non-invasive brain stimulation technique that uses acoustic energy to induce changes in neuronal activity. However, although low-intensity TUS is a promising neuromodulation tool, it has been poorly studied as compared to other methods, i.e., transcranial magnetic and electrical stimulation. In this article, we first focus on experimental studies in animals and humans aimed at explaining its mechanisms of action. We then highlight possible applications of TUS in movement disorders, particularly in patients with parkinsonism, dystonia, and tremor. Finally, we highlight the knowledge gaps and possible limitations that currently limit potential TUS applications in movement disorders. Clarifying the potential role of TUS in movement disorders may further promote studies with therapeutic perspectives in this field.
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Affiliation(s)
| | - Matteo Bologna
- IRCCS Neuromed, 86077 Pozzilli, Italy;
- Department of Human Neurosciences, Sapienza University of Rome, 00185 Rome, Italy
- Correspondence:
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13
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Scarduzio M, Hess EJ, Standaert DG, Eskow Jaunarajs KL. Striatal synaptic dysfunction in dystonia and levodopa-induced dyskinesia. Neurobiol Dis 2022; 166:105650. [DOI: 10.1016/j.nbd.2022.105650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 01/22/2022] [Accepted: 01/24/2022] [Indexed: 12/16/2022] Open
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14
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Exploring the connections between basal ganglia and cortex revealed by transcranial magnetic stimulation, evoked potential and deep brain stimulation in dystonia. Eur J Paediatr Neurol 2022; 36:69-77. [PMID: 34922163 DOI: 10.1016/j.ejpn.2021.12.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 10/30/2021] [Accepted: 12/01/2021] [Indexed: 12/30/2022]
Abstract
We review the findings for motor cortical excitability, plasticity and evoked potentials in dystonia. Plasticity can be induced and assessed in cortical areas by non-invasive brain stimulation techniques such as transcranial magnetic stimulation (TMS) and the invasive technique of deep brain stimulation (DBS), which allows access to deep brain structures. Single-pulse TMS measures have been widely studied in dystonia and consistently showed reduced silent period duration. Paired pulse TMS measures showed reduced short and long interval intracortical inhibition, interhemispheric inhibition, long-latency afferent inhibition and increased intracortical facilitation in dystonia. Repetitive transcranial magnetic stimulation (rTMS) of the premotor cortex improved handwriting with prolongation of the silent period in focal hand dystonia patients. Continuous theta-burst stimulation (cTBS) of the cerebellum or cTBS of the dorsal premotor cortex improved dystonia in some studies. Plasticity induction protocols in dystonia demonstrated excessive motor cortical plasticity with the reduction in cortico-motor topographic specificity. Bilateral DBS of the globus pallidus internus (GPi) improves dystonia, associated pain and functional disability. Local field potentials recordings in dystonia patients suggested that there is increased power in the low-frequency band (4-12 Hz) in the GPi. Cortical evoked potentials at peak latencies of 10 and 25 ms can be recorded with GPi stimulation in dystonia. Plasticity induction protocols based on the principles of spike timing dependent plasticity that involved repeated pairing of GPi-DBS and motor cortical TMS at latencies of cortical evoked potentials induced motor cortical plasticity. These studies expanded our knowledge of the pathophysiology of dystonia and how cortical excitability and plasticity are altered with different treatments such as DBS.
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15
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Morigaki R, Miyamoto R, Matsuda T, Miyake K, Yamamoto N, Takagi Y. Dystonia and Cerebellum: From Bench to Bedside. Life (Basel) 2021; 11:life11080776. [PMID: 34440520 PMCID: PMC8401781 DOI: 10.3390/life11080776] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 12/31/2022] Open
Abstract
Dystonia pathogenesis remains unclear; however, findings from basic and clinical research suggest the importance of the interaction between the basal ganglia and cerebellum. After the discovery of disynaptic pathways between the two, much attention has been paid to the cerebellum. Basic research using various dystonia rodent models and clinical studies in dystonia patients continues to provide new pieces of knowledge regarding the role of the cerebellum in dystonia genesis. Herein, we review basic and clinical articles related to dystonia focusing on the cerebellum, and clarify the current understanding of the role of the cerebellum in dystonia pathogenesis. Given the recent evidence providing new hypotheses regarding dystonia pathogenesis, we discuss how the current evidence answers the unsolved clinical questions.
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Affiliation(s)
- Ryoma Morigaki
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (N.Y.); (Y.T.)
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (T.M.); (K.M.)
- Correspondence:
| | - Ryosuke Miyamoto
- Department of Neurology, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan;
| | - Taku Matsuda
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (T.M.); (K.M.)
| | - Kazuhisa Miyake
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (T.M.); (K.M.)
| | - Nobuaki Yamamoto
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (N.Y.); (Y.T.)
- Department of Neurology, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan;
| | - Yasushi Takagi
- Department of Advanced Brain Research, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (N.Y.); (Y.T.)
- Department of Neurosurgery, Institute of Biomedical Sciences, Graduate School of Medicine, Tokushima University, Tokushima 770-8501, Japan; (T.M.); (K.M.)
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16
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Johnson V, Wilt R, Gilron R, Anso J, Perrone R, Beudel M, Piña-Fuentes D, Saal J, Ostrem JL, Bledsoe I, Starr P, Little S. Embedded adaptive deep brain stimulation for cervical dystonia controlled by motor cortex theta oscillations. Exp Neurol 2021; 345:113825. [PMID: 34331900 DOI: 10.1016/j.expneurol.2021.113825] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/08/2021] [Accepted: 07/26/2021] [Indexed: 12/23/2022]
Abstract
Dystonia is a disabling movement disorder characterized by excessive muscle contraction for which the underlying pathophysiology is incompletely understood and treatment interventions limited in efficacy. Here we utilize a novel, sensing-enabled, deep brain stimulator device, implanted in a patient with cervical dystonia, to record local field potentials from chronically implanted electrodes in the sensorimotor cortex and subthalamic nuclei bilaterally. This rechargeable device was able to record large volumes of neural data at home, in the naturalistic environment, during unconstrained activity. We confirmed the presence of theta (3-7 Hz) oscillatory activity, which was coherent throughout the cortico-subthalamic circuit and specifically suppressed by high-frequency stimulation. Stimulation also reduced the duration, rate and height of theta bursts. These findings motivated a proof-of-principle trial of a new form of adaptive deep brain stimulation - triggered by theta-burst activity recorded from the motor cortex. This facilitated increased peak stimulation amplitudes without induction of dyskinesias and demonstrated improved blinded clinical ratings compared to continuous DBS, despite reduced total electrical energy delivered. These results further strengthen the pathophysiological role of low frequency (theta) oscillations in dystonia and demonstrate the potential for novel adaptive stimulation strategies linked to cortico-basal theta bursts.
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Affiliation(s)
- Vinith Johnson
- Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
| | - Robert Wilt
- Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
| | - Roee Gilron
- Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
| | - Juan Anso
- Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
| | - Randy Perrone
- Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
| | - Martijn Beudel
- Department of Neurology, Amsterdam Neuroscience Institute, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Dan Piña-Fuentes
- Department of Neurology, Amsterdam Neuroscience Institute, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jeremy Saal
- Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
| | - Jill L Ostrem
- Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
| | - Ian Bledsoe
- Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
| | - Philip Starr
- Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA
| | - Simon Little
- Movement Disorders and Neuromodulation Centre, University of California San Francisco, San Francisco, CA, USA.
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17
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Sirica D, Hewitt AL, Tarolli CG, Weber MT, Zimmerman C, Santiago A, Wensel A, Mink JW, Lizárraga KJ. Neurophysiological biomarkers to optimize deep brain stimulation in movement disorders. Neurodegener Dis Manag 2021; 11:315-328. [PMID: 34261338 PMCID: PMC8977945 DOI: 10.2217/nmt-2021-0002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Intraoperative neurophysiological information could increase accuracy of surgical deep brain stimulation (DBS) lead placement. Subsequently, DBS therapy could be optimized by specifically targeting pathological activity. In Parkinson’s disease, local field potentials (LFPs) excessively synchronized in the beta band (13–35 Hz) correlate with akinetic-rigid symptoms and their response to DBS therapy, particularly low beta band suppression (13–20 Hz) and high frequency gamma facilitation (35–250 Hz). In dystonia, LFPs abnormally synchronize in the theta/alpha (4–13 Hz), beta and gamma (60–90 Hz) bands. Phasic dystonic symptoms and their response to DBS correlate with changes in theta/alpha synchronization. In essential tremor, LFPs excessively synchronize in the theta/alpha and beta bands. Adaptive DBS systems will individualize pathological characteristics of neurophysiological signals to automatically deliver therapeutic DBS pulses of specific spatial and temporal parameters.
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Affiliation(s)
- Daniel Sirica
- Motor Physiology & Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester, Rochester, NY 14618, USA
| | - Angela L Hewitt
- Motor Physiology & Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester, Rochester, NY 14618, USA.,Division of Child Neurology, Department of Neurology, University of Rochester, Rochester, NY 14623, USA
| | - Christopher G Tarolli
- Motor Physiology & Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester, Rochester, NY 14618, USA.,Center for Health & Technology (CHeT), University of Rochester, Rochester, NY 14642, USA
| | - Miriam T Weber
- Motor Physiology & Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester, Rochester, NY 14618, USA
| | - Carol Zimmerman
- Motor Physiology & Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester, Rochester, NY 14618, USA
| | - Aida Santiago
- Motor Physiology & Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester, Rochester, NY 14618, USA
| | - Andrew Wensel
- Motor Physiology & Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester, Rochester, NY 14618, USA.,Department of Neurosurgery, University of Rochester, Rochester, NY 14618, USA
| | - Jonathan W Mink
- Motor Physiology & Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester, Rochester, NY 14618, USA.,Division of Child Neurology, Department of Neurology, University of Rochester, Rochester, NY 14623, USA
| | - Karlo J Lizárraga
- Motor Physiology & Neuromodulation Program, Division of Movement Disorders, Department of Neurology, University of Rochester, Rochester, NY 14618, USA.,Center for Health & Technology (CHeT), University of Rochester, Rochester, NY 14642, USA
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18
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Knorr S, Rauschenberger L, Pasos UR, Friedrich MU, Peach RL, Grundmann-Hauser K, Ott T, O'Leary A, Reif A, Tovote P, Volkmann J, Ip CW. The evolution of dystonia-like movements in TOR1A rats after transient nerve injury is accompanied by dopaminergic dysregulation and abnormal oscillatory activity of a central motor network. Neurobiol Dis 2021; 154:105337. [PMID: 33753289 DOI: 10.1016/j.nbd.2021.105337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/08/2021] [Accepted: 03/17/2021] [Indexed: 12/25/2022] Open
Abstract
TOR1A is the most common inherited form of dystonia with still unclear pathophysiology and reduced penetrance of 30-40%. ∆ETorA rats mimic the TOR1A disease by expression of the human TOR1A mutation without presenting a dystonic phenotype. We aimed to induce dystonia-like symptoms in male ∆ETorA rats by peripheral nerve injury and to identify central mechanism of dystonia development. Dystonia-like movements (DLM) were assessed using the tail suspension test and implementing a pipeline of deep learning applications. Neuron numbers of striatal parvalbumin+, nNOS+, calretinin+, ChAT+ interneurons and Nissl+ cells were estimated by unbiased stereology. Striatal dopaminergic metabolism was analyzed via in vivo microdialysis, qPCR and western blot. Local field potentials (LFP) were recorded from the central motor network. Deep brain stimulation (DBS) of the entopeduncular nucleus (EP) was performed. Nerve-injured ∆ETorA rats developed long-lasting DLM over 12 weeks. No changes in striatal structure were observed. Dystonic-like ∆ETorA rats presented a higher striatal dopaminergic turnover and stimulus-induced elevation of dopamine efflux compared to the control groups. Higher LFP theta power in the EP of dystonic-like ∆ETorA compared to wt rats was recorded. Chronic EP-DBS over 3 weeks led to improvement of DLM. Our data emphasizes the role of environmental factors in TOR1A symptomatogenesis. LFP analyses indicate that the pathologically enhanced theta power is a physiomarker of DLM. This TOR1A model replicates key features of the human TOR1A pathology on multiple biological levels and is therefore suited for further analysis of dystonia pathomechanism.
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Affiliation(s)
- Susanne Knorr
- Department of Neurology, University Hospital of Würzburg, 97080, Germany
| | | | - Uri Ramirez Pasos
- Department of Neurology, University Hospital of Würzburg, 97080, Germany
| | | | - Robert L Peach
- Department of Neurology, University Hospital of Würzburg, 97080, Germany
| | - Kathrin Grundmann-Hauser
- Institute for Medical Genetics and Applied Genomics, University of Tübingen, 72076, Germany; Centre for Rare Diseases, University of Tübingen, 72076, Germany
| | - Thomas Ott
- Institute for Medical Genetics and Applied Genomics, University of Tübingen, 72076, Germany; Core Facility Transgenic Animals, University Hospital of Tübingen, 72076, Germany
| | - Aet O'Leary
- Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital Frankfurt, 60528, Germany
| | - Andreas Reif
- Department of Psychiatry, Psychosomatic Medicine, and Psychotherapy, University Hospital Frankfurt, 60528, Germany
| | - Philip Tovote
- Systems Neurobiology, Institute of Clinical Neurobiology, University Hospital of Würzburg, Versbacher Straße 5, 97080, Germany
| | - Jens Volkmann
- Department of Neurology, University Hospital of Würzburg, 97080, Germany
| | - Chi Wang Ip
- Department of Neurology, University Hospital of Würzburg, 97080, Germany.
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19
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Neurophysiological insights in dystonia and its response to deep brain stimulation treatment. Exp Brain Res 2020; 238:1645-1657. [PMID: 32638036 PMCID: PMC7413898 DOI: 10.1007/s00221-020-05833-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 05/11/2020] [Indexed: 01/29/2023]
Abstract
Dystonia is a movement disorder characterised by involuntary muscle contractions resulting in abnormal movements, postures and tremor. The pathophysiology of dystonia is not fully understood but loss of neuronal inhibition, excessive sensorimotor plasticity and defective sensory processing are thought to contribute to network dysfunction underlying the disorder. Neurophysiology studies have been important in furthering our understanding of dystonia and have provided insights into the mechanism of effective dystonia treatment with pallidal deep brain stimulation. In this article we review neurophysiology studies in dystonia and its treatment with Deep Brain Stimulation, including Transcranial magnetic stimulation studies, studies of reflexes and sensory processing, and oscillatory activity recordings including local field potentials, micro-recordings, EEG and evoked potentials.
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20
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Basal ganglia oscillations as biomarkers for targeting circuit dysfunction in Parkinson's disease. PROGRESS IN BRAIN RESEARCH 2020; 252:525-557. [PMID: 32247374 DOI: 10.1016/bs.pbr.2020.02.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Oscillations are a naturally occurring phenomenon in highly interconnected dynamical systems. However, it is thought that excessive synchronized oscillations in brain circuits can be detrimental for many brain functions by disrupting neuronal information processing. Because synchronized basal ganglia oscillations are a hallmark of Parkinson's disease (PD), it has been suggested that aberrant rhythmic activity associated with symptoms of the disease could be used as a physiological biomarker to guide pharmacological and electrical neuromodulatory interventions. We here briefly review the various manifestations of basal ganglia oscillations observed in human subjects and in animal models of PD. In this context, we also review the evidence supporting a pathophysiological role of different oscillations for the suppression of voluntary movements as well as for the induction of excessive motor activity. In light of these findings, it is discussed how oscillations could be used to guide a more precise targeting of dysfunctional circuits to obtain improved symptomatic treatment of PD.
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21
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Local Field Potentials and ECoG. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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22
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Leta V, Jenner P, Chaudhuri KR, Antonini A. Can therapeutic strategies prevent and manage dyskinesia in Parkinson’s disease? An update. Expert Opin Drug Saf 2019; 18:1203-1218. [DOI: 10.1080/14740338.2019.1681966] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Valentina Leta
- King’s College London, Department of Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, London, UK
- Parkinson’s Foundation Centre of Excellence, King’s College Hospital, London, UK
| | - Peter Jenner
- Neurodegenerative Diseases Research Group, School of Cancer and Pharmaceutical Sciences, Faculty of Life Science and Medicine, King’s College London, London, UK
| | - K. Ray Chaudhuri
- King’s College London, Department of Neurosciences, Institute of Psychiatry, Psychology & Neuroscience, London, UK
- Parkinson’s Foundation Centre of Excellence, King’s College Hospital, London, UK
| | - Angelo Antonini
- Department of Neuroscience, University of Padova, Padua, Italy
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23
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Piña-Fuentes D, Beudel M, Little S, van Zijl J, Elting JW, Oterdoom DLM, van Egmond ME, van Dijk JMC, Tijssen MAJ. Toward adaptive deep brain stimulation for dystonia. Neurosurg Focus 2019; 45:E3. [PMID: 30064317 DOI: 10.3171/2018.5.focus18155] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The presence of abnormal neural oscillations within the cortico-basal ganglia-thalamo-cortical (CBGTC) network has emerged as one of the current principal theories to explain the pathophysiology of movement disorders. In theory, these oscillations can be used as biomarkers and thereby serve as a feedback signal to control the delivery of deep brain stimulation (DBS). This new form of DBS, dependent on different characteristics of pathological oscillations, is called adaptive DBS (aDBS), and it has already been applied in patients with Parkinson's disease. In this review, the authors summarize the scientific research to date on pathological oscillations in dystonia and address potential biomarkers that might be used as a feedback signal for controlling aDBS in patients with dystonia.
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Affiliation(s)
- Dan Piña-Fuentes
- Departments of1Neurosurgery and.,2Neurology, University Medical Center Groningen, University of Groningen
| | - Martijn Beudel
- 2Neurology, University Medical Center Groningen, University of Groningen.,3Department of Neurology, Isala Klinieken, Zwolle, The Netherlands; and
| | - Simon Little
- 4Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, United Kingdom
| | - Jonathan van Zijl
- 2Neurology, University Medical Center Groningen, University of Groningen
| | - Jan Willem Elting
- 2Neurology, University Medical Center Groningen, University of Groningen
| | | | | | | | - Marina A J Tijssen
- 2Neurology, University Medical Center Groningen, University of Groningen
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24
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Scheller U, Lofredi R, Wijk BC, Saryyeva A, Krauss JK, Schneider G, Kroneberg D, Krause P, Neumann W, Kühn AA. Pallidal low‐frequency activity in dystonia after cessation of long‐term deep brain stimulation. Mov Disord 2019; 34:1734-1739. [DOI: 10.1002/mds.27838] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/05/2019] [Accepted: 08/05/2019] [Indexed: 01/05/2023] Open
Affiliation(s)
- Ute Scheller
- Charité, Universitätsmedizin Berlin Campus Mitte, Movement Disorders and Neuromodulation Unit, Department of Neurology Berlin Germany
| | - Roxanne Lofredi
- Charité, Universitätsmedizin Berlin Campus Mitte, Movement Disorders and Neuromodulation Unit, Department of Neurology Berlin Germany
| | - Bernadette C.M. Wijk
- Charité, Universitätsmedizin Berlin Campus Mitte, Movement Disorders and Neuromodulation Unit, Department of Neurology Berlin Germany
- Integrative Model‐Based Cognitive Neuroscience Research Unit, Department of Psychology University of Amsterdam Amsterdam the Netherlands
- Wellcome Centre for Human Neuroimaging University College London Institute of Neurology London UK
| | - Assel Saryyeva
- Medizinische Hochschule Hannover Department of Neurosurgery Hannover Germany
| | - Joachim K. Krauss
- Medizinische Hochschule Hannover Department of Neurosurgery Hannover Germany
| | - Gerd‐Helge Schneider
- Charité, Universitätsmedizin Berlin Campus Mitte, Department of Neurosurgery Berlin Germany
| | - Daniel Kroneberg
- Charité, Universitätsmedizin Berlin Campus Mitte, Movement Disorders and Neuromodulation Unit, Department of Neurology Berlin Germany
| | - Patricia Krause
- Charité, Universitätsmedizin Berlin Campus Mitte, Movement Disorders and Neuromodulation Unit, Department of Neurology Berlin Germany
| | - Wolf‐Julian Neumann
- Charité, Universitätsmedizin Berlin Campus Mitte, Movement Disorders and Neuromodulation Unit, Department of Neurology Berlin Germany
| | - Andrea A. Kühn
- Charité, Universitätsmedizin Berlin Campus Mitte, Movement Disorders and Neuromodulation Unit, Department of Neurology Berlin Germany
- NeuroCure Universitätsmedizin Berlin Berlin Germany
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25
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Tekriwal A, Afshar NM, Santiago-Moreno J, Kuijper FM, Kern DS, Halpern CH, Felsen G, Thompson JA. Neural Circuit and Clinical Insights from Intraoperative Recordings During Deep Brain Stimulation Surgery. Brain Sci 2019; 9:brainsci9070173. [PMID: 31330813 PMCID: PMC6681002 DOI: 10.3390/brainsci9070173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/17/2019] [Accepted: 07/18/2019] [Indexed: 12/15/2022] Open
Abstract
Observations using invasive neural recordings from patient populations undergoing neurosurgical interventions have led to critical breakthroughs in our understanding of human neural circuit function and malfunction. The opportunity to interact with patients during neurophysiological mapping allowed for early insights in functional localization to improve surgical outcomes, but has since expanded into exploring fundamental aspects of human cognition including reward processing, language, the storage and retrieval of memory, decision-making, as well as sensory and motor processing. The increasing use of chronic neuromodulation, via deep brain stimulation, for a spectrum of neurological and psychiatric conditions has in tandem led to increased opportunity for linking theories of cognitive processing and neural circuit function. Our purpose here is to motivate the neuroscience and neurosurgical community to capitalize on the opportunities that this next decade will bring. To this end, we will highlight recent studies that have successfully leveraged invasive recordings during deep brain stimulation surgery to advance our understanding of human cognition with an emphasis on reward processing, improving clinical outcomes, and informing advances in neuromodulatory interventions.
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Affiliation(s)
- Anand Tekriwal
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO 80203, USA
- Department of Physiology and Biophysics, University of Colorado School of Medicine, Aurora, CO 80203, USA
- Medical Scientist Training Program, University of Colorado School of Medicine, Aurora, CO 80203, USA
| | - Neema Moin Afshar
- Department of Physiology and Biophysics, University of Colorado School of Medicine, Aurora, CO 80203, USA
| | - Juan Santiago-Moreno
- Medical Scientist Training Program, University of Colorado School of Medicine, Aurora, CO 80203, USA
| | - Fiene Marie Kuijper
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Drew S Kern
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO 80203, USA
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80203, USA
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Gidon Felsen
- Department of Physiology and Biophysics, University of Colorado School of Medicine, Aurora, CO 80203, USA
| | - John A Thompson
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO 80203, USA.
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO 80203, USA.
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26
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Halje P, Brys I, Mariman JJ, da Cunha C, Fuentes R, Petersson P. Oscillations in cortico-basal ganglia circuits: implications for Parkinson’s disease and other neurologic and psychiatric conditions. J Neurophysiol 2019; 122:203-231. [DOI: 10.1152/jn.00590.2018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cortico-basal ganglia circuits are thought to play a crucial role in the selection and control of motor behaviors and have also been implicated in the processing of motivational content and in higher cognitive functions. During the last two decades, electrophysiological recordings in basal ganglia circuits have shown that several disease conditions are associated with specific changes in the temporal patterns of neuronal activity. In particular, synchronized oscillations have been a frequent finding suggesting that excessive synchronization of neuronal activity may be a pathophysiological mechanism involved in a wide range of neurologic and psychiatric conditions. We here review the experimental support for this hypothesis primarily in relation to Parkinson’s disease but also in relation to dystonia, essential tremor, epilepsy, and psychosis/schizophrenia.
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Affiliation(s)
- Pär Halje
- Group for Integrative Neurophysiology and Neurotechnology, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Ivani Brys
- Federal University of Vale do São Francisco, Petrolina, Brazil
| | - Juan J. Mariman
- Research and Development Direction, Universidad Tecnológica de Chile, Inacap, Santiago, Chile
- Department of Physical Therapy, Faculty of Medicine, Universidad de Chile, Santiago, Chile
- Department of Physical Therapy, Faculty of Arts and Physical Education, Universidad Metropolitana de Ciencias de la Educación, Santiago, Chile
| | - Claudio da Cunha
- Laboratório de Fisiologia e Farmacologia do Sistema Nervoso Central, Programas de Pós-Graduação em Farmacologia e Bioquímica, Universidade Federal do Paraná, Curitiba, Brazil
| | - Romulo Fuentes
- Department of Neurocience, Faculty of Medicine, Universidad de Chile, Santiago, Chile
| | - Per Petersson
- Group for Integrative Neurophysiology and Neurotechnology, Department of Experimental Medical Science, Lund University, Lund, Sweden
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
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Huebl J, Poshtiban A, Brücke C, Siegert S, Bock A, Koziara H, Kmiec T, Rola R, Mandat T, Kühn AA. Subthalamic and pallidal oscillatory activity in patients with Neurodegeneration with Brain Iron Accumulation type I (NBIA-I). Clin Neurophysiol 2019; 130:469-473. [DOI: 10.1016/j.clinph.2018.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 12/11/2018] [Accepted: 12/23/2018] [Indexed: 01/24/2023]
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The role of pallidum in the neural integrator model of cervical dystonia. Neurobiol Dis 2019; 125:45-54. [PMID: 30677494 DOI: 10.1016/j.nbd.2019.01.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/15/2019] [Accepted: 01/20/2019] [Indexed: 01/17/2023] Open
Abstract
Dystonia is the third most common movement disorder affecting three million people worldwide. Cervical dystonia is the most common form of dystonia. Despite common prevalence the pathophysiology of cervical dystonia is unclear. Traditional view is that basal ganglia is involved in pathophysiology of cervical dystonia, while contemporary theories suggested the role of cerebellum and proprioception in the pathophysiology of cervical dystonia. It was recently proposed that the cervical dystonia is due to malfunctioning of the head neural integrator - the neuron network that normally converts head velocity to position. Most importantly the neural integrator model was inclusive of traditional proposal emphasizing the role of basal ganglia while also accommodating the contemporary view suggesting the involvement of cerebellum and proprioception. It was hypothesized that the head neural integrator malfunction is the result of impairment in cerebellar, basal ganglia, or proprioceptive feedback that converge onto the integrator. The concept of converging input from the basal ganglia, cerebellum, and proprioception to the network participating in head neural integrator explains that abnormality originating anywhere in the network can lead to the identical motor deficits - drifts followed by rapid corrective movements - a signature of neural integrator dysfunction. We tested this hypothesis in an experiment examining simultaneously recorded globus pallidal single-unit activity, synchronized neural activity (local field potential), and electromyography (EMG) measured from the neck muscles during the standard-of-care deep brain stimulation surgery in 12 cervical dystonia patients (24 hemispheres). Physiological data were collected spontaneously or during voluntary shoulder shrug activating the contralateral trapezius muscle. The activity of pallidal neurons during shoulder shrug exponentially decayed with time constants that were comparable to one measured from the pretectal neural integrator and the trapezius electromyography. These results show that evidence of abnormal neural integration is also seen in globus pallidum, and that latter is connected with the neural integrator. Pretectal single neuron responses consistently preceded the muscle activity; while the globus pallidum internus response always lagged behind the muscle activity. Globus pallidum externa had equal proportion of lag and lead neurons. These results suggest globus pallidum receive feedback from the muscles or the efference copy from the integrator or the other source of the feedback. There was bi-hemispheric asymmetry in the pallidal single-unit activity and local field potentials. The asymmetry correlated with degree of lateral head turning in cervical dystonia patients. These results suggest that bihemispheric asymmetry in the feedback leads to asymmetric dysfunction in the neural integrator causing head turning.
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Georgescu EL, Georgescu IA, Zahiu CDM, Şteopoaie AR, Morozan VP, Pană AŞ, Zăgrean AM, Popa D. Oscillatory Cortical Activity in an Animal Model of Dystonia Caused by Cerebellar Dysfunction. Front Cell Neurosci 2018; 12:390. [PMID: 30459559 PMCID: PMC6232371 DOI: 10.3389/fncel.2018.00390] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/10/2018] [Indexed: 12/11/2022] Open
Abstract
The synchronization of neuronal activity in the sensorimotor cortices is crucial for motor control and learning. This synchrony can be modulated by upstream activity in the cerebello-cortical network. However, many questions remain over the details of how the cerebral cortex and the cerebellum communicate. Therefore, our aim is to study the contribution of the cerebellum to oscillatory brain activity, in particular in the case of dystonia, a severely disabling motor disease associated with altered sensorimotor coupling. We used a kainic-induced dystonia model to evaluate cerebral cortical oscillatory activity and connectivity during dystonic episodes. We performed microinjections of low doses of kainic acid into the cerebellar vermis in mice and examined activities in somatosensory, motor and parietal cortices. We showed that repeated applications of kainic acid into the cerebellar vermis, for five consecutive days, generate reproducible dystonic motor behavior. No epileptiform activity was recorded on electrocorticogram (ECoG) during the dystonic postures or movements. We investigated the ECoG power spectral density and coherence between motor cortex, somatosensory and parietal cortices before and during dystonic attacks. During the baseline condition, we found a phenomenon of permanent adaptation with a change of baseline locomotor activity coupled to an ECoG gamma band increase in all cortices. In addition, after kainate administration, we observed an increase in muscular activity, but less signs of dystonia together with modulations of the ECoG power spectra with an increase in gamma band in motor, parietal and somatosensory cortices. Moreover, we found reduced coherence in all measured frequency bands between the motor cortex and somatosensory or parietal cortices compared to baseline. In conclusion, examination of cortical oscillatory activities in this animal model of chronic dystonia caused by cerebellar dysfunction reveals a disruption in the coordination of neuronal activity across the cortical sensorimotor/parietal network, which may underlie motor skill deficits.
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Affiliation(s)
- Elena Laura Georgescu
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Institut de Biologie de l'Ecole Normale Supérieure (IBENS), Ecole Normale Supérieure, CNRS, INSERM, PSL Research University, Paris, France
| | - Ioana Antoaneta Georgescu
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Carmen Denise Mihaela Zahiu
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Alexandru Răzvan Şteopoaie
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Vlad Petru Morozan
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Adrian Ştefan Pană
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Ana-Maria Zăgrean
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Daniela Popa
- Division of Physiology and Neuroscience, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Institut de Biologie de l'Ecole Normale Supérieure (IBENS), Ecole Normale Supérieure, CNRS, INSERM, PSL Research University, Paris, France
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30
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Piña-Fuentes D, van Zijl JC, van Dijk JMC, Little S, Tinkhauser G, Oterdoom DLM, Tijssen MAJ, Beudel M. The characteristics of pallidal low-frequency and beta bursts could help implementing adaptive brain stimulation in the parkinsonian and dystonic internal globus pallidus. Neurobiol Dis 2018; 121:47-57. [PMID: 30227227 DOI: 10.1016/j.nbd.2018.09.014] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/08/2018] [Accepted: 09/13/2018] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Adaptive deep brain stimulation (aDBS) has been applied in Parkinson's disease (PD), based on the presence of brief high-amplitude beta (13-35 Hz) oscillation bursts in the subthalamic nucleus (STN), which correlate with symptom severity. Analogously, average low-frequency (LF) oscillatory power (4-12 Hz) in the internal globus pallidus (GPi) correlates with dystonic symptoms and might be a suitable physiomarker for aDBS in dystonia. Characterization of pallidal bursts could facilitate the implementation of aDBS in the GPi of PD and dystonia patients. OBJECTIVE AND METHODS We aimed to describe the bursting behaviour of LF and beta oscillations in a cohort of five GPi-DBS PD patients and compare their amplitude and length with those of a cohort of seven GPi-DBS dystonia, and six STN-DBS PD patients (n electrodes = 34). Furthermore, we used the information obtained to set up aDBS and test it in the GPi of both a dystonia and a PD patient (n = 2), using either LF (dystonia) or beta oscillations (PD) as feedback signals. RESULTS LF and beta oscillations in the dystonic and parkinsonian GPi occur as phasic, short-lived bursts, similarly to the parkinsonian STN. The amplitude profile of such bursts, however, differed significantly. Dystonia showed higher LF burst amplitudes, while PD presented higher beta burst amplitudes. Burst characteristics in the parkinsonian GPi and STN were similar. Furthermore, aDBS applied in the GPi was feasible and well tolerated in both diseases. CONCLUSION Pallidal LF and beta burst amplitudes have different characteristics in PD and dystonia. The presence of increased burst amplitudes could be employed as feedback for GPi-aDBS.
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Affiliation(s)
- Dan Piña-Fuentes
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jonathan C van Zijl
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Simon Little
- Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology, Queen Square, London, UK
| | - Gerd Tinkhauser
- Medical Research Council Brain Network Dynamics Unit and Nuffield Department of Clinical Neurosciences, University of Oxford, United Kingdom; Department of Neurology, Bern University Hospital and University of Bern, Bern, Switzerland
| | - D L Marinus Oterdoom
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Marina A J Tijssen
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Martijn Beudel
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands; Department of Neurology, Isala Clinics, Zwolle, The Netherlands.
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31
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Yokochi F, Kato K, Iwamuro H, Kamiyama T, Kimura K, Yugeta A, Okiyama R, Taniguchi M, Kumada S, Ushiba J. Resting-State Pallidal-Cortical Oscillatory Couplings in Patients With Predominant Phasic and Tonic Dystonia. Front Neurol 2018; 9:375. [PMID: 29904367 PMCID: PMC5990626 DOI: 10.3389/fneur.2018.00375] [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: 02/05/2018] [Accepted: 05/08/2018] [Indexed: 11/13/2022] Open
Abstract
Pallidal deep brain stimulation (DBS) improves the symptoms of dystonia. The improvement processes of dystonic movements (phasic symptoms) and tonic symptoms differ. Phasic symptoms improve rapidly after starting DBS treatment, but tonic symptoms improve gradually. This difference implies distinct neuronal mechanisms for phasic and tonic symptoms in the underlying cortico-basal ganglia neuronal network. Phasic symptoms are related to the pallido-thalamo-cortical pathway. The pathway related to tonic symptoms has been assumed to be different from that for phasic symptoms. In the present study, local field potentials of the globus pallidus internus (GPi) and globus pallidus externus (GPe) and electroencephalograms from the motor cortex (MCx) were recorded in 19 dystonia patients to analyze the differences between the two types of symptoms. The 19 patients were divided into two groups, 10 with predominant phasic symptoms (phasic patients) and 9 with predominant tonic symptoms (tonic patients). To investigate the distinct features of oscillations and functional couplings across the GPi, GPe, and MCx by clinical phenotype, power and coherence were calculated over the delta (2-4 Hz), theta (5-7 Hz), alpha (8-13 Hz), and beta (14-35 Hz) frequencies. In phasic patients, the alpha spectral peaks emerged in the GPi oscillatory activities, and alpha GPi coherence with the GPe and MCx was higher than in tonic patients. On the other hand, delta GPi oscillatory activities were prominent, and delta GPi-GPe coherence was significantly higher in tonic than in phasic patients. However, there was no significant delta coherence between the GPi/GPe and MCx in tonic patients. These results suggest that different pathophysiological cortico-pallidal oscillations are related to tonic and phasic symptoms.
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Affiliation(s)
- Fusako Yokochi
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Kenji Kato
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan.,Department of Biosciences and Informatics, Faculty of Science and Technology, Keio University, Kanagawa, Japan
| | - Hirokazu Iwamuro
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Tsutomu Kamiyama
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Katsuo Kimura
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Akihiro Yugeta
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Ryoichi Okiyama
- Department of Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Makoto Taniguchi
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Satoko Kumada
- Department of Pediatric Neurology, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Junichi Ushiba
- Department of Biosciences and Informatics, Faculty of Science and Technology, Keio University, Kanagawa, Japan
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32
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Pallidal deep brain stimulation in juvenile Huntington's disease: local field potential oscillations and clinical data. J Neurol 2018; 265:1573-1579. [DOI: 10.1007/s00415-018-8880-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/22/2018] [Accepted: 04/23/2018] [Indexed: 11/25/2022]
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33
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Sadnicka A, Stevenson A, Bhatia KP, Rothwell JC, Edwards MJ, Galea JM. High motor variability in DYT1 dystonia is associated with impaired visuomotor adaptation. Sci Rep 2018; 8:3653. [PMID: 29483592 PMCID: PMC5826938 DOI: 10.1038/s41598-018-21545-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/06/2018] [Indexed: 11/29/2022] Open
Abstract
For the healthy motor control system, an essential regulatory role is maintaining the equilibrium between keeping unwanted motor variability in check whilst allowing informative elements of motor variability. Kinematic studies in children with generalised dystonia (due to mixed aetiologies) show that movements are characterised by increased motor variability. In this study, the mechanisms by which high motor variability may influence movement generation in dystonia were investigated. Reaching movements in the symptomatic arm of 10 patients with DYT1 dystonia and 12 age-matched controls were captured using a robotic manipulandum and features of motor variability were extracted. Given that task-relevant variability and sensorimotor adaptation are related in health, markers of variability were then examined for any co-variance with performance indicators during an error-based learning visuomotor adaptation task. First, we confirmed that motor variability on a trial-by-trial basis was selectively increased in the homogenous and prototypical dystonic disorder DYT1 dystonia. Second, high baseline variability predicted poor performance in the subsequent visuomotor adaptation task offering insight into the rules which appear to govern dystonic motor control. The potential mechanisms behind increased motor variability and its corresponding implications for the rehabilitation of patients with DYT1 dystonia are highlighted.
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Affiliation(s)
- Anna Sadnicka
- Sobell Department for Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, 33 Queen Square, London, WC1N 3BG, UK. .,Motor Control and Movement Disorder Group, Institute of Molecular and Clinical Sciences, St George's University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK.
| | - Anna Stevenson
- Sobell Department for Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, 33 Queen Square, London, WC1N 3BG, UK
| | - Kailash P Bhatia
- Sobell Department for Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, 33 Queen Square, London, WC1N 3BG, UK
| | - John C Rothwell
- Sobell Department for Motor Neuroscience and Movement Disorders, Institute of Neurology, University College London, 33 Queen Square, London, WC1N 3BG, UK
| | - Mark J Edwards
- Motor Control and Movement Disorder Group, Institute of Molecular and Clinical Sciences, St George's University of London, Cranmer Terrace, Tooting, London, SW17 0RE, UK
| | - Joseph M Galea
- Galea Lab, School of Psychology, University of Birmingham, Birmingham, B15 2TT, UK
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34
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Miocinovic S, Miller A, Swann NC, Ostrem JL, Starr PA. Chronic deep brain stimulation normalizes scalp EEG activity in isolated dystonia. Clin Neurophysiol 2017; 129:368-376. [PMID: 29288993 DOI: 10.1016/j.clinph.2017.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 09/21/2017] [Accepted: 11/21/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To investigate cortical activity using scalp EEG in patients with isolated dystonia treated with chronic deep brain stimulation (DBS), on and off stimulation. METHODS We analyzed 64-channel scalp EEG in 12 isolated dystonia patients treated with chronic DBS (7 generalized, 5 cervical/segmental; 7 globus pallidus (GP), 5 subthalamic nucleus (STN)), and 20 healthy age-matched controls. Recordings during rest and movement task, and clinical motor scores, were collected with DBS-on and during a 90-min DBS washout. RESULTS Resting state alpha power in the dominant (or contralateral to more dystonic side) motor cortex channel during DBS was comparable to healthy controls, but it increased when DBS was stopped. Resting state and movement-related alpha coherence between bilateral motor cortex channels was increased off DBS. CONCLUSIONS Chronic DBS reduces exaggerated alpha oscillations and interhemispheric alpha coherence in the motor cortex of patients with isolated dystonia. SIGNIFICANCE These findings complement related studies in Parkinson's disease and support the view that network desynchronization is a prominent mechanism of DBS in movement disorders.
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Affiliation(s)
| | - Andrew Miller
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
| | - Nicole C Swann
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
| | - Jill L Ostrem
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States.
| | - Philip A Starr
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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35
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Abstract
Parkinson disease is the second-most common neurodegenerative disorder that affects 2-3% of the population ≥65 years of age. Neuronal loss in the substantia nigra, which causes striatal dopamine deficiency, and intracellular inclusions containing aggregates of α-synuclein are the neuropathological hallmarks of Parkinson disease. Multiple other cell types throughout the central and peripheral autonomic nervous system are also involved, probably from early disease onwards. Although clinical diagnosis relies on the presence of bradykinesia and other cardinal motor features, Parkinson disease is associated with many non-motor symptoms that add to overall disability. The underlying molecular pathogenesis involves multiple pathways and mechanisms: α-synuclein proteostasis, mitochondrial function, oxidative stress, calcium homeostasis, axonal transport and neuroinflammation. Recent research into diagnostic biomarkers has taken advantage of neuroimaging in which several modalities, including PET, single-photon emission CT (SPECT) and novel MRI techniques, have been shown to aid early and differential diagnosis. Treatment of Parkinson disease is anchored on pharmacological substitution of striatal dopamine, in addition to non-dopaminergic approaches to address both motor and non-motor symptoms and deep brain stimulation for those developing intractable L-DOPA-related motor complications. Experimental therapies have tried to restore striatal dopamine by gene-based and cell-based approaches, and most recently, aggregation and cellular transport of α-synuclein have become therapeutic targets. One of the greatest current challenges is to identify markers for prodromal disease stages, which would allow novel disease-modifying therapies to be started earlier.
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36
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Cif L, Coubes P. Historical developments in children's deep brain stimulation. Eur J Paediatr Neurol 2017; 21:109-117. [PMID: 27693334 DOI: 10.1016/j.ejpn.2016.08.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 08/19/2016] [Accepted: 08/29/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Heterogeneous by the underlying pathobiology and clinical presentation, childhood onset dystonia is most frequently progressive, with related disability and limitations in functions of daily living. Consequently, there is an obvious need for efficient symptomatic therapies. METHODS AND RESULTS Following lesional surgery to basal ganglia (BG) and thalamus, deep brain stimulation (DBS) is a more conservative and adjustable intervention to and validated for internal segment of the globus pallidus (GPi), highly efficient in treating isolated "primary" dystonia and associated symptoms such as subcortical myoclonus. The role of DBS in acquired, neurometabolic and degenerative disorders with dystonia deserves further exploration to confirm as an efficient and lasting therapy. However, the pathobiological background with distribution of the sequellae over the central nervous system and related clinical features, will limit DBS efficacy in these conditions. Cumulative arguments propose DBS in severe life threatening dystonic conditions called status dystonicus as first line therapy, irrespective of the underlying cause. There are no currently available validated selection criteria for DBS in pediatric dystonia. Concurrent targets such as subthalamic nucleus (STN) and several motor nuclei of the thalamus are under exploration and only little information is available in children. DBS programming in paediatric population was adopted from experience in adults. The choice of neuromodulatory DBS parameters could influence not only the initial therapeutic outcome of dystonic symptoms but also its maintenance over time and potentially the occurrence of DBS related side effects. CONCLUSION DBS allows efficient symptomatic treatment of severe dystonia in children and advances pathophysiological knowledge about local and distributed abnormal neural activity over the motor cortical-subcortical networks in dystonia and other movement disorders.
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Affiliation(s)
- Laura Cif
- Unités de Neurochirurgie Fonctionnelle et Pédiatrique, Département de Neurochirurgie, Centre Hospitalier Universitaire Montpellier, France; Unité de Recherche sur les Comportements et Mouvements Anormaux (URCMA), France; Institut de Génomique Fonctionnelle, Centre National de la Recherche Scientifique, Unité Mixte de la Recherche 5203, France; Université Montpellier, 34000, Montpellier, France; Laboratoire de Recherche en Neurosciences Cliniques (LRENC), France.
| | - Philippe Coubes
- Unités de Neurochirurgie Fonctionnelle et Pédiatrique, Département de Neurochirurgie, Centre Hospitalier Universitaire Montpellier, France; Unité de Recherche sur les Comportements et Mouvements Anormaux (URCMA), France; Institut de Génomique Fonctionnelle, Centre National de la Recherche Scientifique, Unité Mixte de la Recherche 5203, France; Université Montpellier, 34000, Montpellier, France
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37
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Comparison of oscillatory activity in subthalamic nucleus in Parkinson's disease and dystonia. Neurobiol Dis 2016; 98:100-107. [PMID: 27940307 DOI: 10.1016/j.nbd.2016.12.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/06/2016] [Accepted: 12/05/2016] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been successfully used to treat both Parkinson's disease (PD) and dystonia. Local field potentials (LFPs) recorded from the STN of PD patients demonstrate prominent beta frequency band activity. It is unclear whether such activity occurs in the STN in dystonia, and, if not, whether dystonia has another distinctive neural population activity in the STN. METHODS Twelve patients with PD, and eight patients with dystonia underwent DBS electrode implantation targeting the STN. Seven dystonia patients were off medication and one was on aripiprazole and clonazepam. LFPs were recorded from the DBS electrodes in PD in the on/off medication states and in dystonia. Power spectra and temporal dynamics measured by the with Lempel-Ziv complexity of the LFPs were compared among these states. RESULTS Normalised power spectra and Lempel-Ziv complexity of subthalamic LFPs differed between dystonia off and PD on/off, and between PD off and on over the low frequency, beta and high gamma bands. Patients with dystonia and off medication had lower beta power but higher low frequency and high gamma power than PD. Spectral power in the low beta frequency (11-20Hz) range was attenuated in medicated PD. CONCLUSION The results suggest that dystonia and PD are characterized by different patterns of oscillatory activities even within the same nucleus, and exaggerated beta activity may relate to hypo-dopaminergic status.
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38
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Local field potential oscillations of the globus pallidus in cervical and tardive dystonia. J Neurol Sci 2016; 366:68-73. [DOI: 10.1016/j.jns.2016.04.033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Revised: 03/16/2016] [Accepted: 04/16/2016] [Indexed: 01/06/2023]
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Neumann WJ, Kühn AA. Reply: Role of cortico-pallidal connectivity in the pathophysiology of dystonia. Brain 2016; 139:e49. [PMID: 27190018 DOI: 10.1093/brain/aww105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Wolf-Julian Neumann
- Sektion Bewegungsstörungen und Neuromodulation, Klinik für Neurologie, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea A Kühn
- Sektion Bewegungsstörungen und Neuromodulation, Klinik für Neurologie, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany
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40
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Wichmann T, DeLong MR. Deep Brain Stimulation for Movement Disorders of Basal Ganglia Origin: Restoring Function or Functionality? Neurotherapeutics 2016; 13:264-83. [PMID: 26956115 PMCID: PMC4824026 DOI: 10.1007/s13311-016-0426-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Deep brain stimulation (DBS) is highly effective for both hypo- and hyperkinetic movement disorders of basal ganglia origin. The clinical use of DBS is, in part, empiric, based on the experience with prior surgical ablative therapies for these disorders, and, in part, driven by scientific discoveries made decades ago. In this review, we consider anatomical and functional concepts of the basal ganglia relevant to our understanding of DBS mechanisms, as well as our current understanding of the pathophysiology of two of the most commonly DBS-treated conditions, Parkinson's disease and dystonia. Finally, we discuss the proposed mechanism(s) of action of DBS in restoring function in patients with movement disorders. The signs and symptoms of the various disorders appear to result from signature disordered activity in the basal ganglia output, which disrupts the activity in thalamocortical and brainstem networks. The available evidence suggests that the effects of DBS are strongly dependent on targeting sensorimotor portions of specific nodes of the basal ganglia-thalamocortical motor circuit, that is, the subthalamic nucleus and the internal segment of the globus pallidus. There is little evidence to suggest that DBS in patients with movement disorders restores normal basal ganglia functions (e.g., their role in movement or reinforcement learning). Instead, it appears that high-frequency DBS replaces the abnormal basal ganglia output with a more tolerable pattern, which helps to restore the functionality of downstream networks.
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Affiliation(s)
- Thomas Wichmann
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
- Yerkes National Primate Research Center, Emory University, Atlanta, GA, USA.
| | - Mahlon R DeLong
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
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Subthalamic local field potentials in Parkinson's disease and isolated dystonia: An evaluation of potential biomarkers. Neurobiol Dis 2016; 89:213-22. [PMID: 26884091 DOI: 10.1016/j.nbd.2016.02.015] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/07/2016] [Accepted: 02/10/2016] [Indexed: 12/18/2022] Open
Abstract
Local field potentials (LFP) recorded from the subthalamic nucleus in patients with Parkinson's disease (PD) demonstrate prominent oscillations in the beta (13-30 Hz) frequency range, and reduction of beta band spectral power by levodopa and deep brain stimulation (DBS) is correlated with motor symptom improvement. Several features of beta activity have been theorized to be specific biomarkers of the parkinsonian state, though these have rarely been studied in non-parkinsonian conditions. To compare resting state LFP features in PD and isolated dystonia and evaluate disease-specific biomarkers, we recorded subthalamic LFPs from 28 akinetic-rigid PD and 12 isolated dystonia patients during awake DBS implantation. Spectral power and phase-amplitude coupling characteristics were analyzed. In 26/28 PD and 11/12 isolated dystonia patients, the LFP power spectrum had a peak in the beta frequency range, with similar amplitudes between groups. Resting state power did not differ between groups in the theta (5-8 Hz), alpha (8-12 Hz), beta (13-30 Hz), broadband gamma (50-200 Hz), or high frequency oscillation (HFO, 250-350 Hz) bands. Analysis of phase-amplitude coupling between low frequency phase and HFO amplitude revealed significant interactions in 19/28 PD and 6/12 dystonia recordings without significant differences in maximal coupling or preferred phase. Two features of subthalamic LFPs that have been proposed as specific parkinsonian biomarkers, beta power and coupling of beta phase to HFO amplitude, were also present in isolated dystonia, including focal dystonias. This casts doubt on the utility of these metrics as disease-specific diagnostic biomarkers.
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Salvadè A, D'Angelo V, Di Giovanni G, Tinkhauser G, Sancesario G, Städler C, Möller JC, Stefani A, Kaelin-Lang A, Galati S. Distinct roles of cortical and pallidal β and γ frequencies in hemiparkinsonian and dyskinetic rats. Exp Neurol 2016; 275 Pt 1:199-208. [DOI: 10.1016/j.expneurol.2015.11.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 09/21/2015] [Accepted: 11/10/2015] [Indexed: 01/25/2023]
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Neumann WJ, Jha A, Bock A, Huebl J, Horn A, Schneider GH, Sander TH, Litvak V, Kühn AA. Cortico-pallidal oscillatory connectivity in patients with dystonia. Brain 2015; 138:1894-906. [PMID: 25935723 DOI: 10.1093/brain/awv109] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 02/26/2015] [Indexed: 12/12/2022] Open
Abstract
Primary dystonia has been associated with an underlying dysfunction of a wide network of brain regions including the motor cortex, basal ganglia, cerebellum, brainstem and spinal cord. Dystonia can be effectively treated by pallidal deep brain stimulation although the mechanism of this effect is not well understood. Here, we sought to characterize cortico-basal ganglia functional connectivity using a frequency-specific measure of connectivity-coherence. We recorded direct local field potentials from the human pallidum simultaneously with whole head magnetoencephalography to characterize functional connectivity in the cortico-pallidal oscillatory network in nine patients with idiopathic dystonia. Three-dimensional cortico-pallidal coherence images were compared to surrogate images of phase shuffled data across patients to reveal clusters of significant coherence (family-wise error P < 0.01, voxel extent 1000). Three frequency-specific, spatially-distinct cortico-pallidal networks have been identified: a pallido-temporal source of theta band (4-8 Hz) coherence, a pallido-cerebellar source of alpha band (7-13 Hz) coherence and a cortico-pallidal source of beta band (13-30 Hz) coherence over sensorimotor areas. Granger-based directionality analysis revealed directional coupling with the pallidal local field potentials leading in the theta and alpha band and the magnetoencephalographic cortical source leading in the beta band. The degree of pallido-cerebellar coupling showed an inverse correlation with dystonic symptom severity. Our data extend previous findings in patients with Parkinson's disease describing motor cortex-basal ganglia oscillatory connectivity in the beta band to patients with dystonia. Source coherence analysis revealed two additional frequency-specific networks involving the temporal cortex and the cerebellum. Pallido-cerebellar oscillatory connectivity and its association with dystonic symptoms provides further confirmation of cerebellar involvement in dystonia that has been recently reported using functional magnetic resonance imaging and fibre tracking.
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Affiliation(s)
- Wolf-Julian Neumann
- 1 Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Augustenburger Platz 1,13353 Berlin, Germany 2 The Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, 12 Queen Square, London WC1N 3BG, UK
| | - Ashwani Jha
- 3 Sobell Department of Movement Disorders, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Antje Bock
- 1 Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Augustenburger Platz 1,13353 Berlin, Germany
| | - Julius Huebl
- 1 Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Augustenburger Platz 1,13353 Berlin, Germany
| | - Andreas Horn
- 1 Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Augustenburger Platz 1,13353 Berlin, Germany
| | - Gerd-Helge Schneider
- 4 Department of Neurosurgery, Campus Virchow Klinikum, Charité-University Medicine Berlin, Augustenburger Platz 1,13353 Berlin, Germany
| | - Tillmann H Sander
- 5 Physikalisch-Technische Bundesanstalt, Institut Berlin, Abbestr. 2-12, 10587 Berlin, Germany
| | - Vladimir Litvak
- 2 The Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, 12 Queen Square, London WC1N 3BG, UK
| | - Andrea A Kühn
- 1 Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Augustenburger Platz 1,13353 Berlin, Germany 6 Berlin School of Mind and Brain, Charité - University Medicine Berlin, Unter den Linden 6, 10099 Berlin,Germany Berlin, Germany 7 NeuroCure, Charité - University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Welter ML, Grabli D, Karachi C, Jodoin N, Fernandez-Vidal S, Brun Y, Navarro S, Rogers A, Cornu P, Pidoux B, Yelnik J, Roze E, Bardinet E, Vidailhet M. Pallidal activity in myoclonus dystonia correlates with motor signs. Mov Disord 2015; 30:992-6. [PMID: 25880339 DOI: 10.1002/mds.26244] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 03/18/2015] [Accepted: 03/21/2015] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Myoclonus-dystonia related to epsilon-sarcoglycan gene mutations is characterized by myoclonic jerks and mild to moderate dystonia. The role of basal ganglia dysfunction in the pathogenesis is unknown. METHODS Pallidal neuronal activity was recorded in six myoclonus-dystonia and six primary generalized dystonia patients operated on for internal globus pallidus deep brain stimulation. RESULTS In myoclonus-dystonia patients compared with primary-dystonia patients, internal pallidum neurons showed higher burst frequency, lower mean burst, and pause durations. External pallidum neurons showed higher mean pause frequency. Oscillatory activity was present in 33% and 35% of internal pallidum neurons in myoclonus-dystonia and primary-dystonia patients, respectively, predominantly in the theta frequency band (3-8 Hz). In myoclonus-dystonia patients with more severe myoclonus, internal pallidum neurons exhibited a higher bursting activity with high intraburst frequency and lower oscillatory activity frequency. CONCLUSIONS Myoclonus-dystonia appears to be related to specific changes in internal pallidum activity, leading to disruption in striato-pallido-thalamo-cortical circuits. © 2015 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Marie-Laure Welter
- Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle épiniere (CRICM), UMR-S975, Paris, France.,Inserm, U1127, Paris, France.,CNRS, UMR 7225, Paris, France.,Centre d'Investigation Clinique Pitié Neurosciences (Inserm CIC-1422), Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - David Grabli
- Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle épiniere (CRICM), UMR-S975, Paris, France.,Inserm, U1127, Paris, France.,CNRS, UMR 7225, Paris, France.,Centre d'Investigation Clinique Pitié Neurosciences (Inserm CIC-1422), Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Carine Karachi
- Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle épiniere (CRICM), UMR-S975, Paris, France.,Inserm, U1127, Paris, France.,CNRS, UMR 7225, Paris, France.,Centre d'Investigation Clinique Pitié Neurosciences (Inserm CIC-1422), Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Service de Neurochirurgie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Nicolas Jodoin
- Centre d'Investigation Clinique Pitié Neurosciences (Inserm CIC-1422), Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Service de Neurologie, Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Sara Fernandez-Vidal
- Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle épiniere (CRICM), UMR-S975, Paris, France.,Centre de Neuroimagerie de Recherche (CENIR), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Yohann Brun
- Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle épiniere (CRICM), UMR-S975, Paris, France.,Inserm, U1127, Paris, France.,CNRS, UMR 7225, Paris, France
| | - Soledad Navarro
- Service de Neurochirurgie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Alister Rogers
- Service de Neurochirurgie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Philippe Cornu
- Service de Neurochirurgie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bernard Pidoux
- Service de Neurochirurgie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jérôme Yelnik
- Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle épiniere (CRICM), UMR-S975, Paris, France.,Inserm, U1127, Paris, France.,CNRS, UMR 7225, Paris, France.,Centre d'Investigation Clinique Pitié Neurosciences (Inserm CIC-1422), Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Emmanuel Roze
- Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle épiniere (CRICM), UMR-S975, Paris, France.,Inserm, U1127, Paris, France.,CNRS, UMR 7225, Paris, France.,Centre d'Investigation Clinique Pitié Neurosciences (Inserm CIC-1422), Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Eric Bardinet
- Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle épiniere (CRICM), UMR-S975, Paris, France.,Centre de Neuroimagerie de Recherche (CENIR), Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Marie Vidailhet
- Université Pierre et Marie Curie-Paris 6, Centre de Recherche de l'Institut du Cerveau et de la Moelle épiniere (CRICM), UMR-S975, Paris, France.,Inserm, U1127, Paris, France.,CNRS, UMR 7225, Paris, France.,Centre d'Investigation Clinique Pitié Neurosciences (Inserm CIC-1422), Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,Département de Neurologie, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France
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Abstract
The basal ganglia are a series of interconnected subcortical nuclei. The function and dysfunction of these nuclei have been studied intensively in motor control, but more recently our knowledge of these functions has broadened to include prominent roles in cognition and affective control. This review summarizes historical models of basal ganglia function, as well as findings supporting or conflicting with these models, while emphasizing recent work in animals and humans directly testing the hypotheses generated by these models.
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Barow E, Neumann WJ, Brücke C, Huebl J, Horn A, Brown P, Krauss JK, Schneider GH, Kühn AA. Deep brain stimulation suppresses pallidal low frequency activity in patients with phasic dystonic movements. ACTA ACUST UNITED AC 2014; 137:3012-3024. [PMID: 25212852 DOI: 10.1093/brain/awu258] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Deep brain stimulation of the globus pallidus internus alleviates involuntary movements in patients with dystonia. However, the mechanism is still not entirely understood. One hypothesis is that deep brain stimulation suppresses abnormally enhanced synchronized oscillatory activity within the motor cortico-basal ganglia network. Here, we explore deep brain stimulation-induced modulation of pathological low frequency (4-12 Hz) pallidal activity that has been described in local field potential recordings in patients with dystonia. Therefore, local field potentials were recorded from 16 hemispheres in 12 patients undergoing deep brain stimulation for severe dystonia using a specially designed amplifier allowing simultaneous high frequency stimulation at therapeutic parameter settings and local field potential recordings. For coherence analysis electroencephalographic activity (EEG) over motor areas and electromyographic activity (EMG) from affected neck muscles were recorded before and immediately after cessation of high frequency stimulation. High frequency stimulation led to a significant reduction of mean power in the 4-12 Hz band by 24.8 ± 7.0% in patients with predominantly phasic dystonia. A significant decrease of coherence between cortical EEG and pallidal local field potential activity in the 4-12 Hz range was revealed for the time period of 30 s after switching off high frequency stimulation. Coherence between EMG activity and pallidal activity was mainly found in patients with phasic dystonic movements where it was suppressed after high frequency stimulation. Our findings suggest that high frequency stimulation may suppress pathologically enhanced low frequency activity in patients with phasic dystonia. These dystonic features are the quickest to respond to high frequency stimulation and may thus directly relate to modulation of pathological basal ganglia activity, whereas improvement in tonic features may depend on long-term plastic changes within the motor network.
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Affiliation(s)
- Ewgenia Barow
- Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany
| | - Wolf-Julian Neumann
- Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany
| | - Christof Brücke
- Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany
| | - Julius Huebl
- Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany
| | - Andreas Horn
- Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany
| | - Peter Brown
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Joachim K Krauss
- Department of Neurosurgery, Medical University Hannover, MHH, Hannover, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany
| | - Andrea A Kühn
- Department of Neurology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Berlin, Germany
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Thompson JA, Lanctin D, Ince NF, Abosch A. Clinical implications of local field potentials for understanding and treating movement disorders. Stereotact Funct Neurosurg 2014; 92:251-63. [PMID: 25170784 DOI: 10.1159/000364913] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 05/30/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) for the treatment of movement disorders has provided researchers with an opportunity to record electrical oscillatory activity from electrodes implanted in deep brain structures. Extracellular activity recorded from a population of neurons, termed local field potentials (LFPs), has shed light on the pathophysiology of movement disorders and holds the potential to lead to refinement in existing treatments. OBJECTIVE This paper reviews the clinical significance of LFPs recorded from macroelectrodes implanted in basal ganglia and thalamic targets for the treatment of Parkinson's disease, essential tremor and dystonia. METHODS Neural population dynamics and subthreshold events, which are undetectable by single-unit recordings, can be examined with frequency band analysis of LFPs (frequency range: 1-250 Hz). RESULTS Of clinical relevance, reliable correlations between motor symptoms and components of the LFP power spectrum suggest that LFPs may serve as a biomarker for movement disorders. In particular, Parkinson's rigidity has been shown to correlate with the power of beta oscillations (13-30 Hz), and essential tremor coheres with oscillations of 8-27 Hz. Furthermore, evidence indicates that the optimal contacts for DBS programming can be predicted from the anatomic location of beta and gamma bands (48-200 Hz). CONCLUSION LFP analysis has implications for improved electrode targeting and the development of a real-time, individualized, 'closed-loop' stimulation system.
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Affiliation(s)
- John A Thompson
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colo., USA
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48
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McCracken CB, Kiss ZHT. Time and frequency-dependent modulation of local field potential synchronization by deep brain stimulation. PLoS One 2014; 9:e102576. [PMID: 25029468 PMCID: PMC4100931 DOI: 10.1371/journal.pone.0102576] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 06/20/2014] [Indexed: 11/18/2022] Open
Abstract
High-frequency electrical stimulation of specific brain structures, known as deep brain stimulation (DBS), is an effective treatment for movement disorders, but mechanisms of action remain unclear. We examined the time-dependent effects of DBS applied to the entopeduncular nucleus (EP), the rat homolog of the internal globus pallidus, a target used for treatment of both dystonia and Parkinson's disease (PD). We performed simultaneous multi-site local field potential (LFP) recordings in urethane-anesthetized rats to assess the effects of high-frequency (HF, 130 Hz; clinically effective), low-frequency (LF, 15 Hz; ineffective) and sham DBS delivered to EP. LFP activity was recorded from dorsal striatum (STR), ventroanterior thalamus (VA), primary motor cortex (M1), and the stimulation site in EP. Spontaneous and acute stimulation-induced LFP oscillation power and functional connectivity were assessed at baseline, and after 30, 60, and 90 minutes of stimulation. HF EP DBS produced widespread alterations in spontaneous and stimulus-induced LFP oscillations, with some effects similar across regions and others occurring in a region- and frequency band-specific manner. Many of these changes evolved over time. HF EP DBS produced an initial transient reduction in power in the low beta band in M1 and STR; however, phase synchronization between these regions in the low beta band was markedly suppressed at all time points. DBS also enhanced low gamma synchronization throughout the circuit. With sustained stimulation, there were significant reductions in low beta synchronization between M1-VA and STR-VA, and increases in power within regions in the faster frequency bands. HF DBS also suppressed the ability of acute EP stimulation to induce beta oscillations in all regions along the circuit. This dynamic pattern of synchronizing and desynchronizing effects of EP DBS suggests a complex modulation of activity along cortico-BG-thalamic circuits underlying the therapeutic effects of GPi DBS for conditions such as PD and dystonia.
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Affiliation(s)
- Clinton B. McCracken
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Zelma H. T. Kiss
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
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49
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Lee JR, Kiss ZHT. Interhemispheric difference of pallidal local field potential activity in cervical dystonia. J Neurol Neurosurg Psychiatry 2014; 85:306-10. [PMID: 23990682 DOI: 10.1136/jnnp-2013-305476] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Cervical dystonia (CD) produces involuntary neck muscle contractions that result in abnormal and often asymmetrical postures of the head and neck. Basal ganglia oscillatory activity in the 3-12 Hz band correlating with involuntary muscle activity suggests a role in the pathophysiology of primary dystonia. Despite the asymmetrical postures seen with CD, no comparison of interhemispheric differences of pallidal local field potential (LFP) activity has been reported. OBJECTIVE The aim of this study was to examine the interhemispheric differences of LFP power in globus pallidus interna (GPi) in CD patients and compare these with their predominant head excursion identified as torticollis, laterocollis and retrocollis. METHODS LFPs were recorded from bilateral GPi in 11 patients with CD using microelectrodes during deep brain stimulation surgery. LFP power was measured in right and left GPi separately. The mean percentage of total GPi LFP power in 4-30 Hz frequency band on each brain side was determined and related to their predominant CD symptoms. RESULTS Interhemispheric difference in the mean percentage of LFP power in 4-12 Hz and 13-30 Hz band frequencies was found in patients with torticollis and laterocollis regardless of excursion direction. However, patients with retrocollis did not show interhemispheric difference in LFP activity in any band frequency. CONCLUSIONS Interhemispheric differences in synchronisation of pallidal LFP activity in 4-12 Hz and 13-30 Hz bands are related to the CD clinical condition, suggesting that these frequencies are important in the pathophysiology of dystonia.
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Affiliation(s)
- Jung Ryun Lee
- Department of Clinical Neurosciences, Faculty of Medicine, Hotchkiss Brain Institute, University of Calgary, , Calgary, Alberta, Canada
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50
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Moll CKE, Galindo-Leon E, Sharott A, Gulberti A, Buhmann C, Koeppen JA, Biermann M, Bäumer T, Zittel S, Westphal M, Gerloff C, Hamel W, Münchau A, Engel AK. Asymmetric pallidal neuronal activity in patients with cervical dystonia. Front Syst Neurosci 2014; 8:15. [PMID: 24574981 PMCID: PMC3920073 DOI: 10.3389/fnsys.2014.00015] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/23/2014] [Indexed: 11/24/2022] Open
Abstract
The origin of asymmetric clinical manifestation of symptoms in patients suffering from cervical dystonia (CD) is hitherto poorly understood. Dysregulated neuronal activity in the basal ganglia has been suggested to have a role in the pathophysiology of CD. Here, we re-assessed the question to what extent relative changes occur in the direct vs. indirect basal ganglia pathway in CD, whether these circuit changes are lateralized, and how these alterations relate to CD symptoms. To this end, we recorded ongoing single cell and local field potential (LFP) activity from the external (GPe) and internal pallidal segment (GPi) of 13 CD patients undergoing microelectrode-guided stereotactic surgery for deep brain stimulation in the GPi. We compared pallidal recordings from CD patients operated under local anaesthesia (LA) with those obtained in CD patients operated under general anaesthesia (GA). In awake patients, mean GPe discharge rate (52 Hz) was lower than that of GPi (72 Hz). Mean GPi discharge ipsilateral to the side of head turning was higher than contralateral and correlated with torticollis symptom severity. Lateralized differences were absent at the level of the GPe and in recordings from patients operated under GA. Furthermore, in the GPi of CD patients there was a subpopulation of theta-oscillatory cells with unique bursting characteristics. Power and coherence of GPe– and GPi–LFPs were dominated by a theta peak and also exhibited band-specific interhemispheric differences. Strong cross-frequency coupling of low-gamma amplitude to theta phase was a feature of pallidal LFPs recorded under LA, but not GA. These results indicate that CD is associated with an asymmetric pallidal outflow. Based on the finding of symmetric neuronal discharges in the GPe, we propose that an imbalanced interhemispheric direct pathway gain may be involved in CD pathophysiology.
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Affiliation(s)
- Christian K E Moll
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Edgar Galindo-Leon
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Andrew Sharott
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany ; Medical Research Council Anatomical Neuropharmacology Unit, Department of Pharmacology, University of Oxford Oxford, UK
| | - Alessandro Gulberti
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Johannes A Koeppen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Maxine Biermann
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Tobias Bäumer
- Department of Paediatric and Adult Movement Disorders and Neuropsychiatry, Institute of Neurology, University Medical Center Schleswig-Holstein Lübeck, Germany
| | - Simone Zittel
- Department of Paediatric and Adult Movement Disorders and Neuropsychiatry, Institute of Neurology, University Medical Center Schleswig-Holstein Lübeck, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf Hamburg, Germany
| | - Alexander Münchau
- Department of Paediatric and Adult Movement Disorders and Neuropsychiatry, Institute of Neurology, University Medical Center Schleswig-Holstein Lübeck, Germany
| | - Andreas K Engel
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf Hamburg, Germany
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