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Sun YR, Beylergil SB, Gupta P, Ghasia FF, Shaikh AG. Monitoring Eye Movement in Patients with Parkinson's Disease: What Can It Tell Us? Eye Brain 2023; 15:101-112. [PMID: 37519412 PMCID: PMC10377572 DOI: 10.2147/eb.s384763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 06/01/2023] [Indexed: 08/01/2023] Open
Abstract
Parkinson's disease (PD) affects approximately 10 million individuals worldwide. Visual impairments are a common feature of PD. Patients report difficulties with visual scanning, impaired depth perception and spatial navigation, and blurry and double vision. Examination of PD patients reveals abnormal fixational saccades, strabismus, impaired convergence, and abnormal visually-guided saccades. This review aims to describe objective features of abnormal eye movements in PD and to discuss the structures and pathways through which these abnormalities may manifest.
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Affiliation(s)
- Yue Ran Sun
- Department of Neurology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
| | - Sinem B Beylergil
- Neurology Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Palak Gupta
- Neurology Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | | | - Aasef G Shaikh
- Department of Neurology, University Hospitals, Case Western Reserve University, Cleveland, OH, USA
- Neurology Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
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2
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DBS-evoked cortical responses index optimal contact orientations and motor outcomes in Parkinson's disease. NPJ Parkinsons Dis 2023; 9:37. [PMID: 36906723 PMCID: PMC10008535 DOI: 10.1038/s41531-023-00474-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 02/13/2023] [Indexed: 03/13/2023] Open
Abstract
Although subthalamic deep brain stimulation (DBS) is a highly-effective treatment for alleviating motor dysfunction in patients with Parkinson's disease (PD), clinicians currently lack reliable neurophysiological correlates of clinical outcomes for optimizing DBS parameter settings, which may contribute to treatment inefficacies. One parameter that could aid DBS efficacy is the orientation of current administered, albeit the precise mechanisms underlying optimal contact orientations and associated clinical benefits are not well understood. Herein, 24 PD patients received monopolar stimulation of the left STN during magnetoencephalography and standardized movement protocols to interrogate the directional specificity of STN-DBS current administration on accelerometer metrics of fine hand movements. Our findings demonstrate that optimal contact orientations elicit larger DBS-evoked cortical responses in the ipsilateral sensorimotor cortex, and importantly, are differentially predictive of smoother movement profiles in a contact-dependent manner. Moreover, we summarize traditional evaluations of clinical efficacy (e.g., therapeutic windows, side effects) for a comprehensive review of optimal/non-optimal STN-DBS contact settings. Together, these data suggest that DBS-evoked cortical responses and quantitative movement outcomes may provide clinical insight for characterizing the optimal DBS parameters necessary for alleviating motor symptoms in patients with PD in the future.
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3
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Debove I, Petermann K, Nowacki A, Nguyen TK, Tinkhauser G, Michelis JP, Muellner J, Amstutz D, Bargiotas P, Fichtner J, Schlaeppi JA, Krack P, Schuepbach M, Pollo C, Lachenmayer ML. Deep Brain Stimulation: When to Test Directional? Mov Disord Clin Pract 2023; 10:434-439. [PMID: 36949800 PMCID: PMC10026308 DOI: 10.1002/mdc3.13667] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 12/09/2022] [Accepted: 01/08/2023] [Indexed: 01/26/2023] Open
Abstract
Background Directional deep brain stimulation (DBS) allows for steering of the stimulation field, but extensive and time-consuming testing of all segmented contacts is necessary to identify the possible benefit of steering. It is therefore important to determine under which circumstances directional current steering is advantageous. Methods Fifty two Parkinson's disease patients implanted in the STN with a directional DBS system underwent a standardized monopolar programming session 5 to 9 months after implantation. Individual contacts were tested for a potential advantage of directional stimulation. Results were used to build a prediction model for the selection of ring levels that would benefit from directional stimulation. Results On average, there was no significant difference in therapeutic window between ring-level contact and best directional contact. However, according to our standardized protocol, 35% of the contacts and 66% of patients had a larger therapeutic window under directional stimulation compared to ring-mode. The segmented contacts warranting directional current steering could be predicted with a sensitivity of 79% and a specificity of 57%. Conclusion To reduce time required for DBS programming, we recommend additional directional contact testing initially only on ring-level contacts with a therapeutic window of less than 2.0 mA.
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Affiliation(s)
- Ines Debove
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Katrin Petermann
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Andreas Nowacki
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Thuy‐Anh Khoa Nguyen
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
- ARTORG Center for Biomedical Engineering ResearchUniversity of BernBernSwitzerland
| | - Gerd Tinkhauser
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Joan Philipp Michelis
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Julia Muellner
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Deborah Amstutz
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Panagiotis Bargiotas
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
- Department of Neurology, Medical SchoolUniversity of CyprusNicosiaCyprus
| | - Jens Fichtner
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
- Cantonal Medical Service, Department of Health of the Canton of BernBernSwitzerland
| | - Janine Ai Schlaeppi
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Paul Krack
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Michael Schuepbach
- Department of Neurology, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
| | - Claudio Pollo
- Department of Neurosurgery, Inselspital, Bern University HospitalUniversity of BernBernSwitzerland
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Waldthaler J, Sperlich A, Stüssel C, Steidel K, Timmermann L, Pedrosa DJ. Stimulation of non-motor subthalamic nucleus impairs selective response inhibition via prefrontal connectivity. Brain Commun 2023; 5:fcad121. [PMID: 37113315 PMCID: PMC10128876 DOI: 10.1093/braincomms/fcad121] [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: 12/02/2022] [Revised: 03/03/2023] [Indexed: 04/29/2023] Open
Abstract
Given the inconsistent results in the past, there is an ongoing debate whether and how deep brain stimulation in the subthalamic nucleus modifies cognitive control processes like response inhibition in persons with Parkinson's disease. In this study, we examined how the location of the stimulation volume within the subthalamic nucleus affects the performance in an antisaccade task but also how its structural connectivity is related to response inhibition. Antisaccade error rates and latencies were collected in 14 participants on and off deep brain stimulation in a randomized order. Stimulation volumes were computed based on patient-specific lead localizations using preoperative MRI and postoperative CT scans. Structural connectivity of the stimulation volumes with pre-defined cortical oculomotor control regions as well as whole-brain connectivity was estimated using a normative connectome. We showed that the detrimental effect of deep brain stimulation on response inhibition, measured as antisaccade error rate, depended upon the magnitude of the intersection of volumes of activated tissue with the non-motor subregion of the subthalamic nucleus and on its structural connectivity with regions of the prefrontal oculomotor network including bilateral frontal eye fields and right anterior cingulate cortex. Our results corroborate previous recommendations for avoidance of stimulation in the ventromedial non-motor subregion of the subthalamic nucleus which connects to the prefrontal cortex to prevent stimulation-induced impulsivity. Furthermore, antisaccades were initiated faster with deep brain stimulation when the stimulation volume was connected to fibres passing the subthalamic nucleus laterally and projecting onto the prefrontal cortex, indicating that improvement of voluntary saccade generation with deep brain stimulation may be an off-target effect driven by stimulation of corticotectal fibres directly projecting from the frontal and supplementary eye fields onto brainstem gaze control areas. Taken together, these findings could help implement individualized circuit-based deep brain stimulation strategies that avoid impulsive side effects while improving voluntary oculomotor control.
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Affiliation(s)
- Josefine Waldthaler
- Correspondence to: Josefine Waldthaler, Department of Neurology, University Hospitals Gießen and Marburg, Baldingerstraße, 35033 Marburg, Hesse, Germany E-mail:
| | - Alexander Sperlich
- Department of Neurology, University Hospital Gießen and Marburg, 35033 Marburg, Germany
| | - Charlotte Stüssel
- Department of Neurology, University Hospital Gießen and Marburg, 35033 Marburg, Germany
| | - Kenan Steidel
- Department of Neurology, University Hospital Gießen and Marburg, 35033 Marburg, Germany
| | - Lars Timmermann
- Department of Neurology, University Hospital Gießen and Marburg, 35033 Marburg, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps-University Marburg and Justus-Liebig-University Giessen, 35033 Marburg, Germany
| | - David J Pedrosa
- Department of Neurology, University Hospital Gießen and Marburg, 35033 Marburg, Germany
- Center for Mind, Brain and Behavior (CMBB), Philipps-University Marburg and Justus-Liebig-University Giessen, 35033 Marburg, Germany
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5
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Abou Khzam R, El Jalbout ND, Seif R, Sadaka A. An unusual presentation of convergence insufficiency in a patient with Parkinson's disease stimulated by deep brain stimulation. Am J Ophthalmol Case Rep 2022; 26:101531. [PMID: 35509285 PMCID: PMC9058585 DOI: 10.1016/j.ajoc.2022.101531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 03/28/2022] [Accepted: 04/01/2022] [Indexed: 11/30/2022] Open
Abstract
Purpose To report convergence insufficiency in a patient with Parkinson's' disease stimulated by turning on the deep brain stimulator. Observations 72-year-old male with Parkinson's disease and hypertension presenting for the evaluation of blurry vision at near and mid distance that started after activation of an implanted Deep brain stimulator.Baseline ophthalmologic evaluation prior to deep brain stimulator implantation surgery and with the deep brain stimulator turned off demonstrated a full motility, centered eyes for distance and near and a best corrected visual acuity of 20/20, normal pupil exam, confrontational visual fields and dilated fundus exam. Following this examination, the Deep brain stimulator was turned on and re-evaluation few minutes later demonstrated the same findings except for a 6-prism diopter exotropia at near consistent with convergence insufficiency.Following our evaluation a set of +3 diopters base-in prisms were added to near glasses with total relief of symptoms. The patient did not require surgical adjustment of the deep brain stimulator leads. Conclusions and importance Given the therapeutic effects of deep brain stimulation on convergence insufficiency reported in several studies, in addition to the influence of deep brain stimulation as Parkinson's Disease treatment in areas possibly associated with vergence control, convergence insufficiency secondary to deep brain stimulation does not seem very unlikely, although not often reported. Further studies are needed to optimize deep brain stimulation surgery to maximize benefits and limit adverse events, as well as being aware of convergence insufficiency as a possible cause for visual disturbance.
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Affiliation(s)
- Rayan Abou Khzam
- Lebanese American University Gillbert and Rose-Marie Chagoury School of Medicine, Byblos, Lebanon
- Department of Ophthalmology, Lebanese American University Medical Center, Rizk Hospital, Beirut, Lebanon
| | - Nahia Dib El Jalbout
- Lebanese American University Gillbert and Rose-Marie Chagoury School of Medicine, Byblos, Lebanon
- Department of Ophthalmology, Lebanese American University Medical Center, Rizk Hospital, Beirut, Lebanon
| | - Roland Seif
- Lebanese American University Gillbert and Rose-Marie Chagoury School of Medicine, Byblos, Lebanon
- Department of Ophthalmology, Lebanese American University Medical Center, Rizk Hospital, Beirut, Lebanon
| | - Ama Sadaka
- Lebanese American University Gillbert and Rose-Marie Chagoury School of Medicine, Byblos, Lebanon
- Department of Ophthalmology, Lebanese American University Medical Center, Rizk Hospital, Beirut, Lebanon
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6
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Mohammed M, Ivica N, Bjartmarz H, Thorbergsson PT, Pettersson LME, Thelin J, Schouenborg J. Microelectrode clusters enable therapeutic deep brain stimulation without noticeable side-effects in a rodent model of Parkinson's disease. J Neurosci Methods 2022; 365:109399. [PMID: 34695455 DOI: 10.1016/j.jneumeth.2021.109399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/01/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Deep Brain Stimulation (DBS) is an established treatment for motor symptoms in Parkinson's disease (PD). However, side effects often limit the usefulness of the treatment. NEW METHOD To mitigate this problem, we developed a novel cluster of ultrathin platinum-iridium microelectrodes (n = 16) embedded in a needle shaped gelatin vehicle. In an established rodent PD-model (6-OHDA unilateral lesion), the clusters were implanted in the subthalamic area for up to 8 weeks. In an open field setting, combinations of microelectrodes yielding therapeutic effects were identified using statistical methods. Immunofluorescence techniques were used for histological assessments of biocompatibility. RESULTS In all rats tested (n = 5), we found subsets of 3-4 microelectrodes which, upon stimulation (160 Hz, 60 μs pulse width, 25-40 μA/microelectrode), prompted normal movements without noticeable side effects. Other microelectrode subsets often caused side effects such as rotation, dyskinesia and tremor. The threshold (per microelectrode) to elicit normal movements strongly depended on the number of activated microelectrodes in the selected subset. The histological analysis revealed viable neurons close to the electrode contacts, minor microglial and astrocytic reactions and no major changes in the vasculature, indicating high biocompatibility. COMPARISON TO EXISTING METHODS AND CONCLUSION By contrast to the continuous and relatively large stimulation fields produced by existing DBS electrodes, the developed microelectrode cluster enables a fine-tuned granular and individualized microstimulation. This granular type of stimulation pattern provided powerful and specific therapeutic effects, free of noticeable side effects, in a PD animal model.
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Affiliation(s)
| | | | - Hjalmar Bjartmarz
- Neuronano Research Center, Lund University, Lund, Sweden; Department of Neurosurgery, Lund University and Skåne University Hospital in Lund, Lund, Sweden
| | | | - Lina M E Pettersson
- Neuronano Research Center, Lund University, Lund, Sweden; NanoLund, Lund University, Lund, Sweden
| | - Jonas Thelin
- Neuronano Research Center, Lund University, Lund, Sweden
| | - Jens Schouenborg
- Neuronano Research Center, Lund University, Lund, Sweden; NanoLund, Lund University, Lund, Sweden.
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7
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Strotzer QD, Kohl Z, Anthofer JM, Faltermeier R, Schmidt NO, Torka E, Greenlee MW, Fellner C, Schlaier JR, Beer AL. Structural Connectivity Patterns of Side Effects Induced by Subthalamic Deep Brain Stimulation for Parkinson's Disease. Brain Connect 2021; 12:374-384. [PMID: 34210163 DOI: 10.1089/brain.2021.0051] [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] [Indexed: 11/12/2022] Open
Abstract
Background: Tractography based on diffusion-weighted magnetic resonance imaging (DWI) models the structural connectivity of the human brain. Deep brain stimulation (DBS) targeting the subthalamic nucleus is an effective treatment for advanced Parkinson's disease, but may induce adverse effects. This study investigated the relationship between structural connectivity patterns of DBS electrodes and stimulation-induced side effects. Materials and Methods: Twenty-one patients with Parkinson's disease treated with bilateral subthalamic DBS were examined. Overall, 168 electrode contacts were categorized as inducing or noninducing depending on their capability for inducing side effects such as motor effects, paresthesia, dysarthria, oculomotor effects, hyperkinesia, and other complications as assessed during the initial programming session. Furthermore, the connectivity of each contact with target regions was evaluated by probabilistic tractography based on DWI. Finally, stimulation sites and structural connectivity patterns of inducing and noninducing contacts were compared. Results: Inducing contacts differed across the various side effects and from those mitigating Parkinson's symptoms. Although contacts showed a largely overlapping spatial distribution within the subthalamic region, they could be distinguished by their connectivity patterns. In particular, inducing contacts were more likely connected with supplementary motor areas (hyperkinesia, dysarthria), frontal cortex (oculomotor), fibers of the internal capsule (paresthesia), and the basal ganglia-thalamo-cortical circuitry (dysarthria). Discussion: Side effects induced by DBS seem to be associated with distinct connectivity patterns. Cerebellar connections are hardly associated with side effects, although they seem relevant for mitigating motor symptoms in Parkinson's disease. A symptom-specific, connectivity-based approach for target planning in DBS may enhance treatment outcomes and reduce adverse effects.
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Affiliation(s)
- Quirin D Strotzer
- Department of Neurosurgery, University of Regensburg Medical Center, Regensburg, Germany.,Center for Deep Brain Stimulation, University of Regensburg Medical Center, Regensburg, Germany.,Institute of Radiology, and University of Regensburg Medical Center, Regensburg, Germany
| | - Zacharias Kohl
- Center for Deep Brain Stimulation, University of Regensburg Medical Center, Regensburg, Germany.,Department of Neurology, University of Regensburg Medical Center, Regensburg, Germany.,Department of Molecular Neurology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Judith M Anthofer
- Department of Neurosurgery, University of Regensburg Medical Center, Regensburg, Germany.,Center for Deep Brain Stimulation, University of Regensburg Medical Center, Regensburg, Germany
| | - Rupert Faltermeier
- Department of Neurosurgery, University of Regensburg Medical Center, Regensburg, Germany
| | - Nils O Schmidt
- Department of Neurosurgery, University of Regensburg Medical Center, Regensburg, Germany
| | - Elisabeth Torka
- Center for Deep Brain Stimulation, University of Regensburg Medical Center, Regensburg, Germany.,Department of Neurology, University of Regensburg Medical Center, Regensburg, Germany
| | - Mark W Greenlee
- Institute of Psychology, University of Regensburg, Regensburg, Germany
| | - Claudia Fellner
- Institute of Radiology, and University of Regensburg Medical Center, Regensburg, Germany
| | - Juergen R Schlaier
- Department of Neurosurgery, University of Regensburg Medical Center, Regensburg, Germany.,Center for Deep Brain Stimulation, University of Regensburg Medical Center, Regensburg, Germany
| | - Anton L Beer
- Institute of Psychology, University of Regensburg, Regensburg, Germany
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8
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Kimura Y, Enatsu R, Yokoyama R, Suzuki H, Sasagawa A, Hirano T, Arihara M, Kuribara T, Ochi S, Mikuni N. Eye Movement Network Originating from Frontal Eye Field: Electric Cortical Stimulation and Diffusion Tensor Imaging. Neurol Med Chir (Tokyo) 2021; 61:219-227. [PMID: 33504731 PMCID: PMC7966202 DOI: 10.2176/nmc.oa.2020-0306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study investigated the networks originating from frontal eye fields (FEFs) using electric cortical stimulation and diffusion tensor imaging (DTI). Seven patients with intractable focal epilepsy, in which FEFs were identified by electrical cortical stimulation, were enrolled in this study. Electric stimulation at 50 Hz was applied to the electrodes for functional mapping. DTI was used to identify the subcortical fibers originating from the FEFs with two regions of interests (ROIs) in the FEF and contralateral paramedian pontine reticular formation (PPRF). FEFs were found in the superior precentral sulcus (pre-CS) in six patients and superior frontal gyrus (SFG) in three patients. DTI detected fibers connecting FEFs and contralateral PPRFs, passing within the internal capsule. The fibers were located close to the lateral antero-superior border of the subthalamic nucleus (STN) and medial posterior border of the globus pallidus internus (GPi). This study found the characteristic subcortical networks of the FEF. These tracts should be noted to prevent complications of deep brain stimulation (DBS) of the STN or GPi.
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Affiliation(s)
- Yusuke Kimura
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Rei Enatsu
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Rintaro Yokoyama
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Hime Suzuki
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Ayaka Sasagawa
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Tsukasa Hirano
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Masayasu Arihara
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Tomoyoshi Kuribara
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Satoko Ochi
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University, Sapporo, Hokkaido, Japan
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9
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Miyagi Y, Urasaki E. Diplopia associated with loop routing in deep brain stimulation: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2031. [PMID: 35854685 PMCID: PMC9236169 DOI: 10.3171/case2031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) is a powerful surgical option for drug-resistant movement disorders; however, electromagnetic interference (EMI) from external sources poses a potential risk for implanted electronics. OBSERVATIONS A 61-year-old woman with Parkinson’s disease originally had two implantable pulse generators (IPGs) for bilateral subthalamic DBS, which were then replaced with one dual-channel IPG routed in a loop. After the replacement surgery, with the same DBS programming as before the IPG replacement (bipolar setting for right, unipolar setting for left), the patient began to complain of transient paroxysmal diplopia. After multiple attempts to adjust the stimulation parameters, the diplopia was resolved by changing the left unipolar setting to a bipolar setting. At the authors’ institution, before the present case, four other patients had undergone IPG replacement with loop routing. None of these previous patients complained of diplopia; however, two of the four presented with diplopia in an experimental unipolar setting. LESSONS Clinicians should be aware that loop-routed circuits may generate distortion of the stimulus field in DBS, even in the absence of external EMI sources.
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Affiliation(s)
- Yasushi Miyagi
- Department of Stereotactic and Functional Neurosurgery and
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10
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Koeglsperger T, Palleis C, Hell F, Mehrkens JH, Bötzel K. Deep Brain Stimulation Programming for Movement Disorders: Current Concepts and Evidence-Based Strategies. Front Neurol 2019; 10:410. [PMID: 31231293 PMCID: PMC6558426 DOI: 10.3389/fneur.2019.00410] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/04/2019] [Indexed: 11/16/2022] Open
Abstract
Deep brain stimulation (DBS) has become the treatment of choice for advanced stages of Parkinson's disease, medically intractable essential tremor, and complicated segmental and generalized dystonia. In addition to accurate electrode placement in the target area, effective programming of DBS devices is considered the most important factor for the individual outcome after DBS. Programming of the implanted pulse generator (IPG) is the only modifiable factor once DBS leads have been implanted and it becomes even more relevant in cases in which the electrodes are located at the border of the intended target structure and when side effects become challenging. At present, adjusting stimulation parameters depends to a large extent on personal experience. Based on a comprehensive literature search, we here summarize previous studies that examined the significance of distinct stimulation strategies for ameliorating disease signs and symptoms. We assess the effect of adjusting the stimulus amplitude (A), frequency (f), and pulse width (pw) on clinical symptoms and examine more recent techniques for modulating neuronal elements by electrical stimulation, such as interleaving (Medtronic®) or directional current steering (Boston Scientific®, Abbott®). We thus provide an evidence-based strategy for achieving the best clinical effect with different disorders and avoiding adverse effects in DBS of the subthalamic nucleus (STN), the ventro-intermedius nucleus (VIM), and the globus pallidus internus (GPi).
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Affiliation(s)
- Thomas Koeglsperger
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Carla Palleis
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Franz Hell
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität München, Martinsried, Germany
| | - Jan H Mehrkens
- Department of Neurosurgery, Ludwig Maximilians University, Munich, Germany
| | - Kai Bötzel
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
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11
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Güngör A, Baydın ŞS, Holanda VM, Middlebrooks EH, Isler C, Tugcu B, Foote K, Tanriover N. Microsurgical anatomy of the subthalamic nucleus: correlating fiber dissection results with 3-T magnetic resonance imaging using neuronavigation. J Neurosurg 2019; 130:716-732. [PMID: 29726781 DOI: 10.3171/2017.10.jns171513] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 10/18/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Despite the extensive use of the subthalamic nucleus (STN) as a deep brain stimulation (DBS) target, unveiling the extensive functional connectivity of the nucleus, relating its structural connectivity to the stimulation-induced adverse effects, and thus optimizing the STN targeting still remain challenging. Mastering the 3D anatomy of the STN region should be the fundamental goal to achieve ideal surgical results, due to the deep-seated and obscure position of the nucleus, variable shape and relatively small size, oblique orientation, and extensive structural connectivity. In the present study, the authors aimed to delineate the 3D anatomy of the STN and unveil the complex relationship between the anatomical structures within the STN region using fiber dissection technique, 3D reconstructions of high-resolution MRI, and fiber tracking using diffusion tractography utilizing a generalized q-sampling imaging (GQI) model. METHODS Fiber dissection was performed in 20 hemispheres and 3 cadaveric heads using the Klingler method. Fiber dissections of the brain were performed from all orientations in a stepwise manner to reveal the 3D anatomy of the STN. In addition, 3 brains were cut into 5-mm coronal, axial, and sagittal slices to show the sectional anatomy. GQI data were also used to elucidate the connections among hubs within the STN region. RESULTS The study correlated the results of STN fiber dissection with those of 3D MRI reconstruction and tractography using neuronavigation. A 3D terrain model of the subthalamic area encircling the STN was built to clarify its anatomical relations with the putamen, globus pallidus internus, globus pallidus externus, internal capsule, caudate nucleus laterally, substantia nigra inferiorly, zona incerta superiorly, and red nucleus medially. The authors also describe the relationship of the medial lemniscus, oculomotor nerve fibers, and the medial forebrain bundle with the STN using tractography with a 3D STN model. CONCLUSIONS This study examines the complex 3D anatomy of the STN and peri-subthalamic area. In comparison with previous clinical data on STN targeting, the results of this study promise further understanding of the structural connections of the STN, the exact location of the fiber compositions within the region, and clinical applications such as stimulation-induced adverse effects during DBS targeting.
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Affiliation(s)
- Abuzer Güngör
- 1Department of Neurosurgery, Acıbadem University
- 2Department of Neurosurgery, Bakirkoy Research & Training Hospital for Psychiatry, Neurology, and Neurosurgery
| | - Şevki Serhat Baydın
- 3Department of Neurosurgery, Kanuni Sultan Süleyman Research & Training Hospital
| | - Vanessa M Holanda
- 4Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | | | - Cihan Isler
- 6Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Bekir Tugcu
- 2Department of Neurosurgery, Bakirkoy Research & Training Hospital for Psychiatry, Neurology, and Neurosurgery
| | - Kelly Foote
- 4Department of Neurosurgery, University of Florida, Gainesville, Florida; and
| | - Necmettin Tanriover
- 6Department of Neurosurgery, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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12
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Kang SL, Shaikh AG, Ghasia FF. Vergence and Strabismus in Neurodegenerative Disorders. Front Neurol 2018; 9:299. [PMID: 29867716 PMCID: PMC5964131 DOI: 10.3389/fneur.2018.00299] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 04/18/2018] [Indexed: 01/03/2023] Open
Abstract
Maintaining proper eye alignment is necessary to generate a cohesive visual image. This involves the coordination of complex neural networks, which can become impaired by various neurodegenerative diseases. When the vergence system is affected, this can result in strabismus and disorienting diplopia. While previous studies have detailed the effect of these disorders on other eye movements, such as saccades, relatively little is known about strabismus. Here, we focus on the prevalence, clinical characteristics, and treatment of strabismus and disorders of vergence in Parkinson’s disease, spinocerebellar ataxia, Huntington disease, and multiple system atrophy. We find that vergence abnormalities may be more common in these disorders than previously thought. In Parkinson’s disease, the evidence suggests that strabismus is related to convergence insufficiency; however, it is responsive to dopamine replacement therapy and can, therefore, fluctuate with medication “on” and “off” periods throughout the day. Diplopia is also established as a side effect of deep brain stimulation and is thought to be related to stimulation of the subthalamic nucleus and extraocular motor nucleus among other structures. In regards to the spinocerebellar ataxias, oculomotor symptoms are common in many subtypes, but diplopia is most common in SCA3 also known as Machado–Joseph disease. Ophthalmoplegia and vergence insufficiency have both been implicated in strabismus in these patients, but cannot fully explain the properties of the strabismus, suggesting the involvement of other structures as well. Strabismus has not been reported as a common finding in Huntington disease or atypical parkinsonian syndromes and more studies are needed to determine how these disorders affect binocular alignment.
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Affiliation(s)
- Sarah L Kang
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Aasef G Shaikh
- Case Western Reserve University School of Medicine, Cleveland, OH, United States.,Daroff-Dell'Osso Ocular Motility Laboratory, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States
| | - Fatema F Ghasia
- Daroff-Dell'Osso Ocular Motility Laboratory, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, United States.,Cole Eye Institute, Cleveland Clinic, Cleveland, OH, United States
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13
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Gomes JGR, Gorgulho AA, de Oliveira López A, Saraiva CWC, Damiani LP, Pássaro AM, Salvajoli JV, de Oliveira Siqueira L, Salvajoli BP, De Salles AAF. The role of diffusion tensor imaging tractography for Gamma Knife thalamotomy planning. J Neurosurg 2016; 125:129-138. [DOI: 10.3171/2016.7.gks161553] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEThe role of tractography in Gamma Knife thalamotomy (GK-T) planning is still unclear. Pyramidal tractography might reduce the risk of radiation injury to the pyramidal tract and reduce motor complications.METHODSIn this study, the ventralis intermedius nucleus (VIM) targets of 20 patients were bilaterally defined using Iplannet Stereotaxy Software, according to the anterior commissure–posterior commissure (AC-PC) line and considering the localization of the pyramidal tract. The 40 targets and tractography were transferred as objects to the GammaPlan Treatment Planning System (GP-TPS). New targets were defined, according to the AC-PC line in the functional targets section of the GP-TPS. The target offsets required to maintain the internal capsule (IC) constraint of < 15 Gy were evaluated. In addition, the strategies available in GP-TPS to maintain the minimum conventional VIM target dose at > 100 Gy were determined.RESULTSA difference was observed between the positions of both targets and the doses to the IC. The lateral (x) and the vertical (z) coordinates were adjusted 1.9 mm medially and 1.3 mm cranially, respectively. The targets defined considering the position of the pyramidal tract were more medial and superior, based on the constraint of 15 Gy touching the object representing the IC in the GP-TPS. The best strategy to meet the set constraints was 90° Gamma angle (GA) with automatic shaping of dose distribution; this was followed by 110° GA. The worst GA was 70°. Treatment time was substantially increased by the shaping strategy, approximately doubling delivery time.CONCLUSIONSRoutine use of DTI pyramidal tractography might be important to fine-tune GK-T planning. DTI tractography, as well as anisotropy showing the VIM, promises to improve Gamma Knife functional procedures. They allow for a more objective definition of dose constraints to the IC and targeting. DTI pyramidal tractography introduced into the treatment planning may reduce the incidence of motor complications and improve efficacy. This needs to be validated in a large clinical series.
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Affiliation(s)
- João Gabriel Ribeiro Gomes
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
- 2Department of Neurosurgery, Real Hospital Português, Recife-PE, Brazil
| | - Alessandra Augusta Gorgulho
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | | | - Crystian Wilian Chagas Saraiva
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Lucas Petri Damiani
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Anderson Martins Pássaro
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - João Victor Salvajoli
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Ludmila de Oliveira Siqueira
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Bernardo Peres Salvajoli
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
| | - Antônio Afonso Ferreira De Salles
- 1Department of Neurosurgery and Radiotherapy of the Hospital do Coração (HCOR Neurosciences), Gamma Knife Unit, São Paulo-SP, Brazil; and
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Chandran AS, Bynevelt M, Lind CRP. Magnetic resonance imaging of the subthalamic nucleus for deep brain stimulation. J Neurosurg 2016; 124:96-105. [DOI: 10.3171/2015.1.jns142066] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The subthalamic nucleus (STN) is one of the most important stereotactic targets in neurosurgery, and its accurate imaging is crucial. With improving MRI sequences there is impetus for direct targeting of the STN. High-quality, distortion-free images are paramount. Image reconstruction techniques appear to show the greatest promise in balancing the issue of geometrical distortion and STN edge detection. Existing spin echo- and susceptibility-based MRI sequences are compared with new image reconstruction methods. Quantitative susceptibility mapping is the most promising technique for stereotactic imaging of the STN.
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Affiliation(s)
| | - Michael Bynevelt
- 2Radiology, Sir Charles Gairdner Hospital, and
- 3School of Surgery, University of Western Australia, Perth, Western Australia, Australia
| | - Christopher R. P. Lind
- Departments of 1Neurosurgery and
- 3School of Surgery, University of Western Australia, Perth, Western Australia, Australia
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15
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Matias CM, Mehanna R, Cooper SE, Amit A, Lempka SF, Silva D, Carlotti CG, Butler RS, Machado AG. Correlation among anatomic landmarks, location of subthalamic deep brain stimulation electrodes, stimulation parameters, and side effects during programming monopolar review. Neurosurgery 2015; 11 Suppl 2:99-108; discussion 108-9. [PMID: 25599207 DOI: 10.1227/neu.0000000000000645] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clinical benefits of deep brain stimulation can be limited by the presence of side effects produced by current spread to adjacent structures. OBJECTIVE To identify a correlation between coordinates for each individual contact, neighboring structures, and pattern of side effects. METHODS Coordinates of the electrodes and anatomic landmarks were obtained with a stereotactic surgical planning software and were correlated with stimulation-related side effects by using univariate and multivariable analyses. RESULTS Monopolar stimulation elicited capsular side effects (CSEs) in 208 of 316 contacts (65.8%) and noncapsular side effects (NCSEs) in 223 of 316 contacts (70.6%). The occurrence of CSEs was correlated with contact number (P = .009) and with the "Z" (P = .03), whereas voltage threshold to CSEs exhibited correlation with the internal capsule angle (P = .035). The occurrence of NCSEs was correlated with contact number (P = .005), "X" (P = .03), "Y" (P = .004), and the distance to the red nucleus (P = .001 and P = .003). There was correlation between voltage threshold to NCSEs and the internal capsule angle (P = .006), electrode's coronal angle (P = .02), "X" (P = .001), "Y" (P < .001), "Z" (P < .001), and the distances to the internal capsule (P = .02) and to the red nucleus (P = .004 and P < .001). CONCLUSION A better understanding how patient anatomy, stimulation parameters, and lead location in relation to neighboring structures influence the occurrence of side effects can be useful to inform targeting strategies.
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Affiliation(s)
- Caio M Matias
- *Center for Neurological Restoration, Cleveland Clinic Neurological Institute, Cleveland, Ohio; ‡Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; §University of Texas Health Science Center, Houston, Texas; ¶Department of Neurology, Cleveland Clinic Neurological Institute, Cleveland, Ohio; ‖Department of Neurosurgery, Cleveland Clinic Neurological Institute, Cleveland, Ohio; #Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
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Sieger T, Bonnet C, Serranová T, Wild J, Novák D, Růžička F, Urgošík D, Růžička E, Gaymard B, Jech R. Basal ganglia neuronal activity during scanning eye movements in Parkinson's disease. PLoS One 2013; 8:e78581. [PMID: 24223158 PMCID: PMC3819366 DOI: 10.1371/journal.pone.0078581] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 09/16/2013] [Indexed: 12/31/2022] Open
Abstract
The oculomotor role of the basal ganglia has been supported by extensive evidence, although their role in scanning eye movements is poorly understood. Nineteen Parkinsońs disease patients, which underwent implantation of deep brain stimulation electrodes, were investigated with simultaneous intraoperative microelectrode recordings and single channel electrooculography in a scanning eye movement task by viewing a series of colored pictures selected from the International Affective Picture System. Four patients additionally underwent a visually guided saccade task. Microelectrode recordings were analyzed selectively from the subthalamic nucleus, substantia nigra pars reticulata and from the globus pallidus by the WaveClus program which allowed for detection and sorting of individual neurons. The relationship between neuronal firing rate and eye movements was studied by crosscorrelation analysis. Out of 183 neurons that were detected, 130 were found in the subthalamic nucleus, 30 in the substantia nigra and 23 in the globus pallidus. Twenty percent of the neurons in each of these structures showed eye movement-related activity. Neurons related to scanning eye movements were mostly unrelated to the visually guided saccades. We conclude that a relatively large number of basal ganglia neurons are involved in eye motion control. Surprisingly, neurons related to scanning eye movements differed from neurons activated during saccades suggesting functional specialization and segregation of both systems for eye movement control.
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Affiliation(s)
- Tomáš Sieger
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic ; Department of Cybernetics, Faculty of Electrical Engineering, Czech Technical University, Prague, Czech Republic
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17
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Castrioto A, Volkmann J, Krack P. Postoperative management of deep brain stimulation in Parkinson's disease. HANDBOOK OF CLINICAL NEUROLOGY 2013; 116:129-46. [PMID: 24112890 DOI: 10.1016/b978-0-444-53497-2.00011-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Deep brain stimulation has become an established treatment for advanced Parkinson's disease. Its postoperative management is a delicate phase, dedicated to finding the optimal balance between stimulation and dopaminergic treatment. Postoperative management can be divided into an acute phase, aimed at the selection of the best stimulation contact, and a stabilization phase, aimed at the progressive adjustment of stimulation parameters and medications. A good knowledge of the electrophysiological anatomy of the target and surrounding structures, of the potential consequences of dopaminergic treatment modifications, and of the time course and interactions between stimulation and medication effects is mandatory for optimal outcome. This chapter focuses on the main strategies for the acute and chronic management of stimulation parameters and medication in the three main nuclei targeted in Parkinson's disease, namely the subthalamic nucleus, the ventral intermediate thalamic nucleus, and the internal part of the globus pallidus.
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Affiliation(s)
- Anna Castrioto
- Movement Disorder Unit, Department of Psychiatry and Neurology, CHU de Grenoble, Joseph Fourier University, and INSERM, Unit 836, Grenoble Institut des Neurosciences, Grenoble, France
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18
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Ostrem JL, Galifianakis NB, Markun LC, Grace JK, Martin AJ, Starr PA, Larson PS. Clinical outcomes of PD patients having bilateral STN DBS using high-field interventional MR-imaging for lead placement. Clin Neurol Neurosurg 2012; 115:708-12. [PMID: 22944465 DOI: 10.1016/j.clineuro.2012.08.019] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 08/05/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Recently, an iMRI-guided technique for implanting DBS electrodes without MER was developed at our center. Here we report the clinical outcomes of PD patients undergoing STN DBS surgery using this surgical approach. METHODS Consecutive PD patients undergoing bilateral STN DBS using this method were prospectively studied. Severity of PD was determined using the UPDRS scores, Hoehn and Yahr staging score, stand-sit-walk testing, and the dyskinesia rating scale. The primary outcome measure was the change in UPDRS III off medication score at 6 months. DBS stimulation parameters, adverse events, levodopa equivalent daily dose (LEDD), and DBS lead locations were also recorded. Seventeen advanced PD patients (9M/8F) were enrolled from 2007 to 2009. RESULTS The mean UPDRS III off medication score improved from 44.5 to 22.5 (49.4%) at 6 months (p=0.001). Other secondary outcome measures (UPDRS II, III on medication, and IV) significantly improved as well (p<0.01). LEDD decreased by an average of 24.7% (p=0.003). Average stimulation parameters were: 2.9V, 66.4μs, 154Hz. CONCLUSION This pilot study demonstrates that STN DBS leads placed using the iMRI-guided method results in significantly improved outcomes in PD symptoms, and these outcomes are similar to what has been reported using traditional frame-based, MER-guided stereotactic methods.
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Affiliation(s)
- Jill L Ostrem
- Department of Neurology, University of California, San Francisco, Surgical Movement Disorders, 1635 Divisadero Street, 5th Floor, Suites 520-530, San Francisco, CA 94115, USA.
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19
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Abstract
The basal ganglia (BG) are a group of subcortical structures involved in diverse functions, such as motor, cognition and emotion. However, the BG do not control these functions directly, but rather modulate functional processes occurring in structures outside the BG. The BG form multiple functional loops, each of which controls different functions with similar architectures. Accordingly, to understand the modulatory role of the BG, it is strategic to uncover the mechanisms of signal processing within specific functional loops that control simple neural circuits outside the BG, and then extend the knowledge to other BG loops. The saccade control system is one of the best-understood neural circuits in the brain. Furthermore, sophisticated saccade paradigms have been used extensively in clinical research in patients with BG disorders as well as in basic research in behaving monkeys. In this review, we describe recent advances of BG research from the viewpoint of saccade control. Specifically, we account for experimental results from neuroimaging and clinical studies in humans based on the updated knowledge of BG functions derived from neurophysiological experiments in behaving monkeys by taking advantage of homologies in saccade behavior. It has become clear that the traditional BG network model for saccade control is too limited to account for recent evidence emerging from the roles of subcortical nuclei not incorporated in the model. Here, we extend the traditional model and propose a new hypothetical framework to facilitate clinical and basic BG research and dialogue in the future.
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Affiliation(s)
- Masayuki Watanabe
- Department of Physiology, Kansai Medical University, Fumizonocho 10-15, Moriguchi, Osaka 570-8506, Japan
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20
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Wu YJ, Tsai TT, Huang CW. Contraversive shift of conjugate eye deviation in hemispheric stroke indicates emerging mass effect. J Clin Neurosci 2011; 18:1276-8. [PMID: 21742502 DOI: 10.1016/j.jocn.2011.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2010] [Revised: 01/28/2011] [Accepted: 02/06/2011] [Indexed: 11/18/2022]
Abstract
Conjugate eye deviation (CED) towards the ipsilateral or the contralateral side of the brain lesion can occur as a result of acute hemispheric stroke. To our knowledge, there have been no reports of CED shifting from the lesional side to the contralateral side in acute hemispheric stroke in the literature. We present four patients with right hemispheric stroke with a forced CED shift from the right to the left side during the acute stage with corresponding mass effect on the right internal capsule and right thalamus, as shown on brain imaging. Mass effect on thalamic mediated circuits and the corticopontine projection within the internal capsule probably underlies this CED shift via the dynamic balance of oculomotor control between the two hemispheres. Contraversive CED shift is a potentially useful early predictor of emerging mass effect in acute hemispheric stroke.
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Affiliation(s)
- Yi-Jen Wu
- Department of Neurology, National Cheng Kung University Hospital, 138 Sheng-Li Road, Tainan 70428, Taiwan
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Sedrak M, Gorgulho A, Frew A, Behnke E, DeSalles A, Pouratian N. Diffusion Tensor Imaging and Colored Fractional Anisotropy Mapping of the Ventralis Intermedius Nucleus of the Thalamus. Neurosurgery 2011; 69:1124-9; discussion 1129-30. [DOI: 10.1227/neu.0b013e3182296a42] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
The ventralis intermedius (VIM) nucleus of the thalamus is the primary surgical target for treatment of tremor. Most centers rely on indirect targeting based on atlas-defined coordinates rather than patient-specific anatomy, making intraoperative physiological mapping critical. Detailed identification of this target based on patient-specific anatomic features can help optimize the surgical treatment of tremor.
OBJECTIVE
To study colored fractional anisotropic images and diffusion tensor imaging (DTI) tractography to identify characteristic magnetic resonance appearances of the VIM nucleus.
METHODS
Four patients undergoing stereotactic surgery for essential tremor (ET) were retrospectively studied with analysis of magnetic resonance imaging-based colored fractional anisotropy (FA) images and fiber tractography. All were scanned with a 1.5-T magnetic resonance imaging unit, and all sequences were obtained before frame placement. Because the goal of this study was to identify the DTI characteristics of physiologically defined VIM nucleus, we selected and studied patients who had undergone DTI and had efficacious tremor control with intraoperative microlesioning effect and tremor reduction with less than 2.0-V stimulation.
RESULTS
Analysis of color FA maps, which graphically illustrate fiber directionality, revealed consistent anatomic patterns. The region of the VIM nucleus can be seen as an intermediate region where there is a characteristic transition of color. Presumptive VIM nucleus interconnectivity with sensorimotor cortex and cerebellum was identified via the internal capsule and the superior cerebellar peduncle, respectively. FA maps could also be used to distinguish segments of gray matter, white matter, and gray-white matter boundaries.
CONCLUSION
Analysis of DTI and FA maps on widely available 1.5-T magnetic resonance imaging yields clear identification of various structures key to neurosurgical targeting. Prospective evaluation of integrating DTI into neurosurgical planning may be warranted.
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Affiliation(s)
- Mark Sedrak
- The Permanente Medical Group, Inc., Redwood City, California
- Departments of Neurosurgery, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Alessandra Gorgulho
- Departments of Neurosurgery, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Andrew Frew
- Departments of Neurology, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Eric Behnke
- Departments of Neurosurgery, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Antonio DeSalles
- Departments of Neurosurgery, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Nader Pouratian
- Departments of Neurosurgery, David Geffen School of Medicine, UCLA, Los Angeles, California
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A role of diffusion tensor imaging in movement disorder surgery. Acta Neurochir (Wien) 2010; 152:2089-95. [PMID: 20652606 PMCID: PMC2991222 DOI: 10.1007/s00701-010-0742-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 07/08/2010] [Indexed: 11/04/2022]
Abstract
The safe and reversible nature of deep brain stimulation (DBS) has allowed movement disorder neurosurgery to become commonplace throughout the world. Fundamental understanding of individual patient’s anatomy is critical for optimizing the effects and side effects of DBS surgery. Three patients undergoing stereotactic surgery for movement disorders, at the institution’s intraoperative magnetic resonance imaging operating suite, were studied with fiber tractography. Stereotactic targets and fiber tractography were determined on preoperative magnetic resonance imagings using the Schaltenbrand–Wahren atlas for definition in the BrainLab iPlan software (BrainLAB Inc., Feldkirchen, Germany). Subthalamic nucleus, globus pallidus interna, and ventral intermediate nucleus targets were studied. Diffusion tensor imaging parameters used ranged from 2 to 8 mm for volume of interest in the x/y/z planes, fiber length was kept constant at 30 mm, and fractional anisotropy threshold varied from 0.20 to 0.45. Diffusion tensor imaging tractography allowed reliable and reproducible visualization and correlation between frontal eye field, premotor, primary motor, and primary sensory cortices via corticospinal tracts and corticopontocerebellar tracts. There is an apparent increase in the number of cortical regions targeted by the fiber tracts as the region of interest is enlarged. This represents a possible mechanism of the increased effects and side effects observed with higher stimulation voltages. Currently available diffusion tensor imaging techniques allow potential methods to characterize the effects and side effects of DBS. This technology has the potential of being a powerful tool to optimize DBS neurosurgery.
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Sedrak M, Gorgulho A, Bari A, Behnke E, Frew A, Gevorkyan I, Pouratian N, DeSalles A. Diffusion tensor imaging (DTI) and colored fractional anisotropy (FA) mapping of the subthalamic nucleus (STN) and the globus pallidus interna (GPi). Acta Neurochir (Wien) 2010; 152:2079-84. [PMID: 20890778 PMCID: PMC2991232 DOI: 10.1007/s00701-010-0813-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 09/16/2010] [Indexed: 11/26/2022]
Abstract
Introduction The subthalamic nucleus (STN) and the globus pallidus internus (GPi) are the most common surgical targets for the treatment of Parkinson’s disease. We studied directionally colored fractional anisotropy (FA) and diffusion tensor imaging (DTI) sequences to better target these anatomical regions. Methods Four patients undergoing stereotactic surgery for movement disorders were studied. Stereotactic targets and fiber tractography were determined on MRIs using the Schaltenbrand–Wahren atlas for definition in the iPlan software. In addition, post-operative imaging was fused to preoperative FA sequences for end-result identification. Axial, sagittal, and coronal images of the FA sequence were studied. DTI parameters used ranged from 2 to 4 mm for voxel size in the x/y/z planes, fiber length was kept constant at 15 mm and FA threshold of 0.25. Results Colored FA maps resulted in a key signature in and around the STN and GPi. Regions identified include, but were not limited to: the internal capsule, nigral projections, the thalamic fasciculus, Forel’s fields H1 and H2, zona incerta, suthalamic fasciculus, tegmental tracts, and cerebello-rubro-thalamic tract. Conclusions Colored FA maps allow a potential method to identify the STN and GPi accurately. DTI has proven to be a powerful tool that can be used to augment identification of the STN nucleus and GPi used for stereotactic surgery.
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Affiliation(s)
- Mark Sedrak
- Department of Neurosurgery, University of California Los Angeles, 90095, USA.
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Starr PA, Martin AJ, Ostrem JL, Talke P, Levesque N, Larson PS. Subthalamic nucleus deep brain stimulator placement using high-field interventional magnetic resonance imaging and a skull-mounted aiming device: technique and application accuracy. J Neurosurg 2010; 112:479-90. [PMID: 19681683 DOI: 10.3171/2009.6.jns081161] [Citation(s) in RCA: 176] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors discuss their method for placement of deep brain stimulation (DBS) electrodes using interventional MR (iMR) imaging and report on the accuracy of the technique, its initial clinical efficacy, and associated complications in a consecutive series of subthalamic nucleus (STN) DBS implants to treat Parkinson disease (PD). METHODS A skull-mounted aiming device (Medtronic NexFrame) was used in conjunction with real-time MR imaging (Philips Intera 1.5T). Preoperative imaging, DBS implantation, and postimplantation MR imaging were integrated into a single procedure performed with the patient in a state of general anesthesia. Accuracy of implantation was assessed using 2 types of measurements: the "radial error," defined as the scalar distance between the location of the intended target and the actual location of the guidance sheath in the axial plane 4 mm inferior to the commissures, and the "tip error," defined as the vector distance between the expected anterior commissure-posterior commissure (AC-PC) coordinates of the permanent DBS lead tip and the actual AC-PC coordinates of the lead tip. Clinical outcome was assessed using the Unified Parkinson's Disease Rating Scale part III (UPDRS III), in the off-medication state. RESULTS Twenty-nine patients with PD underwent iMR imaging-guided placement of 53 DBS electrodes into the STN. The mean (+/- SD) radial error was 1.2 +/- 0.65 mm, and the mean absolute tip error was 2.2 +/- 0.92 mm. The tip error was significantly smaller than for STN DBS electrodes implanted using traditional frame-based stereotaxy (3.1 +/- 1.41 mm). Eighty-seven percent of leads were placed with a single brain penetration. No hematomas were visible on MR images. Two device infections occurred early in the series. In bilaterally implanted patients, the mean improvement on the UPDRS III at 9 months postimplantation was 60%. CONCLUSIONS The authors' technical approach to placement of DBS electrodes adapts the procedure to a standard configuration 1.5-T diagnostic MR imaging scanner in a radiology suite. This method simplifies DBS implantation by eliminating the use of the traditional stereotactic frame and the subsequent requirement for registration of the brain in stereotactic space and the need for physiological recording and patient cooperation. This method has improved accuracy compared with that of anatomical guidance using standard frame-based stereotaxy in conjunction with preoperative MR imaging.
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Affiliation(s)
- Philip A Starr
- Department of Neurosurgery, University of California, San Francisco, California 94143, USA.
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Ortiz-Pérez S, Sánchez-Dalmau B, Molina J, Adán A, Candela S, Rumià J. Ocular Tilt Reaction as a Delayed Complication of Deep Brain Stimulation for Parkinson Disease. J Neuroophthalmol 2009; 29:286-8. [DOI: 10.1097/wno.0b013e3181b2822d] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Gorgulho AA, Shields DC, Malkasian D, Behnke E, DeSalles AAF. Stereotactic coordinates associated with facial musculature contraction during high-frequency stimulation of the subthalamic nucleus. J Neurosurg 2009; 110:1317-21. [DOI: 10.3171/jns.2008.10.jns08835] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
High-frequency stimulation of the subthalamic nucleus (STN) in patients with parkinsonian symptoms is often used to ameliorate debilitating motor symptoms associated with this condition. However, individual variability in the shape and orientation of this relatively small nucleus results in multiple side effects related to the spread of electrical current to surrounding structures. Specifically, contraction of the muscles of facial expression is noted in a small percentage of patients, although the precise mechanism remains poorly understood.
Methods
Facial muscle contraction was triggered by high-frequency stimulation of 49 contacts in 18 patients undergoing deep brain stimulation of the STN. The mean coordinates of these individual contacts relative to the anterior commissure–posterior commissure midpoint (also called the midcommissural point) were calculated to determine the location or structure(s) most often associated with facial contraction during physiological macrostimulation.
Results
The x, y, and z coordinates associated with contraction of the facial musculature were found to be 11.52, 1.29, and 1.15 mm lateral, posterior, and inferior to the midcommissural point, respectively. This location, along the lateral-anterior-superior border of the STN, may allow for the spread of electrical current to the fields of Forel, zona incerta, and/or descending corticospinal/corticobulbar tracts. Because stimulation of corticobulbar tracts produces similar findings, these results are best explained by the spread of electrical current to nearby internal capsule axons coursing lateral to the STN.
Conclusions
Thus, if intraoperative deep brain stimulation lead testing results in facial musculature contraction, placement of the electrode in a more medial, posterior position may reduce the amount of current spread to corticobulbar fibers and resolve this side effect.
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Affiliation(s)
- Alessandra A. Gorgulho
- 1Division of Neurosurgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California; and
| | - Donald C. Shields
- 2Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dennis Malkasian
- 1Division of Neurosurgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California; and
| | - Eric Behnke
- 1Division of Neurosurgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California; and
| | - Antonio A. F. DeSalles
- 1Division of Neurosurgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, California; and
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Starr PA, Martin AJ, Larson PS. Implantation of Deep Brain Stimulator Electrodes Using Interventional MRI. Neurosurg Clin N Am 2009; 20:193-203. [DOI: 10.1016/j.nec.2009.04.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Transient acute depressive state induced by subthalamic region stimulation. J Neurol Sci 2008; 273:135-8. [DOI: 10.1016/j.jns.2008.06.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Revised: 06/02/2008] [Accepted: 06/16/2008] [Indexed: 11/20/2022]
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