1
|
Andrews L, Keller SS, Osman-Farah J, Macerollo A. A structural magnetic resonance imaging review of clinical motor outcomes from deep brain stimulation in movement disorders. Brain Commun 2023; 5:fcad171. [PMID: 37304793 PMCID: PMC10257440 DOI: 10.1093/braincomms/fcad171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 04/05/2023] [Accepted: 05/30/2023] [Indexed: 06/13/2023] Open
Abstract
Patients with movement disorders treated by deep brain stimulation do not always achieve successful therapeutic alleviation of motor symptoms, even in cases where surgery is without complications. Magnetic resonance imaging (MRI) offers methods to investigate structural brain-related factors that may be predictive of clinical motor outcomes. This review aimed to identify features which have been associated with variability in clinical post-operative motor outcomes in patients with Parkinson's disease, dystonia, and essential tremor from structural MRI modalities. We performed a literature search for articles published between 1 January 2000 and 1 April 2022 and identified 5197 articles. Following screening through our inclusion criteria, we identified 60 total studies (39 = Parkinson's disease, 11 = dystonia syndromes and 10 = essential tremor). The review captured a range of structural MRI methods and analysis techniques used to identify factors related to clinical post-operative motor outcomes from deep brain stimulation. Morphometric markers, including volume and cortical thickness were commonly identified in studies focused on patients with Parkinson's disease and dystonia syndromes. Reduced metrics in basal ganglia, sensorimotor and frontal regions showed frequent associations with reduced motor outcomes. Increased structural connectivity to subcortical nuclei, sensorimotor and frontal regions was also associated with greater motor outcomes. In patients with tremor, increased structural connectivity to the cerebellum and cortical motor regions showed high prevalence across studies for greater clinical motor outcomes. In addition, we highlight conceptual issues for studies assessing clinical response with structural MRI and discuss future approaches towards optimizing individualized therapeutic benefits. Although quantitative MRI markers are in their infancy for clinical purposes in movement disorder treatments, structural features obtained from MRI offer the powerful potential to identify candidates who are more likely to benefit from deep brain stimulation and provide insight into the complexity of disorder pathophysiology.
Collapse
Affiliation(s)
- Luke Andrews
- Correspondence to: Luke Andrews The BRAIN Lab, University of Liverpool Cancer Research Centre 200 London Rd, Liverpool L3 9TA, United Kingdom E-mail:
| | - Simon S Keller
- The Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L3 9TA, UK
| | - Jibril Osman-Farah
- Department of Neurology and Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool L97LJ, UK
| | - Antonella Macerollo
- Correspondence may also be sent to: Antonella Macerollo. The Walton Centre NHS Trust, Lower Lane Liverpool L9 7LJ, United Kingdom E-mail:
| |
Collapse
|
2
|
Baláž M, Búřil J, Jurková T, Koriťáková E, Hrabovský D, Kunst J, Bártová P, Chrastina J. Intraoperative electrophysiological monitoring determines the final electrode position for pallidal stimulation in dystonia patients. Front Surg 2023; 10:1206721. [PMID: 37284558 PMCID: PMC10239835 DOI: 10.3389/fsurg.2023.1206721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 05/10/2023] [Indexed: 06/08/2023] Open
Abstract
Background Bilateral deep brain stimulation (DBS) of the globus pallidus internus (GPi) is an effective treatment for refractory dystonia. Neuroradiological target and stimulation electrode trajectory planning with intraoperative microelectrode recordings (MER) and stimulation are used. With improving neuroradiological techniques, the need for MER is in dispute mainly because of the suspected risk of hemorrhage and the impact on clinical post DBS outcome. Objective The aim of the study is to compare the preplanned GPi electrode trajectories with final trajectories selected for electrode implantation after electrophysiological monitoring and to discuss the factors potentially responsible for differences between preplanned and final trajectories. Finally, the potential association between the final trajectory selected for electrode implantation and clinical outcome will be analyzed. Methods Forty patients underwent bilateral GPi DBS (right-sided implants first) for refractory dystonia. The relationship between preplanned and final trajectories (MicroDrive system) was correlated with patient (gender, age, dystonia type and duration) and surgery characteristics (anesthesia type, postoperative pneumocephalus) and clinical outcome measured using CGI (Clinical Global Impression parameter). The correlation between the preplanned and final trajectories together with CGI was compared between patients 1-20 and 21-40 for the learning curve effect. Results The trajectory selected for definitive electrode implantation matched the preplanned trajectory in 72.5% and 70% on the right and left side respectively; 55% had bilateral definitive electrodes implanted along the preplanned trajectories. Statistical analysis did not confirm any of the studied factors as predictor of the difference between the preplanned and final trajectories. Also no association between CGI and final trajectory selected for electrode implantation in the right/left hemisphere has been proven. The percentages of final electrodes implanted along the preplanned trajectory (the correlation between anatomical planning and intraoperative electrophysiology results) did not differ between patients 1-20 and 21-40. Similarly, there were no statistically significant differences in CGI (clinical outcome) between patients 1-20 and 21-40. Conclusion The final trajectory selected after electrophysiological study differed from the preplanned trajectory in a significant percentage of patients. No predictor of this difference was identified. The anatomo-electrophysiological difference was not predictive of the clinical outcome (as measured using CGI parameter).
Collapse
Affiliation(s)
- Marek Baláž
- First Department of Neurology, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jiří Búřil
- First Department of Neurology, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Tereza Jurková
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Eva Koriťáková
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Dušan Hrabovský
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Jonáš Kunst
- First Department of Neurology, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Petra Bártová
- Department of Neurology, Faculty Hospital Ostrava, Ostrava, Czechia
| | - Jan Chrastina
- Department of Neurosurgery, St. Anne’s University Hospital Brno, Faculty of Medicine, Masaryk University, Brno, Czechia
| |
Collapse
|
3
|
Poulen G, Rolland A, Chan-Seng E, Sanrey E, Gélisse P, Crespel A, Coubes P. Microendoscopic transventricular deep brain stimulation of the anterior nucleus of the thalamus as a safe treatment in intractable epilepsy: A feasibility study. Rev Neurol (Paris) 2022; 178:886-895. [PMID: 36153255 DOI: 10.1016/j.neurol.2022.03.023] [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: 12/06/2021] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Deep brain stimulation (DBS) of the anterior nucleus of the thalamus (ANT) is proposed in patients with severe intractable epilepsy. When used, the transventricular approach increases the risk of bleeding due the anatomy around the entry point in the thalamus. To avoid such a complication, we used a transventricular microendoscopic technique. METHODS We performed a retrospective study of nine adult patients who were surgically treated for refractory epilepsy between 2010 and 2019 by DBS of the anterior thalamic nucleus. RESULTS Endoscopy provides a direct visual control of the entry point of the lead in the thalamus through the ventricle by avoiding ependymal vessels. No hemorrhage was recorded and accuracy was systematically checked by intraoperative stereotactic MRI. We reported a responder rate improvement in 88.9% of patients at 1 year and in 87.5% at 2 years. We showed a significant decrease in global seizure count per month one year after DBS (68.1%; P=0.013) leading to an overall improvement in quality of life. No major adverse effect was recorded during the follow-up. ANT DBS showed a prominent significant effect with a decrease of the number of generalized seizures. CONCLUSION We aimed at a better ANT/lead collimation using a vertical transventricular approach under microendoscopic monitoring. This technique permitted to demonstrate the safety and the accuracy of the procedure.
Collapse
Affiliation(s)
- G Poulen
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France.
| | - A Rolland
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| | - E Chan-Seng
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| | - E Sanrey
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| | - P Gélisse
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| | - A Crespel
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| | - P Coubes
- Unité "Pathologies cérébrales résistantes", department of neurosurgery, Montpellier university hospital, Montpellier, France; Unité de recherche sur les comportements et mouvements anormaux, department of neurosurgery, Montpellier university hospital, Montpellier, France
| |
Collapse
|
4
|
da Silva Lapa JD, Godinho FLF, Teixeira MJ, Listik C, Iglesio RF, Duarte KP, Cury RG. Should the Globus Pallidus Targeting Be Refined in Dystonia? J Neurol Surg A Cent Eur Neurosurg 2021; 83:361-367. [PMID: 34808675 DOI: 10.1055/s-0041-1735856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND STUDY AIMS Deep brain stimulation (DBS) of the globus pallidus internus (GPi) is a highly effective therapy for primary generalized and focal dystonias, but therapeutic success is compromised by a nonresponder rate of up to 20%. Variability in electrode placement and in tissue stimulated inside the GPi may explain in part different outcomes among patients. Refinement of the target within the pallidal area could be helpful for surgery planning and clinical outcomes. The objective of this study was to discuss current and potential methodological (somatotopy, neuroimaging, and neurophysiology) aspects that might assist neurosurgical targeting of the GPi, aiming to treat generalized or focal dystonia. METHODS We selected published studies by searching electronic databases and scanning the reference lists for articles that examined the anatomical and electrophysiologic aspects of the GPi in patients with idiopathic/inherited dystonia who underwent functional neurosurgical procedures. RESULTS The sensorimotor sector of the GPi was the best target to treat dystonic symptoms, and was localized at its lateral posteroventral portion. The effective volume of tissue activated (VTA) to treat dystonia had a mean volume of 153 mm3 in the posterior GPi area. Initial tractography studies evaluated the close relation between the electrode localization and pallidothalamic tract to control dystonic symptoms.Regarding the somatotopy, the more ventral, lateral, and posterior areas of the GPi are associated with orofacial and cervical representation. In contrast, the more dorsal, medial, and anterior areas are associated with the lower limbs; between those areas, there is the representation of the upper limb. Excessive pallidal synchronization has a peak at the theta band of 3 to 8 Hz, which might be responsible for generating dystonic symptoms. CONCLUSIONS Somatotopy assessment of posteroventral GPi contributes to target-specific GPi sectors related to segmental body symptoms. Tractography delineates GPi output pathways that might guide electrode implants, and electrophysiology might assist in pointing out areas of excessive theta synchronization. Finally, the identification of oscillatory electrophysiologic features that correlate with symptoms might enable closed-loop approaches in the future.
Collapse
Affiliation(s)
- Jorge Dornellys da Silva Lapa
- Neurosurgery Unit, Fundação de Beneficiência Hospital de Cirurgia, Cirurgia, Aracaju, Sergipe, Brazil.,Division of Functional Neurosurgery, Department of Neurology, University of São Paulo, School of Medicine, Sao Paulo, São Paulo, Brazil
| | - Fábio Luiz Franceschi Godinho
- Division of Functional Neurosurgery, Department of Neurology, University of São Paulo, School of Medicine, Sao Paulo, São Paulo, Brazil
| | | | - Clarice Listik
- Movement Disorders Center, Department of Neurology, School of Medicine, University of Sao Paulo, Sao Paulo, São Paulo, Brazil
| | - Ricardo Ferrareto Iglesio
- Division of Functional Neurosurgery, Department of Neurology, University of São Paulo, School of Medicine, Sao Paulo, São Paulo, Brazil
| | - Kleber Paiva Duarte
- Division of Functional Neurosurgery, Department of Neurology, University of São Paulo, School of Medicine, Sao Paulo, São Paulo, Brazil
| | - Rubens Gisbert Cury
- Movement Disorders Center, Department of Neurology, School of Medicine, University of Sao Paulo, Sao Paulo, São Paulo, Brazil
| |
Collapse
|
5
|
Au KLK, Wong JK, Tsuboi T, Eisinger RS, Moore K, Lemos Melo Lobo Jofili Lopes J, Holland MT, Holanda VM, Peng-Chen Z, Patterson A, Foote KD, Ramirez-Zamora A, Okun MS, Almeida L. Globus Pallidus Internus (GPi) Deep Brain Stimulation for Parkinson's Disease: Expert Review and Commentary. Neurol Ther 2021; 10:7-30. [PMID: 33140286 PMCID: PMC8140010 DOI: 10.1007/s40120-020-00220-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 10/08/2020] [Indexed: 01/20/2023] Open
Abstract
INTRODUCTION The globus pallidus internus (GPi) region has evolved as a potential target for deep brain stimulation (DBS) in Parkinson's disease (PD). DBS of the GPi (GPi DBS) is an established, safe and effective method for addressing many of the motor symptoms associated with advanced PD. It is important that clinicians fully understand this target when considering GPi DBS for individual patients. METHODS The literature on GPi DBS in PD has been comprehensively reviewed, including the anatomy, physiology and potential pitfalls that may be encountered during surgical targeting and post-operative management. Here, we review and address the implications of lead location on GPi DBS outcomes. Additionally, we provide a summary of randomized controlled clinical trials conducted on DBS in PD, together with expert commentary on potential applications of the GPi as target. Finally, we highlight future technologies that will likely impact GPi DBS, including closed-loop adaptive approaches (e.g. sensing-stimulating capabilities), advanced methods for image-based targeting and advances in DBS programming, including directional leads and pulse shaping. RESULTS There are important disease characteristics and factors to consider prior to selecting the GPi as the DBS target of PD surgery. Prior to and during implantation of the leads it is critical to consider the neuroanatomy, which can be defined through the combination of image-based targeting and intraoperative microelectrode recording strategies. There is an increasing body of literature on GPi DBS in patients with PD suggesting both short- and long-term benefits. Understanding the GPi target can be useful in choosing between the subthalamic (STN), GPi and ventralis intermedius nucleus as lead locations to address the motor symptoms and complications of PD. CONCLUSION GPi DBS can be effectively used in select cases of PD. As the ongoing DBS target debate continues (GPi vs. STN as DBS target), clinicians should keep in mind that GPi DBS has been shown to be an effective treatment strategy for a variety of symptoms, including bradykinesia, rigidity and tremor control. GPi DBS also has an important, direct anti-dyskinetic effect. GPi DBS is easier to program in the outpatient setting and will allow for more flexibility in medication adjustments (e.g. levodopa). Emerging technologies, including GPi closed-loop systems, advanced tractography-based targeting and enhanced programming strategies, will likely be future areas of GPi DBS expansion. We conclude that although the GPi as DBS target may not be appropriate for all PD patients, it has specific clinical advantages.
Collapse
Affiliation(s)
- Ka Loong Kelvin Au
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
| | - Joshua K Wong
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Takashi Tsuboi
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Robert S Eisinger
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Kathryn Moore
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | | | - Marshall T Holland
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
- Department of Neurosurgery, University of Iowa, Iowa City, IA, USA
| | - Vanessa M Holanda
- Center of Neurology and Neurosurgery Associates (CENNA), Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Department of Neurosurgery, Mayo Clinic Jackonsville, Jacksonville, FL, USA
| | - Zhongxing Peng-Chen
- Facultad de Medicina Clínica Alemana, Hospital Padre Hurtado-Universidad del Desarrollo, Santiago, Chile
| | - Addie Patterson
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Kelly D Foote
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Adolfo Ramirez-Zamora
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Leonardo Almeida
- Departments of Neurology and Neurosurgery, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA.
| |
Collapse
|
6
|
Mulroy E, Vijiaratnam N, De Roquemaurel A, Bhatia KP, Zrinzo L, Foltynie T, Limousin P. A practical guide to troubleshooting pallidal deep brain stimulation issues in patients with dystonia. Parkinsonism Relat Disord 2021; 87:142-154. [PMID: 34074583 DOI: 10.1016/j.parkreldis.2021.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 04/18/2021] [Accepted: 05/19/2021] [Indexed: 11/17/2022]
Abstract
High frequency deep brain stimulation (DBS) of the internal portion of the globus pallidus has, in the last two decades, become a mainstream therapy for the management of medically-refractory dystonia syndromes. Such increasing uptake places an onus on movement disorder physicians to become familiar with this treatment modality, in particular optimal patient selection for the procedure and how to troubleshoot problems relating to sub-optimal efficacy and therapy-related side effects. Deep brain stimulation for dystonic conditions presents some unique challenges. For example, the frequent lack of immediate change in clinical status following stimulation alterations means that programming often relies on personal experience and local practice rather than real-time indicators of efficacy. Further, dystonia is a highly heterogeneous disorder, making the development of unifying guidelines and programming algorithms for DBS in this population difficult. Consequently, physicians may feel less confident in managing DBS for dystonia as compared to other indications e.g. Parkinson's disease. In this review, we integrate our years of personal experience of the programming of DBS systems for dystonia with a critical appraisal of the literature to produce a practical guide for troubleshooting common issues encountered in patients with dystonia treated with DBS, in the hope of improving the care for these patients.
Collapse
Affiliation(s)
- Eoin Mulroy
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK.
| | - Nirosen Vijiaratnam
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Alexis De Roquemaurel
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Kailash P Bhatia
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Ludvic Zrinzo
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Thomas Foltynie
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| | - Patricia Limousin
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology, London, WC1N 3BG, UK
| |
Collapse
|
7
|
Macerollo A, Sajin V, Bonello M, Barghava D, Alusi SH, Eldridge PR, Osman-Farah J. Deep brain stimulation in dystonia: State of art and future directions. J Neurosci Methods 2020; 340:108750. [DOI: 10.1016/j.jneumeth.2020.108750] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 04/19/2020] [Accepted: 04/20/2020] [Indexed: 01/03/2023]
|
8
|
Reich MM, Horn A, Lange F, Roothans J, Paschen S, Runge J, Wodarg F, Pozzi NG, Witt K, Nickl RC, Soussand L, Ewert S, Maltese V, Wittstock M, Schneider GH, Coenen V, Mahlknecht P, Poewe W, Eisner W, Helmers AK, Matthies C, Sturm V, Isaias IU, Krauss JK, Kühn AA, Deuschl G, Volkmann J. Probabilistic mapping of the antidystonic effect of pallidal neurostimulation: a multicentre imaging study. Brain 2020; 142:1386-1398. [PMID: 30851091 DOI: 10.1093/brain/awz046] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 12/12/2018] [Accepted: 01/08/2019] [Indexed: 11/13/2022] Open
Abstract
Deep brain stimulation of the internal globus pallidus is a highly effective and established therapy for primary generalized and cervical dystonia, but therapeutic success is compromised by a non-responder rate of up to 25%, even in carefully-selected groups. Variability in electrode placement and inappropriate stimulation settings may account for a large proportion of this outcome variability. Here, we present probabilistic mapping data on a large cohort of patients collected from several European centres to resolve the optimal stimulation volume within the pallidal region. A total of 105 dystonia patients with pallidal deep brain stimulation were enrolled and 87 datasets (43 with cervical dystonia and 44 with generalized dystonia) were included into the subsequent 'normative brain' analysis. The average improvement of dystonia motor score was 50.5 ± 30.9% in cervical and 58.2 ± 48.8% in generalized dystonia, while 19.5% of patients did not respond to treatment (<25% benefit). We defined probabilistic maps of anti-dystonic effects by aggregating individual electrode locations and volumes of tissue activated (VTA) in normative atlas space and ranking voxel-wise for outcome distribution. We found a significant relation between motor outcome and the stimulation volume, but not the electrode location per se. The highest probability of stimulation induced motor benefit was found in a small volume covering the ventroposterior globus pallidus internus and adjacent subpallidal white matter. We then used the aggregated VTA-based outcome maps to rate patient individual VTAs and trained a linear regression model to predict individual outcomes. The prediction model showed robustness between the predicted and observed clinical improvement, with an r2 of 0.294 (P < 0.0001). The predictions deviated on average by 16.9 ± 11.6 % from observed dystonia improvements. For example, if a patient improved by 65%, the model would predict an improvement between 49% and 81%. Results were validated in an independent cohort of 10 dystonia patients, where prediction and observed benefit had a correlation of r2 = 0.52 (P = 0.02) and a mean prediction error of 10.3% (±8.9). These results emphasize the potential of probabilistic outcome brain mapping in refining the optimal therapeutic volume for pallidal neurostimulation and advancing computer-assisted planning and programming of deep brain stimulation.
Collapse
Affiliation(s)
- Martin M Reich
- Julius-Maximilians-University Würzburg, Department of Neurology, Germany.,Beth Israel Deaconess Medical Center, Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Andreas Horn
- Charite-Universitätsmedizin Berlin, Movement Disorders and Neuromodulation Unit, Department of Neurology, Germany
| | - Florian Lange
- Julius-Maximilians-University Würzburg, Department of Neurology, Germany
| | - Jonas Roothans
- Julius-Maximilians-University Würzburg, Department of Neurology, Germany
| | | | | | - Fritz Wodarg
- University Kiel, Department of Radiology, Germany
| | - Nicolo G Pozzi
- Julius-Maximilians-University Würzburg, Department of Neurology, Germany
| | - Karsten Witt
- University Kiel, Department of Neurology, Germany.,University Oldenburg, Department of Neurology, Germany
| | - Robert C Nickl
- Julius-Maximilians-University, Department of Neurosurgery, Germany
| | - Louis Soussand
- Beth Israel Deaconess Medical Center, Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Siobhan Ewert
- Charite-Universitätsmedizin Berlin, Movement Disorders and Neuromodulation Unit, Department of Neurology, Germany
| | - Virgina Maltese
- Julius-Maximilians-University Würzburg, Department of Neurology, Germany
| | | | - Gerd-Helge Schneider
- Charite-Universitätsmedizin Berlin, Movement Disorders and Neuromodulation Unit, Department of Neurology, Germany
| | - Volker Coenen
- Freiburg University Medical Center, Department of Stereotactic and Functional Neurosurgery, Germany
| | | | - Werner Poewe
- Department of Neurology, Innsbruck Medical University, Austria
| | - Wilhelm Eisner
- Department of Neurosurgery, Innsbruck Medical University, Austria
| | | | - Cordula Matthies
- Julius-Maximilians-University, Department of Neurosurgery, Germany
| | - Volker Sturm
- Julius-Maximilians-University, Department of Neurosurgery, Germany
| | - Ioannis U Isaias
- Julius-Maximilians-University Würzburg, Department of Neurology, Germany
| | | | - Andrea A Kühn
- Charite-Universitätsmedizin Berlin, Movement Disorders and Neuromodulation Unit, Department of Neurology, Germany
| | | | - Jens Volkmann
- Julius-Maximilians-University Würzburg, Department of Neurology, Germany
| |
Collapse
|
9
|
Parkinsonian Beta Dynamics during Rest and Movement in the Dorsal Pallidum and Subthalamic Nucleus. J Neurosci 2020; 40:2859-2867. [PMID: 32107277 DOI: 10.1523/jneurosci.2113-19.2020] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 02/16/2020] [Accepted: 02/19/2020] [Indexed: 11/21/2022] Open
Abstract
In Parkinson's disease (PD), pathologically high levels of beta activity (12-30 Hz) reflect specific symptomatology and normalize with pharmacological or surgical intervention. Although beta characterization in the subthalamic nucleus (STN) of PD patients undergoing deep brain stimulation (DBS) has now been translated into adaptive DBS paradigms, a limited number of studies have characterized beta power in the globus pallidus internus (GPi), an equally effective DBS target. Our objective was to compare beta power in the STN and GPi during rest and movement in people with PD undergoing DBS. Thirty-seven human female and male participants completed a simple behavioral experiment consisting of periods of rest and button presses, leading to local field potential recordings from 19 (15 participants) STN and 26 (22 participants) GPi nuclei. We examined overall beta power as well as beta time-domain dynamics (i.e., beta bursts). We found higher beta power during rest and movement in the GPi, which also had more beta desynchronization during movement. Beta power was positively associated with bradykinesia and rigidity severity; however, these clinical associations were present only in the GPi cohort. With regards to beta dynamics, bursts were similar in duration and frequency in the GPi and STN, but GPi bursts were stronger and correlated to bradykinesia-rigidity severity. Beta dynamics therefore differ across basal ganglia nuclei. Relative to the STN, beta power in the GPi may be readily detected, modulates more with movement, and relates more to clinical impairment. Together, this could point to the GPi as a potentially effective target for beta-based adaptive DBS.SIGNIFICANCE STATEMENT It is known that subthalamic nucleus (STN) beta activity is linked to symptom severity in Parkinson's disease (PD), but few studies have characterized beta activity in the globus pallidus internus (GPi), another effective target for deep brain stimulation (DBS). We compared beta power in the STN and GPi during rest and movement in 37 people with PD undergoing DBS. We found that beta dynamics differed across basal ganglia nuclei. Our results show that, relative to the STN, beta power in the GPi may be readily detected, modulates more with movement, and relates more to clinical impairment. Together, this could point to the GPi as a potentially effective target for beta-based adaptive DBS.
Collapse
|
10
|
Zittel S, Hidding U, Trumpfheller M, Baltzer VL, Gulberti A, Schaper M, Biermann M, Buhmann C, Engel AK, Gerloff C, Westphal M, Stadler J, Köppen JA, Pötter-Nerger M, Moll CKE, Hamel W. Pallidal lead placement in dystonia: leads of non-responders are contained within an anatomical range defined by responders. J Neurol 2020; 267:1663-1671. [PMID: 32067124 PMCID: PMC7293687 DOI: 10.1007/s00415-020-09753-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 01/10/2023]
Abstract
Background Deep brain stimulation (DBS) within the pallidum represents an effective and well-established treatment for isolated dystonia. However, clinical outcome after surgery may be variable with limited response in 10–25% of patients. The effect of lead location on clinical improvement is still under debate. Objective To identify stimulated brain regions associated with the most beneficial clinical outcome in dystonia patients. Methods 18 patients with cervical and generalized dystonia with chronic DBS of the internal pallidum were investigated. Patients were grouped according to their clinical improvement into responders, intermediate responders and non-responders. Magnetic resonance and computed tomography images were co-registered, and the volume of tissue activated (VTA) with respect to the pallidum of individual patients was analysed. Results VTAs in responders (n = 11), intermediate responders (n = 3) and non-responders (n = 4) intersected with the posterior internal (GPi) and external (GPe) pallidum and the subpallidal area. VTA heat maps showed an almost complete overlap of VTAs of responders, intermediate and non-responders. VTA coverage of the GPi was not higher in responders. In contrast, VTAs of intermediate and non-responders covered the GPi to a significantly larger extent in the left hemisphere (p < 0.01). Conclusions DBS of ventral parts of the posterior GPi, GPe and the adjacent subpallidal area containing pallidothalamic output projections resulted in favourable clinical effects. Of note, non-responders were also stimulated within the same area. This suggests that factors other than mere lead location (e.g., clinical phenotype, genetic background) have determined clinical outcome in the present cohort. Electronic supplementary material The online version of this article (10.1007/s00415-020-09753-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Simone Zittel
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Ute Hidding
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Alessandro Gulberti
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miriam Schaper
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxine Biermann
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas K Engel
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Johannes A Köppen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K E Moll
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
11
|
|
12
|
Patriat R, Cooper SE, Duchin Y, Niederer J, Lenglet C, Aman J, Park MC, Vitek JL, Harel N. Individualized tractography-based parcellation of the globus pallidus pars interna using 7T MRI in movement disorder patients prior to DBS surgery. Neuroimage 2018; 178:198-209. [PMID: 29787868 PMCID: PMC6046264 DOI: 10.1016/j.neuroimage.2018.05.048] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/26/2018] [Accepted: 05/19/2018] [Indexed: 11/19/2022] Open
Abstract
The success of deep brain stimulation (DBS) surgeries for the treatment of movement disorders relies on the accurate placement of an electrode within the motor portion of subcortical brain targets. However, the high number of electrodes requiring relocation indicates that today's methods do not ensure sufficient accuracy for all patients. Here, with the goal of aiding DBS targeting, we use 7 Tesla (T) MRI data to identify the functional territories and parcellate the globus pallidus pars interna (GPi) into motor, associative and limbic regions in individual subjects. 7 T MRI scans were performed in seventeen patients (prior to DBS surgery) and one healthy control. Tractography-based parcellation of each patient's GPi was performed. The cortex was divided into four masks representing motor, limbic, associative and "other" regions. Given that no direct connections between the GPi and the cortex have been shown to exist, the parcellation was carried out in two steps: 1) The thalamus was parcellated based on the cortical targets, 2) The GPi was parcellated using the thalamus parcels derived from step 1. Reproducibility, via repeated scans of a healthy subject, and validity of the findings, using different anatomical pathways for parcellation, were assessed. Lastly, post-operative imaging data was used to validate and determine the clinical relevance of the parcellation. The organization of the functional territories of the GPi observed in our individual patient population agrees with that previously reported in the literature: the motor territory was located posterolaterally, followed anteriorly by the associative region, and further antero-ventrally by the limbic territory. While this organizational pattern was observed across patients, there was considerable variability among patients. The organization of the functional territories of the GPi was remarkably reproducible in intra-subject scans. Furthermore, the organizational pattern was observed consistently by performing the parcellation of the GPi via the thalamus and via a different pathway, going through the striatum. Finally, the active therapeutic contact of the DBS electrode, identified with a combination of post-operative imaging and post-surgery DBS programming, overlapped with the high-probability "motor" region of the GPi as defined by imaging-based methods. The consistency, validity, and clinical relevance of our findings have the potential for improving DBS targeting, by increasing patient-specific knowledge of subregions of the GPi to be targeted or avoided, at the stage of surgical planning, and later, at the stage when stimulation is adjusted.
Collapse
Affiliation(s)
- Rémi Patriat
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, United States.
| | - Scott E Cooper
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States
| | - Yuval Duchin
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, United States
| | - Jacob Niederer
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, United States
| | - Christophe Lenglet
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, United States
| | - Joshua Aman
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States
| | - Michael C Park
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States; Department of Neurosurgery, University of Minnesota, Minneapolis, MN, United States
| | - Jerrold L Vitek
- Department of Neurology, University of Minnesota, Minneapolis, MN, United States
| | - Noam Harel
- Center for Magnetic Resonance Research, Department of Radiology, University of Minnesota, Minneapolis, MN, United States; Department of Neurosurgery, University of Minnesota, Minneapolis, MN, United States
| |
Collapse
|
13
|
Cury RG, Kalia SK, Shah BB, Jimenez-Shahed J, Prashanth LK, Moro E. Surgical treatment of dystonia. Expert Rev Neurother 2018; 18:477-492. [PMID: 29781334 DOI: 10.1080/14737175.2018.1478288] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Treatment of dystonia should be individualized and tailored to the specific needs of patients. Surgical treatment is an important option in medically refractory cases. Several issues regarding type of the surgical intervention, targets, and predict factors of benefit are still under debate. Areas covered: To date, several clinical trials have proven the benefit and safety of deep brain stimulation (DBS) for inherited and idiopathic isolated dystonia, whereas there is still insufficient evidence in combined and acquired dystonia. The globus pallidus internus (GPi) is the target with the best evidence, but data on the subthalamic nucleus seems also to be promising. Evidence suggests that younger patients with shorter disease duration experience greater benefit following DBS. Pallidotomy and thalamotomy are currently used in subset of carefully selected patients. The development of MRI-guided focused ultrasound might bring new options to ablation approach in dystonia. Expert commentary: GPi-DBS is effective and safe in isolated dystonia and should not be delayed when symptoms compromise quality of life and functionality. Identifying the best candidates to surgery on acquired and combined dystonias is still necessary. New insights about pathophysiology of dystonia and new technological advances will undoubtedly help to tailor surgery and optimize clinical effects.
Collapse
Affiliation(s)
- Rubens Gisbert Cury
- a Service de Neurologie, Centre Hospitalier Universitaire de Grenoble , Université Grenoble Alpes , Grenoble , France.,b Department of Neurology, School of Medicine , University of São Paulo , São Paulo , Brazil
| | - Suneil Kumar Kalia
- c Division of Neurosurgery and Krembil Research Institute, Department of Surgery , University of Toronto , Toronto , Canada
| | - Binit Bipin Shah
- d Parkinson's Disease and Movement Disorders Center, Department of Neurology , University of Virginia , Charlottesville , VA , USA
| | - Joohi Jimenez-Shahed
- e Parkinson's Disease Center and Movement Disorders Clinic , Baylor College of Medicine , Houston , TX , USA
| | | | - Elena Moro
- a Service de Neurologie, Centre Hospitalier Universitaire de Grenoble , Université Grenoble Alpes , Grenoble , France
| |
Collapse
|
14
|
Waugh JL, Kuster JK, Levenstein JM, Makris N, Multhaupt-Buell TJ, Sudarsky LR, Breiter HC, Sharma N, Blood AJ. Thalamic Volume Is Reduced in Cervical and Laryngeal Dystonias. PLoS One 2016; 11:e0155302. [PMID: 27171035 PMCID: PMC4865047 DOI: 10.1371/journal.pone.0155302] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 04/27/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Dystonia, a debilitating movement disorder characterized by abnormal fixed positions and/or twisting postures, is associated with dysfunction of motor control networks. While gross brain lesions can produce secondary dystonias, advanced neuroimaging techniques have been required to identify network abnormalities in primary dystonias. Prior neuroimaging studies have provided valuable insights into the pathophysiology of dystonia, but few directly assessed the gross volume of motor control regions, and to our knowledge, none identified abnormalities common to multiple types of idiopathic focal dystonia. METHODS We used two gross volumetric segmentation techniques and one voxelwise volumetric technique (voxel based morphometry, VBM) to compare regional volume between matched healthy controls and patients with idiopathic primary focal dystonia (cervical, n = 17, laryngeal, n = 7). We used (1) automated gross volume measures of eight motor control regions using the FreeSurfer analysis package; (2) blinded, anatomist-supervised manual segmentation of the whole thalamus (also gross volume); and (3) voxel based morphometry, which measures local T1-weighted signal intensity and estimates gray matter density or volume at the level of single voxels, for both whole-brain and thalamus. RESULTS Using both automated and manual gross volumetry, we found a significant volume decrease only in the thalamus in two focal dystonias. Decreases in whole-thalamic volume were independent of head and brain size, laterality of symptoms, and duration. VBM measures did not differ between dystonia and control groups in any motor control region. CONCLUSIONS Reduced thalamic gross volume, detected in two independent analyses, suggests a common anatomical abnormality in cervical dystonia and spasmodic dysphonia. Defining the structural underpinnings of dystonia may require such complementary approaches.
Collapse
Affiliation(s)
- Jeff L. Waugh
- Mood and Motor Control Laboratory, Massachusetts General Hospital, Charlestown, MA, United States of America
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Division of Child Neurology, Boston Children’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Athinoula A. Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States of America
- * E-mail:
| | - John K. Kuster
- Mood and Motor Control Laboratory, Massachusetts General Hospital, Charlestown, MA, United States of America
- Laboratory of Neuroimaging and Genetics, Massachusetts General Hospital, Charlestown, MA, United States of America
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
- Athinoula A. Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States of America
| | - Jacob M. Levenstein
- Mood and Motor Control Laboratory, Massachusetts General Hospital, Charlestown, MA, United States of America
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
- Athinoula A. Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States of America
| | - Nikos Makris
- Center for Morphometric Analysis, Massachusetts General Hospital, Charlestown, MA, United States of America
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
- Psychiatry Neuroimaging Laboratory, Brigham and Women’s Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Athinoula A. Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States of America
| | | | - Lewis R. Sudarsky
- Department of Neurology, Brigham and Women’s Hospital, Boston MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Hans C. Breiter
- Mood and Motor Control Laboratory, Massachusetts General Hospital, Charlestown, MA, United States of America
- Laboratory of Neuroimaging and Genetics, Massachusetts General Hospital, Charlestown, MA, United States of America
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Warren Wright Adolescent Center, Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, IL, United States of America
- Athinoula A. Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States of America
| | - Nutan Sharma
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Neurology, Brigham and Women’s Hospital, Boston MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Anne J. Blood
- Mood and Motor Control Laboratory, Massachusetts General Hospital, Charlestown, MA, United States of America
- Laboratory of Neuroimaging and Genetics, Massachusetts General Hospital, Charlestown, MA, United States of America
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States of America
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
- Athinoula A. Martinos Center for Biomedical Imaging, MGH, Charlestown, MA, United States of America
| |
Collapse
|
15
|
Ghatan S, Kokoszka MA, Ranney AM, Strauss KA. Intraventricular Baclofen for Treatment of Severe Dystonia Associated with Glutaryl-CoA Dehydrogenase Deficiency (GA1): Report of Two Cases. Mov Disord Clin Pract 2016; 3:296-299. [PMID: 30713921 DOI: 10.1002/mdc3.12278] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Revised: 09/09/2015] [Accepted: 09/16/2015] [Indexed: 11/08/2022] Open
Abstract
Two individuals with intractable generalized dystonia secondary to glutaric aciduria type 1 (GA1) were treated with continuous intraventricular baclofen (IVB) infusion. On IVB of 220 μg/day, one 10-year-old girl had an 85% reduction in dystonia, from Barry-Albright Dystonia Scale (BADS) score 30.7 to 4.5 (maximum score: 32) at 30 postoperative months. Her enteral dystonia medications were reduced >60%, and she discontinued medications for pain, anxiety, and depression. A second GA1 patient, age 23, experienced a more modest 18% reduction in dystonia (BADS decrease from 29.7 to 24.3) on IVB of 1,665 μg/day at 14 postoperative months. He substantially reduced his enteral dystonia medications and reported meaningful pain relief. These cases demonstrate that IVB may be a palliative option in the intractable dystonia of GA1. Our provisional observations suggest that IVB may be more beneficial in younger GA1 patients.
Collapse
Affiliation(s)
- Saadi Ghatan
- Department of Neurosurgery Mount Sinai Health System New York New York USA
| | | | - Anne M Ranney
- Department of Pediatrics University of Virginia Charlottesville Virginia USA
| | - Kevin A Strauss
- Clinic for Special Children Strasburg Pennsylvania USA.,Franklin and Marshall College Lancaster Pennsylvania USA.,Lancaster General Hospital Lancaster Pennsylvania USA
| |
Collapse
|
16
|
Cheung T, Noecker AM, Alterman RL, McIntyre CC, Tagliati M. Defining a therapeutic target for pallidal deep brain stimulation for dystonia. Ann Neurol 2014; 76:22-30. [PMID: 24852850 DOI: 10.1002/ana.24187] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 05/19/2014] [Accepted: 05/20/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To create a data-driven computational model that identifies brain regions most frequently influenced by successful deep brain stimulation (DBS) of the globus pallidus (GP) for advanced, medication-resistant, generalized dystonia. METHODS We studied a retrospective cohort of 21 DYT1 primary dystonia patients treated for at least 1 year with bilateral pallidal DBS. We first created individual volume of tissue activation (VTA) models utilizing neuroimaging and postoperative stimulation and clinical data. These models were then combined into a standardized probabilistic dystonia stimulation atlas (DSA). Finally, we constructed a candidate target volume from electrodes demonstrating at least 75% improvement in contralateral symptoms, utilizing voxels stimulated by least 75% of these electrodes. RESULTS Pallidal DBS resulted in a median contralateral hemibody improvement of 90% (mean = 83%, standard deviation [SD] = 20) after 1 year of treatment. Individual VTA models of the 42 active electrodes included in the study demonstrated a mean stimulation volume of 501mm ([SD] = 284). The resulting DSA showed that areas most frequently stimulated were located squarely in the middle of the posterior GP, with a common target volume measuring 153mm(3) . INTERPRETATION Our results provide a map of the region of influence of therapeutic DBS for dystonia and represent a potential target to refine current methods of surgical planning and stimulation parameters selection. Based on their role in alleviating symptoms, these regions may also provide anatomical and physiological information relevant to disease models of dystonia. Further experimental and clinical studies will be needed to validate their importance.
Collapse
Affiliation(s)
- Tyler Cheung
- Cedars Sinai Medical Center, Department of Neurology, Los Angeles, CA
| | | | | | | | | |
Collapse
|
17
|
Abstract
The few controlled studies that have been carried out have shown that bilateral internal globus pallidum stimulation is a safe and long-term effective treatment for hyperkinetic disorders. However, most recent published data on deep brain stimulation (DBS) for dystonia, applied to different targets and patients, are still mainly from uncontrolled case reports (especially for secondary dystonia). This precludes clear determination of the efficacy of this procedure and the choice of the 'good' target for the 'good' patient. We performed a literature analysis on DBS for dystonia according to the expected outcome. We separated those with good evidence of favourable outcome from those with less predictable outcome. In the former group, we review the main results for primary dystonia (generalised/focal) and highlight recent data on myoclonus-dystonia and tardive dystonia (as they share, with primary dystonia, a marked beneficial effect from pallidal stimulation with good risk/benefit ratio). In the latter group, poor or variable results have been obtained for secondary dystonia (with a focus on heredodegenerative and metabolic disorders). From this overview, the main results and limits for each subgroup of patients that may help in the selection of dystonic patients who will benefit from DBS are discussed.
Collapse
Affiliation(s)
- Marie Vidailhet
- AP-HP, Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière, Paris, France.
| | | | | | | |
Collapse
|
18
|
Vidailhet M, Jutras MF, Roze E, Grabli D. Deep brain stimulation for dystonia. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:167-187. [PMID: 24112893 DOI: 10.1016/b978-0-444-53497-2.00014-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
The few reported controlled studies show that bilateral stimulation of the globus pallidus interna (GPi) is a safe and effective long-term treatment for hyperkinetic disorders. However, the recently published data on deep brain stimulation (DBS) applied to different targets or patients (especially those with secondary dystonia) are mainly uncontrolled case reports, precluding a clear determination of its efficacy, and providing little guidance as to the choice of a "good" target in a "good" patient. This chapter reviews the literature on DBS in primary dystonia, paying particular attention to the risk:benefit ratio in focal and segmental dystonias (cervical dystonia, cranial dystonia) and to the predictive factors for a good outcome. The chapter also highlights recent data on the marked benefits of the technique in myoclonus dystonia (in which pallidal, as opposed to thalamic, stimulation is more effective) and in tardive dystonia-dyskinesia. Although, the decision to treat appears relatively straightforward in patients with primary dystonia, myoclonus-dystonia, and tardive dystonia who have a normal findings on magnetic resonance imaging and normal cognitive function, there are still no reliable tools to help predict the timescale of postoperative benefit. This chapter provides a comprehensive analysis of the use of the treatment in various types of secondary dystonia, with little to moderate benefit in most cases, based on single cases or small series. Beyond the reduction in the severity of dystonia, the global motor and functional outcome is difficult to determine owing to the paucity of adequate evaluation tools. Because of the large interpatient variability, different targets may be effective depending on the symptoms in each individual.
Collapse
Affiliation(s)
- Marie Vidailhet
- Department of Neurology, Groupe Hospitalier Pitié-Salpêtrière, Paris, France; Research Center of the Brain and Spinal Cord Institute, Université Paris 6/Inserm UMR S975, Paris, France; Pierre et Marie Curie Paris-6 University, Paris, France
| | | | | | | |
Collapse
|
19
|
Deep Brain Stimulation for Treatment of Voice Disorders. J Voice 2012; 26:769-71. [DOI: 10.1016/j.jvoice.2012.05.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Accepted: 05/15/2012] [Indexed: 11/16/2022]
|
20
|
Cif L, Gonzalez-Martinez V, Vasques X, Corlobé A, Moura AM, Bonafé A, Coubes P. Staged implantation of multiple electrodes in the internal globus pallidus in the treatment of primary generalized dystonia. J Neurosurg 2012; 116:1144-52. [DOI: 10.3171/2012.1.jns102045] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Deep brain stimulation (DBS) is used for treating various types of dystonia. Multiple electrodes could be proposed to improve the therapeutic outcome enabling the targeting of specific neuronal populations not reached by the electrical field generated by the initially implanted electrode. The authors address the question of the feasibility and safety of staged multiple lead implantations in the sensorimotor internal globus pallidus (GPi) in primary generalized dystonia (PGD). Criteria for patient selection, surgical technique, target selection, electrical settings management, and clinical outcome are presented.
Methods
Sixteen patients (8 harbored the DYT1 gene mutation) presented with PGD and were enrolled in this study. Patients underwent clinical assessment using the Burke-Fahn-Marsden Dystonia Rating Scale preoperatively and during follow-up with DBS. Prior to the addition of electrodes, the authors confirmed, by turning off stimulation, that the patient was still benefiting from DBS and that DBS settings adjustment did not provide further improvement. The second target was defined according to the position of the first electrode, to the residual volume within the sensorimotor GPi, and according to residual symptoms. The second surgery followed the same protocol as the first and the new electrode were inserted using the same bur hole as the first electrode.
Results
The addition of a new pair of electrodes was followed by significant improvement in the whole population (p = 0.005), as well as in the DYT1-negative subgroup (p = 0.012) but not in the DYT1 subgroup (p = not significant). Nevertheless, some patients did not exhibit significant additional benefit. Seven hardware-related complications occurred during the entire follow-up, 3 prior to it, and 4 after the addition of the second pair of electrodes.
Conclusions
The addition of a second pair of electrodes in the GPi in patients with PGD with suboptimal or decaying benefit following the first surgery seems to be a safe procedure and is not followed by an increase in surgery-related complications. This staged procedure may provide further clinical improvement in patients with PGD in whom DBS effect is initially incomplete or when disease progression occurs over time. The position of the additional electrode within the GPi is determined by the available volume within the posteroventral GPi and by the distribution of the dystonic symptoms that need to be controlled.
Collapse
Affiliation(s)
- Laura Cif
- 1Département de Neurochirurgie,
- 2Institut National de la Santé et de la Recherche Médicale Unité 661
- 3Université de Montpellier 1
- 4Institut de Génomique Fonctionnelle, Unité Mixte de Recherche 5203, Centre National de la Recherche Scientifique; and
| | - Victoria Gonzalez-Martinez
- 1Département de Neurochirurgie,
- 2Institut National de la Santé et de la Recherche Médicale Unité 661
- 3Université de Montpellier 1
- 4Institut de Génomique Fonctionnelle, Unité Mixte de Recherche 5203, Centre National de la Recherche Scientifique; and
| | - Xavier Vasques
- 1Département de Neurochirurgie,
- 2Institut National de la Santé et de la Recherche Médicale Unité 661
- 3Université de Montpellier 1
- 4Institut de Génomique Fonctionnelle, Unité Mixte de Recherche 5203, Centre National de la Recherche Scientifique; and
- 5Product and Solution Support Center, Centre for Advanced Studies, IBM, Montpellier, France
| | - Astrid Corlobé
- 1Département de Neurochirurgie,
- 6Service de Neurologie, and
| | | | - Alain Bonafé
- 7Département de Neuroradiologie, Hôpital Gui de Chauliac, Centre Hospitalier Régional Universitaire Montpellier
| | - Philippe Coubes
- 1Département de Neurochirurgie,
- 2Institut National de la Santé et de la Recherche Médicale Unité 661
- 3Université de Montpellier 1
- 4Institut de Génomique Fonctionnelle, Unité Mixte de Recherche 5203, Centre National de la Recherche Scientifique; and
| |
Collapse
|
21
|
Abstract
Dystonia is a neurological condition characterised by abnormal muscle contractions, often causing repetitive twisting movements or abnormal postures. Varying forms of surgical intervention, for dystonia unresponsive to medical therapy, have evolved over the years and have often been associated with poor outcomes and high morbidity. The advent of stereotactic neurosurgery and the success of Deep Brain Stimulation (DBS) in treating a number of movement disorders has revolutionized the surgical treatment for dystonia. This chapter reviews the literature concerning the surgical treatment dystonic conditions, from historical origins to the current use of modern functional neurosurgical techniques.
Collapse
|
22
|
Åström M, Lemaire JJ, Wårdell K. Influence of heterogeneous and anisotropic tissue conductivity on electric field distribution in deep brain stimulation. Med Biol Eng Comput 2011; 50:23-32. [DOI: 10.1007/s11517-011-0842-z] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 11/07/2011] [Indexed: 11/27/2022]
|
23
|
Voges J, Krauss J. Neurochirurgische und technische Aspekte der tiefen Hirnstimulation. DER NERVENARZT 2010; 81:702-10. [DOI: 10.1007/s00115-010-2937-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
24
|
Somatotopic organization in the internal segment of the globus pallidus in Parkinson's disease. Exp Neurol 2010; 222:219-25. [PMID: 20059997 DOI: 10.1016/j.expneurol.2009.12.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Accepted: 12/29/2009] [Indexed: 11/24/2022]
Abstract
Ablation or deep brain stimulation in the internal segment of the globus pallidus (GPi) is an effective therapy for the treatment of Parkinson's disease (PD). Yet many patients receive only partial benefit, including varying levels of improvement across different body regions, which may relate to a differential effect of GPi surgery on the different body regions. Unfortunately, our understanding of the somatotopic organization of human GPi is based on a small number of studies with limited sample sizes, including several based upon only a single recording track or plane. To fully address the three-dimensional somatotopic organization of GPi, we examined the receptive field properties of pallidal neurons in a large cohort of patients undergoing stereotactic surgery. The response of neurons to active and passive movements of the limbs and orofacial structures was determined, using a minimum of three tracks across at least two medial-lateral planes. Neurons (3183) were evaluated from 299 patients, of which 1972 (62%) were modulated by sensorimotor manipulation. Of these, 1767 responded to a single, contralateral body region, with the remaining 205 responding to multiple and/or ipsilateral body regions. Leg-related neurons were found dorsal, medial and anterior to arm-related neurons, while arm-related neurons were dorsal and lateral to orofacial-related neurons. This study provides a more detailed map of individual body regions as well as specific joints within each region and provides a potential explanation for the differential effect of lesions or DBS of the GPi on different body parts in patients undergoing surgical treatment of movement disorders.
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW In the past 18 months, several important studies in neuroimaging, epidemiology of dystonia and animal models have been published. Moreover, new advances in genetics have broadened the spectrum of dystonia. Here, we discuss these findings and their implication in the pathophysiology of dystonia. RECENT FINDINGS From neurophysiological studies and animal models, converging arguments support the role of combined corticostriatal, cerebellar and dopaminergic dysfunctions in the pathophysiology of dystonia. A large study in epidemiology identified several risk factors associated with writer's cramp (time spent handwriting each day and the additional burden of an abrupt increase in the writing time in the year before onset). Important studies on the abnormal structure-function relationship in hereditary and sporadic dystonia explored the relationship between genotype, phenotype and endophenotype. SUMMARY Different pathophysiological mechanisms may underlie similar phenotypes whereas different genotypes may share similar functional abnormalities. The respective roles of corticostriatal-cortical and cerebellar loops remain to be clarified as the original causative process (either degenerative or developmental) is accompanied by functional reorganization.
Collapse
|