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Yuan T, Chen Y, Zhu G, Zhang J. The Related Factors and Effect of Electrode Displacement on Motor Outcome of Subthalamic Nuclei Deep Brain Stimulation in Parkinson's Disease. J Clin Med 2023; 12:7561. [PMID: 38137630 PMCID: PMC10744115 DOI: 10.3390/jcm12247561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/11/2023] [Accepted: 11/13/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Previous studies have revealed the existence of electrode displacement during subthalamic nucleus deep brain stimulation (STN-DBS). However, the effect of electrode displacement on treatment outcomes is still unclear. In this study, we aimed to analyze the related factors of electrode displacement and assess postoperative electrode displacement in relation to the motor outcomes of STN-DBS. METHODS A total of 88 patients aged 62.73 ± 6.35 years (55 males and 33 females) with Parkinson's disease undergoing STN-DBS, with comprehensive clinical characterization before and 1 month after surgery, were involved retrospectively and divided into a cross-incision group and cannula puncture group according to different dura opening methods. The electrode displacement, unilateral pneumocephalus volume percent (uPVP), and brain volume percent were estimated. RESULTS A significant anterior and lateral electrode displacement was observed among all implanted electrodes after pneumocephalus absorption (p < 0.0001). The degree of electrode displacement was positively correlated with the uPVP (p = 0.005) and smaller in females than males (p = 0.0384). Electrode displacement was negatively correlated with motor improvement following STN-DBS in both on-medication and off-medication conditions (p < 0.05). Dural puncture reduced the uPVP (p < 0.0001) and postoperative electrode displacement (p = 0.0086) compared with dural incision. CONCLUSIONS Electrode displacement had a negative impact on the therapeutic efficacy of STN-DBS. Opening the dura via cannula puncture is recommended to increase the accuracy of the lead implantation.
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Affiliation(s)
- Tianshuo Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Yingchuan Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Guanyu Zhu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University, Beijing 100070, China
- Beijing Key Laboratory of Neurostimulation, Beijing 100070, China
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2
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Melo M, Furlanetti L, Hasegawa H, Mundil N, Ashkan K. Comparison of direct MRI guided versus atlas-based targeting for subthalamic nucleus and globus pallidus deep brain stimulation. Br J Neurosurg 2023; 37:1040-1045. [PMID: 33416411 DOI: 10.1080/02688697.2020.1850641] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/10/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The subthalamic nucleus (STN) and globus pallidus internus (GPi) targets for deep brain stimulation (DBS) can be defined by atlas coordinates or direct visualisation of the target on MRI. The aim of this study was to evaluate geometric differences between atlas-based targeting and MRI-guided direct targeting. METHODS One-hundred-nine Parkinson's disease or dystonia patients records who underwent DBS surgery between 2005 and 2016 were prospectively reviewed. MRI-guided direct targeting coordinates was used to implant 205 STN and 64 GPi electrodes and compared with atlas-based coordinates. RESULTS The directly targeted coordinates (mean, SD, range) for STN were x: [9.9 ± 1.1 (7.1 - 13.2)], y: [-0.8 ± 1.1 (-4.2 - 2)] and z: [-4.7 ± 0.53 (-5.9 - -3.2)]. The mean value for the STN was 2.1 mm more medial (p < 0.0001), 1.2 mm more anterior (p < 0.0001) and 0.7 mm more ventral (p < 0.0001) than the atlas target. The targeted coordinates for GPi were x: [22.3 ± 2.0 (17.8 - 26.1)], y: [-0.2 ± 2.2 (-4.5 - 3.4)], z: [-4.3 ± 0.8 (-6.2 - -2.3)]. The mean value for the GPi was 2.2 mm (p < 0.001) more posterior and 0.3 mm (p < 0.01) more ventral than the atlas-based coordinates. CONCLUSION MRI-guided targeting may be more accurate than atlas-based targeting due to individual variations in anatomy.
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Affiliation(s)
- Mariane Melo
- Department of Neurosurgery, King's College Hospital, London, UK
| | | | | | - Nilesh Mundil
- Department of Neurosurgery, King's College Hospital, London, UK
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3
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Kremer NI, van Laar T, Lange SF, Statius Muller S, la Bastide-van Gemert S, Oterdoom DM, Drost G, van Dijk JMC. STN-DBS electrode placement accuracy and motor improvement in Parkinson's disease: systematic review and individual patient meta-analysis. J Neurol Neurosurg Psychiatry 2023; 94:236-244. [PMID: 36207065 DOI: 10.1136/jnnp-2022-329192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 09/21/2022] [Indexed: 11/05/2022]
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective neurosurgical treatment for Parkinson's disease. Surgical accuracy is a critical determinant to achieve an adequate DBS effect on motor performance. A two-millimetre surgical accuracy is commonly accepted, but scientific evidence is lacking. A systematic review and meta-analysis of study-level and individual patient data (IPD) was performed by a comprehensive search in MEDLINE, EMBASE and Cochrane Library. Primary outcome measures were (1) radial error between the implanted electrode and target; (2) DBS motor improvement on the Unified Parkinson's Disease Rating Scale part III (motor examination). On a study level, meta-regression analysis was performed. Also, publication bias was assessed. For IPD meta-analysis, a linear mixed effects model was used. Forty studies (1391 patients) were included, reporting radial errors of 0.45-1.86 mm. Errors within this range did not significantly influence the DBS effect on motor improvement. Additional IPD analysis (206 patients) revealed that a mean radial error of 1.13±0.75 mm did not significantly change the extent of DBS motor improvement. Our meta-analysis showed a huge publication bias on accuracy data in DBS. Therefore, the current literature does not provide an unequivocal upper threshold for acceptable accuracy of STN-DBS surgery. Based on the current literature, DBS-electrodes placed within a 2 mm range of the intended target do not have to be repositioned to enhance motor improvement after STN-DBS for Parkinson's disease. However, an indisputable upper cut-off value for surgical accuracy remains to be established. PROSPERO registration number is CRD42018089539.
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Affiliation(s)
- Naomi I Kremer
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Teus van Laar
- Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Stèfan F Lange
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Sijmen Statius Muller
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | | | - Dl Marinus Oterdoom
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gea Drost
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Neurosurgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
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4
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Lee AT, Han KJ, Nichols N, Sudhakar VR, Burke JF, Wozny TA, Chung JE, Volz MM, Ostrem JL, Martin AJ, Larson PS, Starr PA, Wang DD. Targeting Accuracy and Clinical Outcomes of Awake Vs Asleep Interventional MRI-Guided Deep Brain Stimulation for Parkinson's Disease: The UCSF Experience. Neurosurgery 2022; 91:717-725. [PMID: 36069560 DOI: 10.1227/neu.0000000000002111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/05/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Interventional MRI (iMRI)-guided implantation of deep brain stimulator (DBS) leads has been developed to treat patients with Parkinson's disease (PD) without the need for awake testing. OBJECTIVE Direct comparisons of targeting accuracy and clinical outcomes for awake stereotactic with asleep iMRI-DBS for PD are limited. METHODS We performed a retrospective review of patients with PD who underwent awake or iMRI-guided DBS surgery targeting the subthalamic nucleus or globus pallidus interna between 2013 and 2019 at our institution. Outcome measures included Unified Parkinson's Disease Rating Scale Part III scores, levodopa equivalent daily dose, radial error between intended and actual lead locations, stimulation parameters, and complications. RESULTS Of the 218 patients included in the study, the iMRI cohort had smaller radial errors (iMRI: 1.27 ± 0.72 mm, awake: 1.59 ± 0.96 mm, P < .01) and fewer lead passes (iMRI: 1.0 ± 0.16, awake: 1.2 ± 0.41, P < .01). Changes in Unified Parkinson's Disease Rating Scale were similar between modalities, but awake cases had a greater reduction in levodopa equivalent daily dose than iMRI cases (P < .01), which was attributed to the greater number of awake subthalamic nucleus cases on multivariate analysis. Effective clinical contacts used for stimulation, side effect thresholds, and complication rates were similar between modalities. CONCLUSION Although iMRI-DBS may result in more accurate lead placement for intended target compared with awake-DBS, clinical outcomes were similar between surgical approaches. Ultimately, patient preference and surgeon experience with a given DBS technique should be the main factors when determining the "best" method for DBS implantation.
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Affiliation(s)
- Anthony T Lee
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Kasey J Han
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Noah Nichols
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Vivek R Sudhakar
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John F Burke
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Thomas A Wozny
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Jason E Chung
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Monica M Volz
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Jill L Ostrem
- Department of Neurology, Movement Disorders and Neuromodulation Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Alastair J Martin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, California, USA
| | - Paul S Larson
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Philip A Starr
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Doris D Wang
- Department of Neurological Surgery, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, USA
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5
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Bokulić E, Medenica T, Knezović V, Štajduhar A, Almahariq F, Baković M, Judaš M, Sedmak G. The Stereological Analysis and Spatial Distribution of Neurons in the Human Subthalamic Nucleus. Front Neuroanat 2022; 15:749390. [PMID: 34970124 PMCID: PMC8712451 DOI: 10.3389/fnana.2021.749390] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
The subthalamic nucleus (STN) is a small, ovoid structure, and an important site of deep brain stimulation (DBS) for the treatment of Parkinson’s disease. Although the STN is a clinically important structure, there are many unresolved issues with regard to it. These issues are especially related to the anatomical subdivision, neuronal phenotype, neuronal composition, and spatial distribution. In this study, we have examined the expression pattern of 8 neuronal markers [nNOS, NeuN, parvalbumin (PV), calbindin (CB), calretinin (CR), FOXP2, NKX2.1, and PAX6] in the adult human STN. All of the examined markers, except CB, were present in the STN. To determine the neuronal density, we have performed stereological analysis on Nissl-stained and immunohistochemical slides of positive markers. The stereology data were also used to develop a three-dimensional map of the spatial distribution of neurons within the STN. The nNOS population exhibited the largest neuronal density. The estimated total number of nNOS STN neurons is 281,308 ± 38,967 (± 13.85%). The STN neuronal subpopulations can be divided into two groups: one with a neuronal density of approximately 3,300 neurons/mm3 and the other with a neuronal density of approximately 2,200 neurons/mm3. The largest density of STN neurons was observed along the ventromedial border of the STN and the density gradually decreased toward the dorsolateral border. In this study, we have demonstrated the presence of 7 neuronal markers in the STN, three of which were not previously described in the human STN. The human STN is a collection of diverse, intermixed neuronal subpopulations, and our data, as far as the cytoarchitectonics is concerned, did not support the tripartite STN subdivision.
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Affiliation(s)
- Ema Bokulić
- Croatian Institute for Brain Research, University of Zagreb School of Medicine, Zagreb, Croatia.,Centre of Excellence for Basic, Clinical and Translational Neuroscience, Zagreb, Croatia
| | - Tila Medenica
- Croatian Institute for Brain Research, University of Zagreb School of Medicine, Zagreb, Croatia.,Centre of Excellence for Basic, Clinical and Translational Neuroscience, Zagreb, Croatia
| | - Vinka Knezović
- Croatian Institute for Brain Research, University of Zagreb School of Medicine, Zagreb, Croatia.,Centre of Excellence for Basic, Clinical and Translational Neuroscience, Zagreb, Croatia
| | - Andrija Štajduhar
- Croatian Institute for Brain Research, University of Zagreb School of Medicine, Zagreb, Croatia.,Centre of Excellence for Basic, Clinical and Translational Neuroscience, Zagreb, Croatia.,School of Public Health "Andrija Štampar," University of Zagreb School of Medicine, Zagreb, Croatia
| | - Fadi Almahariq
- Centre of Excellence for Basic, Clinical and Translational Neuroscience, Zagreb, Croatia.,Department of Neurosurgery, Clinical Hospital "Dubrava," Zagreb, Croatia
| | - Marija Baković
- Department of Forensic Medicine, University of Zagreb School of Medicine, Zagreb, Croatia
| | - Miloš Judaš
- Croatian Institute for Brain Research, University of Zagreb School of Medicine, Zagreb, Croatia.,Centre of Excellence for Basic, Clinical and Translational Neuroscience, Zagreb, Croatia
| | - Goran Sedmak
- Croatian Institute for Brain Research, University of Zagreb School of Medicine, Zagreb, Croatia.,Centre of Excellence for Basic, Clinical and Translational Neuroscience, Zagreb, Croatia
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Hart M, Posa M, Buttery P, Morris R. Increased variance in second electrode accuracy during deep brain stimulation and its relationship to pneumocephalus, brain shift, and clinical outcomes: A retrospective cohort study. BRAIN AND SPINE 2022; 2:100893. [PMID: 36248097 PMCID: PMC9560590 DOI: 10.1016/j.bas.2022.100893] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 04/12/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022]
Abstract
Overall electrode accuracy was 0.22+/-0.4 mm with only 3 (4%) electrodes out with 2 mm from the intended target. Accuracy was significantly worse in the GPi versus the STN and on the second side implanted. Inaccuracy occurred in the X (lateral) plane but was not related to pneumocephalus or brain shift.
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Affiliation(s)
- M.G. Hart
- St George’s University of London, Cranmer Terrace, London, SW17 0RE, UK
- Corresponding author.
| | - M. Posa
- Department of Neurosurgery, Addenbrooke’s Hospital, Cambridge, CB2 0QQ, UK
| | - P.C. Buttery
- Department of Neurology, Addenbrooke’s Hospital, Cambridge, CB2 0QQ, UK
| | - R.C. Morris
- Department of Neurosurgery, Addenbrooke’s Hospital, Cambridge, CB2 0QQ, UK
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7
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Khaledi-Nasab A, Kromer JA, Tass PA. Long-Lasting Desynchronization Effects of Coordinated Reset Stimulation Improved by Random Jitters. Front Physiol 2021; 12:719680. [PMID: 34630142 PMCID: PMC8497886 DOI: 10.3389/fphys.2021.719680] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/12/2021] [Indexed: 12/30/2022] Open
Abstract
Abnormally strong synchronized activity is related to several neurological disorders, including essential tremor, epilepsy, and Parkinson's disease. Chronic high-frequency deep brain stimulation (HF DBS) is an established treatment for advanced Parkinson's disease. To reduce the delivered integral electrical current, novel theory-based stimulation techniques such as coordinated reset (CR) stimulation directly counteract the abnormal synchronous firing by delivering phase-shifted stimuli through multiple stimulation sites. In computational studies in neuronal networks with spike-timing-dependent plasticity (STDP), it was shown that CR stimulation down-regulates synaptic weights and drives the network into an attractor of a stable desynchronized state. This led to desynchronization effects that outlasted the stimulation. Corresponding long-lasting therapeutic effects were observed in preclinical and clinical studies. Computational studies suggest that long-lasting effects of CR stimulation depend on the adjustment of the stimulation frequency to the dominant synchronous rhythm. This may limit clinical applicability as different pathological rhythms may coexist. To increase the robustness of the long-lasting effects, we study randomized versions of CR stimulation in networks of leaky integrate-and-fire neurons with STDP. Randomization is obtained by adding random jitters to the stimulation times and by shuffling the sequence of stimulation site activations. We study the corresponding long-lasting effects using analytical calculations and computer simulations. We show that random jitters increase the robustness of long-lasting effects with respect to changes of the number of stimulation sites and the stimulation frequency. In contrast, shuffling does not increase parameter robustness of long-lasting effects. Studying the relation between acute, acute after-, and long-lasting effects of stimulation, we find that both acute after- and long-lasting effects are strongly determined by the stimulation-induced synaptic reshaping, whereas acute effects solely depend on the statistics of administered stimuli. We find that the stimulation duration is another important parameter, as effective stimulation only entails long-lasting effects after a sufficient stimulation duration. Our results show that long-lasting therapeutic effects of CR stimulation with random jitters are more robust than those of regular CR stimulation. This might reduce the parameter adjustment time in future clinical trials and make CR with random jitters more suitable for treating brain disorders with abnormal synchronization in multiple frequency bands.
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Affiliation(s)
- Ali Khaledi-Nasab
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
| | - Justus A Kromer
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
| | - Peter A Tass
- Department of Neurosurgery, Stanford University, Stanford, CA, United States
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8
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de Roquemaurel A, Wirth T, Vijiaratnam N, Ferreira F, Zrinzo L, Akram H, Foltynie T, Limousin P. Stimulation Sweet Spot in Subthalamic Deep Brain Stimulation - Myth or Reality? A Critical Review of Literature. Stereotact Funct Neurosurg 2021; 99:425-442. [PMID: 34120117 DOI: 10.1159/000516098] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/23/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION While deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been extensively used for more than 20 years in Parkinson's disease (PD), the optimal area of stimulation to relieve motor symptoms remains elusive. OBJECTIVE We aimed at localizing the sweet spot within the subthalamic region by performing a systematic review of the literature. METHOD PubMed database was searched for published studies exploring optimal stimulation location for STN DBS in PD, published between 2000 and 2019. A standardized assessment procedure based on methodological features was applied to select high-quality publications. Studies conducted more than 3 months after the DBS procedure, employing lateralized scores and/or stimulation condition, and reporting the volume of tissue activated or the position of the stimulating contact within the subthalamic region were considered in the final analysis. RESULTS Out of 439 references, 24 were finally retained, including 21 studies based on contact location and 3 studies based on volume of tissue activated (VTA). Most studies (all VTA-based studies and 13 of the 21 contact-based studies) suggest the superior-lateral STN and the adjacent white matter as the optimal sites for stimulation. Remaining contact-based studies were either inconclusive (5/21), favoured the caudal zona incerta (1/21), or suggested a better outcome of STN stimulation than adjacent white matter stimulation (2/21). CONCLUSION Using a standardized methodological approach, our review supports the presence of a sweet spot located within the supero-lateral STN and extending to the adjacent white matter.
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Affiliation(s)
- Alexis de Roquemaurel
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Thomas Wirth
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Neurology department, Strasbourg University Hospital, Strasbourg, France.,INSERM-U964/CNRS-UMR7104/University of Strasbourg, Illkirch-Graffenstaden, France
| | - Nirosen Vijiaratnam
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Francisca Ferreira
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Ludvic Zrinzo
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Harith Akram
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Thomas Foltynie
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Patricia Limousin
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
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Scorza D, El Hadji S, Cortés C, Bertelsen Á, Cardinale F, Baselli G, Essert C, Momi ED. Surgical planning assistance in keyhole and percutaneous surgery: A systematic review. Med Image Anal 2020; 67:101820. [PMID: 33075642 DOI: 10.1016/j.media.2020.101820] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 08/07/2020] [Accepted: 09/07/2020] [Indexed: 11/29/2022]
Abstract
Surgical planning of percutaneous interventions has a crucial role to guarantee the success of minimally invasive surgeries. In the last decades, many methods have been proposed to reduce clinician work load related to the planning phase and to augment the information used in the definition of the optimal trajectory. In this survey, we include 113 articles related to computer assisted planning (CAP) methods and validations obtained from a systematic search on three databases. First, a general formulation of the problem is presented, independently from the surgical field involved, and the key steps involved in the development of a CAP solution are detailed. Secondly, we categorized the articles based on the main surgical applications, which have been object of study and we categorize them based on the type of assistance provided to the end-user.
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Affiliation(s)
- Davide Scorza
- Vicomtech Foundation, Basque Research and Technology Alliance (BRTA), Donostia-San Sebastián, Spain; Department of Electronics, Information and Bioengineering (DEIB), Politecnico di Milano, Milan, Italy; Biodonostia Health Research Institute, Donostia-San Sebastián, Spain.
| | - Sara El Hadji
- Department of Electronics, Information and Bioengineering (DEIB), Politecnico di Milano, Milan, Italy.
| | - Camilo Cortés
- Vicomtech Foundation, Basque Research and Technology Alliance (BRTA), Donostia-San Sebastián, Spain; Biodonostia Health Research Institute, Donostia-San Sebastián, Spain
| | - Álvaro Bertelsen
- Vicomtech Foundation, Basque Research and Technology Alliance (BRTA), Donostia-San Sebastián, Spain; Biodonostia Health Research Institute, Donostia-San Sebastián, Spain
| | - Francesco Cardinale
- Claudio Munari Centre for Epilepsy and Parkinson surgery, Azienda Socio-Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda (ASST GOM Niguarda), Milan, Italy
| | - Giuseppe Baselli
- Department of Electronics, Information and Bioengineering (DEIB), Politecnico di Milano, Milan, Italy
| | - Caroline Essert
- ICube Laboratory, CNRS, UMR 7357, Université de Strasbourg, Strasbourg, France
| | - Elena De Momi
- Department of Electronics, Information and Bioengineering (DEIB), Politecnico di Milano, Milan, Italy
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10
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Park HR, Lim YH, Song EJ, Lee JM, Park K, Park KH, Lee WW, Kim HJ, Jeon B, Paek SH. Bilateral Subthalamic Nucleus Deep Brain Stimulation under General Anesthesia: Literature Review and Single Center Experience. J Clin Med 2020; 9:jcm9093044. [PMID: 32967337 PMCID: PMC7564882 DOI: 10.3390/jcm9093044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023] Open
Abstract
Bilateral subthalamic nucleus (STN) Deep brain stimulation (DBS) is a well-established treatment in patients with Parkinson's disease (PD). Traditionally, STN DBS for PD is performed by using microelectrode recording (MER) and/or intraoperative macrostimulation under local anesthesia (LA). However, many patients cannot tolerate the long operation time under LA without medication. In addition, it cannot be even be performed on PD patients with poor physical and neurological condition. Recently, it has been reported that STN DBS under general anesthesia (GA) can be successfully performed due to the feasible MER under GA, as well as the technical advancement in direct targeting and intraoperative imaging. The authors reviewed the previously published literature on STN DBS under GA using intraoperative imaging and MER, focused on discussing the technique, clinical outcome, and the complication, as well as introducing our single-center experience. Based on the reports of previously published studies and ours, GA did not interfere with the MER signal from STN. STN DBS under GA without intraoperative stimulation shows similar or better clinical outcome without any additional complication compared to STN DBS under LA. Long-term follow-up with a large number of the patients would be necessary to validate the safety and efficacy of STN DBS under GA.
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Affiliation(s)
- Hye Ran Park
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul 04401, Korea;
| | - Yong Hoon Lim
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (Y.H.L.); (E.J.S.)
| | - Eun Jin Song
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (Y.H.L.); (E.J.S.)
| | - Jae Meen Lee
- Department of Neurosurgery, Pusan National University Hospital, Busan 49241, Korea;
| | - Kawngwoo Park
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon 21565, Korea;
| | - Kwang Hyon Park
- Department of Neurosurgery, Chuungnam National University Sejong Hospital, Sejong 30099, Korea;
| | - Woong-Woo Lee
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul 01830, Korea;
| | - Han-Joon Kim
- Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea; (H.-J.K.); (B.J.)
| | - Beomseok Jeon
- Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea; (H.-J.K.); (B.J.)
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (Y.H.L.); (E.J.S.)
- Correspondence: ; Tel.: +82-22-072-2876
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11
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Oishi K, Mori S, Troncoso JC, Lenz FA. Mapping tracts in the human subthalamic area by 11.7T ex vivo diffusion tensor imaging. Brain Struct Funct 2020; 225:1293-1312. [PMID: 32303844 PMCID: PMC7584118 DOI: 10.1007/s00429-020-02066-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 04/03/2020] [Indexed: 02/07/2023]
Abstract
The cortico-basal ganglia-thalamo-cortical feedback loops that consist of distinct white matter pathways are important for understanding in vivo imaging studies of functional and anatomical connectivity, and for localizing subthalamic white matter structures in surgical approaches for movement disorders, such as Parkinson's disease. Connectomic analysis in animals has identified fiber connections between the basal ganglia and thalamus, which pass through the fields of Forel, where other fiber pathways related to motor, sensory, and cognitive functions co-exist. We now report these pathways in the human brain on ex vivo mesoscopic (250 μm) diffusion tensor imaging and on tractography. The locations of the tracts were identified relative to the adjacent gray matter structures, such as the internal and external segments of the globus pallidus; the zona incerta; the subthalamic nucleus; the substantia nigra pars reticulata and compacta; and the thalamus. The connectome atlas of the human subthalamic region may serve as a resource for imaging studies and for neurosurgical planning.
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Affiliation(s)
- Kenichi Oishi
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 208 Traylor Building, 720 Rutland Ave., Baltimore, MD, 21205, USA.
| | - Susumu Mori
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 208 Traylor Building, 720 Rutland Ave., Baltimore, MD, 21205, USA
- Kennedy Krieger Institute, Baltimore, MD, USA
| | - Juan C Troncoso
- Division of Neuropathology, Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Frederick A Lenz
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Meyer 8181 Neurosurgery, 600 North Wolfe Street, Baltimore, MD, 21287, USA.
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12
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Latency of subthalamic nucleus deep brain stimulation-evoked cortical activity as a potential biomarker for postoperative motor side effects. Clin Neurophysiol 2020; 131:1221-1229. [PMID: 32299006 DOI: 10.1016/j.clinph.2020.02.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 02/07/2020] [Accepted: 02/11/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Here, we investigate whether cortical activation predicts motor side effects of deep brain stimulation (DBS) and whether these potential biomarkers have utility under general anesthesia. METHODS We recorded scalp potentials elicited by DBS during surgery (n = 11), both awake and under general anesthesia, and in an independent ambulatory cohort (n = 8). Across a range of stimulus configurations, we measured the amplitude and timing of short- and long-latency response components and linked them to motor side effects. RESULTS Regardless of anesthesia state, in both cohorts, DBS settings with capsular side effects elicited early responses with peak latencies clustering at <1 ms. This early response was preserved under anesthesia in all participants (11/11). In contrast, the long-latency components were suppressed completely in 6/11 participants. Finally, the latency of the earliest response could predict the presence of postoperative motor side effects both awake and under general anesthesia (84.8% and 75.8% accuracy, awake and under anesthesia, respectively). CONCLUSION DBS elicits short-latency cortical activation, both awake and under general anesthesia, which appears to reveal interactions between the stimulus and the corticospinal tract. SIGNIFICANCE Short-latency evoked cortical activity can potentially be used to aid both DBS lead placement and post-operative programming.
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13
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Nguyen AA, Maia PD, Gao X, Damasceno PF, Raj A. Dynamical Role of Pivotal Brain Regions in Parkinson Symptomatology Uncovered with Deep Learning. Brain Sci 2020; 10:E73. [PMID: 32019067 PMCID: PMC7071401 DOI: 10.3390/brainsci10020073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 01/22/2020] [Accepted: 01/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The release of a broad, longitudinal anatomical dataset by the Parkinson's Progression Markers Initiative promoted a surge of machine-learning studies aimed at predicting disease onset and progression. However, the excessive number of features used in these models often conceals their relationship to the Parkinsonian symptomatology. OBJECTIVES The aim of this study is two-fold: (i) to predict future motor and cognitive impairments up to four years from brain features acquired at baseline; and (ii) to interpret the role of pivotal brain regions responsible for different symptoms from a neurological viewpoint. METHODS We test several deep-learning neural network configurations, and report our best results obtained with an autoencoder deep-learning model, run on a 5-fold cross-validation set. Comparison with Existing Methods: Our approach improves upon results from standard regression and others. It also includes neuroimaging biomarkers as features. RESULTS The relative contributions of pivotal brain regions to each impairment change over time, suggesting a dynamical reordering of culprits as the disease progresses. Specifically, the Putamen is initially the most critical region accounting for the overall cognitive state, only being surpassed by the Substantia Nigra in later years. The Pallidum is the first region to influence motor scores, followed by the parahippocampal and ambient gyri, and the anterior orbital gyrus. CONCLUSIONS While the causal link between regional brain atrophy and Parkinson symptomatology is poorly understood, our methods demonstrate that the contributions of pivotal regions to cognitive and motor impairments are more dynamical than generally appreciated.
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Affiliation(s)
- Alex A. Nguyen
- Department of Radiology and Biomedical Imaging, UC San Francisco, San Francisco, CA 94107, USA; (A.A.N.); (X.G.); (P.F.D.)
| | - Pedro D. Maia
- Department of Radiology and Biomedical Imaging, UC San Francisco, San Francisco, CA 94107, USA; (A.A.N.); (X.G.); (P.F.D.)
| | - Xiao Gao
- Department of Radiology and Biomedical Imaging, UC San Francisco, San Francisco, CA 94107, USA; (A.A.N.); (X.G.); (P.F.D.)
| | - Pablo F. Damasceno
- Department of Radiology and Biomedical Imaging, UC San Francisco, San Francisco, CA 94107, USA; (A.A.N.); (X.G.); (P.F.D.)
- Bakar Computational Health Sciences Institute, UC San Francisco, San Francisco, CA 94158, USA
- Center for Intelligent Imaging, UC San Francisco, San Francisco, CA 94107, USA
| | - Ashish Raj
- Department of Radiology and Biomedical Imaging, UC San Francisco, San Francisco, CA 94107, USA; (A.A.N.); (X.G.); (P.F.D.)
- Bakar Computational Health Sciences Institute, UC San Francisco, San Francisco, CA 94158, USA
- Center for Intelligent Imaging, UC San Francisco, San Francisco, CA 94107, USA
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14
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Ponce FA. Intraoperative Magnetic Resonance Imaging and Computed Tomography. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Wang J, Ponce FA, Tao J, Yu HM, Liu JY, Wang YJ, Luan GM, Ou SW. Comparison of Awake and Asleep Deep Brain Stimulation for Parkinson's Disease: A Detailed Analysis Through Literature Review. Neuromodulation 2019; 23:444-450. [PMID: 31830772 DOI: 10.1111/ner.13061] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/22/2019] [Accepted: 09/11/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Deep brain stimulation (DBS) for Parkinson's disease (PD) has been applied to clinic for approximately 30 years. The goal of this review is to explore the similarities and differences between "awake" and "asleep" DBS techniques. METHODS A comprehensive literature review was carried out to identify relevant studies and review articles describing applications of "awake" or "asleep" DBS for Parkinson's disease. The surgical procedures, clinical outcomes, costs and complications of each technique were compared in detail through literature review. RESULTS The surgical procedures of awake and asleep DBS surgeries rely upon different methods for verification of intended target acquisition. The existing research results demonstrated that the stereotactic targeting accuracy of lead placement obtained by either method is reliable. There were no significant differences in clinical outcomes, costs, or complications between the two techniques. CONCLUSION The surgical and clinical outcomes of asleep DBS for PD are comparable to those of awake DBS.
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Affiliation(s)
- Jun Wang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jun Tao
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Hong-Mei Yu
- Department of Neurology, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Ji-Yuan Liu
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Yun-Jie Wang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Guo-Ming Luan
- Department of Neurosurgery, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing, P. R., China
| | - Shao-Wu Ou
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
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16
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Isaacs BR, Trutti AC, Pelzer E, Tittgemeyer M, Temel Y, Forstmann BU, Keuken MC. Cortico-basal white matter alterations occurring in Parkinson's disease. PLoS One 2019; 14:e0214343. [PMID: 31425517 PMCID: PMC6699705 DOI: 10.1371/journal.pone.0214343] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/17/2019] [Indexed: 01/01/2023] Open
Abstract
Magnetic resonance imaging studies typically use standard anatomical atlases for identification and analyses of (patho-)physiological effects on specific brain areas; these atlases often fail to incorporate neuroanatomical alterations that may occur with both age and disease. The present study utilizes Parkinson's disease and age-specific anatomical atlases of the subthalamic nucleus for diffusion tractography, assessing tracts that run between the subthalamic nucleus and a-priori defined cortical areas known to be affected by Parkinson's disease. The results show that the strength of white matter fiber tracts appear to remain structurally unaffected by disease. Contrary to that, Fractional Anisotropy values were shown to decrease in Parkinson's disease patients for connections between the subthalamic nucleus and the pars opercularis of the inferior frontal gyrus, anterior cingulate cortex, the dorsolateral prefrontal cortex and the pre-supplementary motor, collectively involved in preparatory motor control, decision making and task monitoring. While the biological underpinnings of fractional anisotropy alterations remain elusive, they may nonetheless be used as an index of Parkinson's disease. Moreover, we find that failing to account for structural changes occurring in the subthalamic nucleus with age and disease reduce the accuracy and influence the results of tractography, highlighting the importance of using appropriate atlases for tractography.
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Affiliation(s)
- Bethany. R. Isaacs
- Integrative Model-based Cognitive Neuroscience research unit, University of Amsterdam, Amsterdam, the Netherlands
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Anne. C. Trutti
- Integrative Model-based Cognitive Neuroscience research unit, University of Amsterdam, Amsterdam, the Netherlands
- Cognitive Psychology, University of Leiden, Leiden, the Netherlands
| | - Esther Pelzer
- Translational Neurocircuitry, Max Planck Institute for Metabolism Research, Cologne, Germany
- Department of Neurology, University Clinics, Cologne, Germany
| | - Marc Tittgemeyer
- Translational Neurocircuitry, Max Planck Institute for Metabolism Research, Cologne, Germany
- Department of Neurology, University Clinics, Cologne, Germany
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Birte. U. Forstmann
- Integrative Model-based Cognitive Neuroscience research unit, University of Amsterdam, Amsterdam, the Netherlands
| | - Max. C. Keuken
- Integrative Model-based Cognitive Neuroscience research unit, University of Amsterdam, Amsterdam, the Netherlands
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17
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Lozano CS, Ranjan M, Boutet A, Xu DS, Kucharczyk W, Fasano A, Lozano AM. Imaging alone versus microelectrode recording-guided targeting of the STN in patients with Parkinson's disease. J Neurosurg 2019; 130:1847-1852. [PMID: 30074454 DOI: 10.3171/2018.2.jns172186] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/23/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The clinical results of deep brain stimulation (DBS) of the subthalamic nucleus (STN) are highly dependent on accurate targeting and target implantation. Several targeting tactics are in current use, including image-only and/or electrophysiologically guided approaches using microelectrode recordings (MERs). The purpose of the present study was to make an appraisal of imaging only-based versus imaging with the addition of intraoperative MER-guided STN electrode targeting. METHODS The authors evaluated 100 consecutive patients undergoing STN DBS. The position of the STN target was estimated from preoperative MR images (direct target) or in relation to the position of the anterior and posterior commissures (indirect target). MERs were obtained for each trajectory. The authors tracked which targets were adjusted intraoperatively as a consequence of MER data. The final placement of 182 total STN electrodes was validated by intraoperative macrostimulation through the implanted DBS electrodes. The authors compared the image-based direct, indirect, MER-guided target adjustments and the final coordinates of the electrodes as seen on postoperative MRI. RESULTS In approximately 80% of the trajectories, there was a good correspondence between the imaging-based and the MER-guided localization of the STN target. In approximately 20% of image-based targeting trajectories, however, the electrophysiological data revealed that the trajectory was suboptimal, missing the important anatomical structures to a significant extent. The greatest mismatch was in the superior-inferior axis, but this had little impact because it could be corrected without changing trajectories. Of more concern were mismatches of 2 mm or more in the mediolateral (x) or anteroposterior (y) planes, discrepancies that necessitated a new targeting trajectory to correct for the mis-targeting. The incidence of mis-targetting requiring a second MER trajectory on the first and second sides was similar (18% and 22%). CONCLUSIONS According to the present analysis, approximately 80% of electrodes were appropriately targeted using imaging alone. In the other 20%, imaging alone led to suboptimal targeting that could be corrected by a trajectory course correction guided by the acquired MER data. The authors' results suggest that preoperative imaging is insufficient to obtain optimal results in all patients undergoing STN DBS.
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Affiliation(s)
| | - Manish Ranjan
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
| | - Alexandre Boutet
- 2Division of Neuroimaging, Department of Medical Imaging, University of Toronto; and
| | - David S Xu
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
| | - Walter Kucharczyk
- 2Division of Neuroimaging, Department of Medical Imaging, University of Toronto; and
| | - Alfonso Fasano
- 3Morton and Gloria Shulman Movement Disorders Centre and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital, University Health Network and Division of Neurology, University of Toronto; Krembil Research Institute, Toronto, Ontario, Canada
| | - Andres M Lozano
- 1Division of Neurosurgery, Department of Surgery, University of Toronto
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18
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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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19
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Asahi T, Ikeda K, Yamamoto J, Tsubono H, Sato S. Pilot Study for Considering Subthalamic Nucleus Anatomy during Stimulation Using Directional Leads. J Mov Disord 2019; 12:97-102. [PMID: 30944286 PMCID: PMC6547037 DOI: 10.14802/jmd.18054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/06/2019] [Indexed: 12/22/2022] Open
Abstract
Objective Directional leads are used for deep brain stimulation (DBS). Two of the four contacts of the leads are divided into three parts, enabling controlled stimulation in a circumferential direction. The direction of adverse effects evoked by DBS in the subthalamic nucleus (STN) and stimulation strategies using directional leads were evaluated. Methods Directional leads were implanted into the bilateral STN of six parkinsonian patients (1 man, 5 women; mean age 66.2 years). The contact centers were located within the upper border of the STN, and the locations were identified electrically using microrecordings. Adverse effects were evaluated with electrical stimulation (30 μs, 130 Hz, limit 11 mA) using the directional part of each lead after surgery, and the final stimulation direction was investigated. Unified Parkinson’s disease rating scale (UPDRS) scores were evaluated before and after DBS. Results Fifty-six motor and four sensory symptoms were evoked by stimulation; no adverse effect was evoked in 14 contacts. Motor and sensory symptoms were evoked by stimulation in the anterolateral direction and medial to posterolateral direction, respectively. Stimulation in the posteromedial direction produced adverse effects less frequently. The most frequently used contacts were located above the STN (63%), followed by the upper part of the STN (32%). The mean UPDRS part III and dyskinesia scores decreased after DBS from 30.2 ± 11.7 to 7.2 ± 2.9 and 3.3 ± 2.4 to 0.5 ± 0.8, respectively. Conclusion The incidence of adverse effects was low for the posteromedial stimulation of the STN. Placing the directional part of the lead above the STN may facilitate the control of dyskinesia.
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Affiliation(s)
- Takashi Asahi
- Department of Neurosurgery, Kanazawa Neurosurgical Hospital, Ishikawa, Japan
| | - Kiyonobu Ikeda
- Department of Neurosurgery, Kanazawa Neurosurgical Hospital, Ishikawa, Japan
| | - Jiro Yamamoto
- Department of Neurosurgery, Kanazawa Neurosurgical Hospital, Ishikawa, Japan
| | - Hiroyuki Tsubono
- Department of Medical Engineering, Kanazawa Neurosurgical Hospital, Ishikawa, Japan
| | - Shuji Sato
- Department of Neurosurgery, Kanazawa Neurosurgical Hospital, Ishikawa, Japan
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20
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Telkes I, Viswanathan A, Jimenez-Shahed J, Abosch A, Ozturk M, Gupte A, Jankovic J, Ince NF. Local field potentials of subthalamic nucleus contain electrophysiological footprints of motor subtypes of Parkinson's disease. Proc Natl Acad Sci U S A 2018; 115:E8567-E8576. [PMID: 30131429 PMCID: PMC6130371 DOI: 10.1073/pnas.1810589115] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Although motor subtypes of Parkinson's disease (PD), such as tremor dominant (TD) and postural instability and gait difficulty (PIGD), have been defined based on symptoms since the mid-1990s, no underlying neural correlates of these clinical subtypes have yet been identified. Very limited data exist regarding the electrophysiological abnormalities within the subthalamic nucleus (STN) that likely accompany the symptom severity or the phenotype of PD. Here, we show that activity in subbands of local field potentials (LFPs) recorded with multiple microelectrodes from subterritories of STN provide distinguishing neurophysiological information about the motor subtypes of PD. We studied 24 patients with PD and found distinct patterns between TD (n = 13) and PIGD (n = 11) groups in high-frequency oscillations (HFOs) and their nonlinear interactions with beta band in the superior and inferior regions of the STN. Particularly, in the superior region of STN, the power of the slow HFO (sHFO) (200-260 Hz) and the coupling of its amplitude with beta-band phase were significantly stronger in the TD group. The inferior region of STN exhibited fast HFOs (fHFOs) (260-450 Hz), which have a significantly higher center frequency in the PIGD group. The cross-frequency coupling between fHFOs and beta band in the inferior region of STN was significantly stronger in the PIGD group. Our results indicate that the spatiospectral dynamics of STN-LFPs can be used as an objective method to distinguish these two motor subtypes of PD. These observations might lead to the development of sensing and stimulation strategies targeting the subterritories of STN for the personalization of deep-brain stimulation (DBS).
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Affiliation(s)
- Ilknur Telkes
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060
| | - Ashwin Viswanathan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030
| | - Joohi Jimenez-Shahed
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX 77030
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO 80045
| | - Musa Ozturk
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060
| | - Akshay Gupte
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN 55455
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX 77030
| | - Nuri F Ince
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060;
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21
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Conrad E, Mossner J, Chou K, Patil P. Atlas-Independent, Electrophysiological Mapping of the Optimal Locus of Subthalamic Deep Brain Stimulation for the Motor Symptoms of Parkinson Disease. Stereotact Funct Neurosurg 2018; 96:91-99. [DOI: 10.1159/000486643] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 01/08/2018] [Indexed: 11/19/2022]
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22
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Gunalan K, Howell B, McIntyre CC. Quantifying axonal responses in patient-specific models of subthalamic deep brain stimulation. Neuroimage 2018; 172:263-277. [PMID: 29331449 PMCID: PMC5910209 DOI: 10.1016/j.neuroimage.2018.01.015] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 12/08/2017] [Accepted: 01/09/2018] [Indexed: 02/07/2023] Open
Abstract
Medical imaging has played a major role in defining the general anatomical targets for deep brain stimulation (DBS) therapies. However, specifics on the underlying brain circuitry that is directly modulated by DBS electric fields remain relatively undefined. Detailed biophysical modeling of DBS provides an approach to quantify the theoretical responses to stimulation at the cellular level, and has established a key role for axonal activation in the therapeutic mechanisms of DBS. Estimates of DBS-induced axonal activation can then be coupled with advances in defining the structural connectome of the human brain to provide insight into the modulated brain circuitry and possible correlations with clinical outcomes. These pathway-activation models (PAMs) represent powerful tools for DBS research, but the theoretical predictions are highly dependent upon the underlying assumptions of the particular modeling strategy used to create the PAM. In general, three types of PAMs are used to estimate activation: 1) field-cable (FC) models, 2) driving force (DF) models, and 3) volume of tissue activated (VTA) models. FC models represent the "gold standard" for analysis but at the cost of extreme technical demands and computational resources. Consequently, DF and VTA PAMs, derived from simplified FC models, are typically used in clinical research studies, but the relative accuracy of these implementations is unknown. Therefore, we performed a head-to-head comparison of the different PAMs, specifically evaluating DBS of three different axonal pathways in the subthalamic region. The DF PAM was markedly more accurate than the VTA PAMs, but none of these simplified models were able to match the results of the patient-specific FC PAM across all pathways and combinations of stimulus parameters. These results highlight the limitations of using simplified predictors to estimate axonal stimulation and emphasize the need for novel algorithms that are both biophysically realistic and computationally simple.
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Affiliation(s)
- Kabilar Gunalan
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Bryan Howell
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA
| | - Cameron C McIntyre
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, OH, USA.
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23
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Automatic preoperative planning of DBS electrode placement using anatomo-clinical atlases and volume of tissue activated. Int J Comput Assist Radiol Surg 2018; 13:1117-1128. [PMID: 29557997 DOI: 10.1007/s11548-018-1724-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 02/28/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Deep brain stimulation (DBS) is a procedure requiring accurate targeting and electrode placement. The two key elements for successful planning are preserving patient safety by ensuring a safe trajectory and creating treatment efficacy through optimal selection of the stimulation point. In this work, we present the first approach of computer-assisted preoperative DBS planning to automatically optimize both the safety of the electrode's trajectory and location of the stimulation point so as to provide the best clinical outcome. METHODS Building upon the findings of previous works focused on electrode trajectory, we added a set of constraints guiding the choice of stimulation point. These took into account retrospective data represented by anatomo-clinical atlases and intersections between the stimulation region and sensitive anatomical structures causing side effects. We implemented our method into automatic preoperative planning software to assess if the algorithm was able to simultaneously optimize electrode trajectory and the stimulation point. RESULTS Leave-one-out cross-validation on a dataset of 18 cases demonstrated an improvement in the expected outcome when using the new constraints. The distance to critical structures was not reduced. The intersection between the stimulation region and structures sensitive to stimulation was minimized. CONCLUSIONS Introducing these new constraints guided the planning to select locations showing a trend toward symptom improvement, while minimizing the risks of side effects, and there was no cost in terms of trajectory safety.
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24
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Velasco F, Esqueda-Liquidano M, Velasco A, García-Gomar M. Prelemniscal Lesion for Selective Improvement of Parkinson Disease Tremor. Stereotact Funct Neurosurg 2018; 96:54-59. [DOI: 10.1159/000486318] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 12/05/2017] [Indexed: 12/19/2022]
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Predictors of deep brain stimulation outcome in tremor patients. Brain Stimul 2018; 11:592-599. [PMID: 29330020 DOI: 10.1016/j.brs.2017.12.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/27/2017] [Accepted: 12/28/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Deep brain stimulation of the ventro-intermedius nucleus of the thalamus is an established treatment for tremor of differing etiologies but factors that may predict the short- and especially long-term outcome of surgery are still largely unknown. METHODS We retrospectively investigated the clinical, pharmacological, electrophysiological and anatomical features that might predict the initial response and preservation of benefit in all patients who underwent deep brain stimulation for tremor. Data were collected at the following time points: baseline (preoperative), one-year post-surgery, and most recent visit. Tremor severity was recorded using the Fahn-Tolosa-Marin Tremor Rating Scale and/or the Unified Parkinson's Disease Rating Scale. RESULTS A total of 52 patients were included in the final analysis: 31 with essential tremor, 15 with cerebellar tremor of different etiologies, and 6 with Parkinson's disease. Long-term success (mean follow-up duration 34.7 months, range 1.7-121.1 months) was reported in 63.5%. Predictors of long-term benefit were: underlying tremor etiology (best outcome in Parkinson's disease, worst outcome in cerebellar tremor); age at surgery (the older the better); baseline tremor severity (the greater the better); lack of response to benzodiazepines; a more anterior electrode placement and single-unit beta power (the greater the better). CONCLUSIONS Specific patients' features (including single unit beta activity) and electrode locations may predict the short- and long-term benefit of thalamic stimulation for tremor. Future prospective studies enrolling a much larger sample of patients are needed to substantiate the associations detected by this retrospective study.
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Ispierto L, Muñoz J, Cladellas JM, Cuadras P, Capellades J, Latorre P, Dávalos A, Vancamp T, Álvarez R. Post-Operative Localization of Deep Brain Stimulation Electrodes in the Subthalamus Using Transcranial Sonography. Neuromodulation 2017; 21:574-581. [PMID: 29178240 DOI: 10.1111/ner.12733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/19/2017] [Accepted: 06/16/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The correct positioning of deep brain stimulation electrodes determines the success of surgery. In this study, we attempt to validate transcranial sonography (TCS) as a method for early postoperative confirmation of electrode location in the subthalamic nucleus (STN). MATERIALS AND METHODS Nineteen patients diagnosed with Parkinson's disease were enrolled in the study. Postoperative TCS was applied to measure the distance between the implanted electrodes and the third ventricle in the axial plane. Whether the electrodes were positioned within or outside the substantia nigra (SN) was evaluated through measurements in the coronal plane. The obtained metrics through TCS were compared with those from postoperative computed tomography (CT) and magnetic resonance imaging (MRI). RESULTS A statistically significant correlation between distances from electrode to third ventricle by TCS and CT/MRI (r = 0.75, p < 0.01) was observed. Distances from third ventricle to electrodes tips were different when sonographically they showed to be inside or outside the SN (p < 0.01). A cut-off value of 8.85mm in these distances was the most sensitive (100%) and specific (90.5%) to predict if electrodes were positioned inside the SN (CI 95% 0.81-10.30, p = 0.001). CONCLUSIONS Transcranial sonography is a useful technique to reliably identify targeted positioning of deep brain stimulation electrodes in or out of the SN.
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Affiliation(s)
- Lourdes Ispierto
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Jorge Muñoz
- Department of Neurosurgery and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Josep Maria Cladellas
- Department of Neurosurgery and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Patricia Cuadras
- Department of Radiology, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Jaume Capellades
- Image Diagnosis Institute, Badalona, Spain.,Department of Medical Imaging Consorci MAR Parc de Salut, Barcelona, Spain
| | - Pilar Latorre
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Antoni Dávalos
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Tim Vancamp
- BRAI2N, St. Augustinus Hospital, Wilrijk, Belgium
| | - Ramiro Álvarez
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
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Shenai MB, Patel DM, Romeo A, Whisenhunt JD, Walker HC, Guthrie S, Guthrie BL. The Relationship of Electrophysiologic Subthalamic Nucleus Length as a Predictor of Outcomes in Deep Brain Stimulation for Parkinson Disease. Stereotact Funct Neurosurg 2017; 95:341-347. [PMID: 28982098 DOI: 10.1159/000478023] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 06/05/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Intraoperative measurement of subthalamic nucleus (STN) width through microelectrode recording (MER) is a common proxy for optimal electrode location during deep brain stimulation (DBS) surgery for Parkinson disease. We assessed whether the MER-determined STN width is a predictor of postoperative Unified Parkinson Disease Rating Scale (UPDRS) improvement. METHODS Records were reviewed for patients who underwent single-sided STN DBS placement for Parkinson disease between 2005 and 2010 at the UAB Medical Center. Reviews of preoperative and 3-month postoperative UPDRS part III, intraoperative MER records, and postoperative MRI scans were conducted. RESULTS The final cohort consisted of 73 patients (mean age 59 ± 9.7 years, length of disease 13 ± 9.7 years). STN widths were defined as depths associated with increased background activity and motor-driven, spiking action potentials on MER. The mean contralateral UPDRS improvement was 58% (± 24). The mean STN width was 5.1 mm (± 1.6, min = 0.0, max = 8.7). No significant relationship between STN width and UPDRS improvement was found, with and without AC-PC normalization (R2 < 0.05). CONCLUSION This analysis raises questions about seeking the maximal electrophysiological width of STN as a proxy for optimal outcome in DBS for PD. We suggest this strategy for DBS placement in Parkinson disease be subject to more robust prospective investigation.
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Affiliation(s)
- Mahesh B Shenai
- Inova Medical Group Department of Neurosurgery, Fairfax, VA, USA
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Qi D, Liu Z, Liu Y, Jiang Y, Leow WR, Pal M, Pan S, Yang H, Wang Y, Zhang X, Yu J, Li B, Yu Z, Wang W, Chen X. Highly Stretchable, Compliant, Polymeric Microelectrode Arrays for In Vivo Electrophysiological Interfacing. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2017; 29:1702800. [PMID: 28869690 DOI: 10.1002/adma.201702800] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 07/05/2017] [Indexed: 06/07/2023]
Abstract
Polymeric microelectrode arrays (MEAs) are emerging as a new generation of biointegrated microelectrodes to transduce original electrochemical signals in living tissues to external electrical circuits, and vice versa. So far, the challenge of stretchable polymeric MEAs lies in the competition between high stretchability and good electrode-substrate adhesion. The larger the stretchability, the easier the delamination of electrodes from the substrate due to the mismatch in their Young's modulus. In this work, polypyrrole (PPy) electrode materials are designed, with PPy nanowires integrated on the high conductive PPy electrode arrays. By utilizing this electrode material, for the first time, stretchable polymeric MEAs are fabricated with both high stretchability (≈100%) and good electrode-substrate adhesion (1.9 MPa). In addition, low Young's modulus (450 kPa), excellent recycling stability (10 000 cycles of stretch), and high conductivity of the MEAs are also achieved. As a proof of concept, the as-prepared polymeric MEAs are successfully used for conformally recording the electrocorticograph signals from rats in normal and epileptic states, respectively. Further, these polymeric MEAs are also successful in stimulating the ischiadic nerve of the rat. This strategy provides a new perspective to the highly stretchable and mechanically stable polymeric MEAs, which are vital for compliant neural electrodes.
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Affiliation(s)
- Dianpeng Qi
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Zhiyuan Liu
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Yan Liu
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Ying Jiang
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Wan Ru Leow
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Mayank Pal
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Shaowu Pan
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Hui Yang
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Yu Wang
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Xiaoqian Zhang
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Jiancan Yu
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Bin Li
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
| | - Zhe Yu
- Institute of Biomedical and Health Engineering, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen University Town, 1068 Xueyuan Avenue, Shenzhen, 518055, P. R. China
| | - Wei Wang
- State Key Laboratory of Urban Water Resource and Environment, School of Municipal and Environmental Engineering, Harbin Institute of Technology, Harbin, 150090, P. R. China
| | - Xiaodong Chen
- School of Materials Science and Engineering, Nanyang Technological University, 639798, Singapore
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Ko AL, Ibrahim A, Magown P, Macallum R, Burchiel KJ. Factors Affecting Stereotactic Accuracy in Image-Guided Deep Brain Stimulator Electrode Placement. Stereotact Funct Neurosurg 2017; 95:315-324. [DOI: 10.1159/000479527] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/11/2017] [Indexed: 11/19/2022]
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van Wijk BCM, Pogosyan A, Hariz MI, Akram H, Foltynie T, Limousin P, Horn A, Ewert S, Brown P, Litvak V. Localization of beta and high-frequency oscillations within the subthalamic nucleus region. NEUROIMAGE-CLINICAL 2017; 16:175-183. [PMID: 28794978 PMCID: PMC5540829 DOI: 10.1016/j.nicl.2017.07.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/05/2017] [Accepted: 07/22/2017] [Indexed: 12/01/2022]
Abstract
Parkinsonian bradykinesia and rigidity are typically associated with excessive beta band oscillations in the subthalamic nucleus. Recently another spectral peak has been identified that might be implicated in the pathophysiology of the disease: high-frequency oscillations (HFO) within the 150–400 Hz range. Beta-HFO phase-amplitude coupling (PAC) has been found to correlate with severity of motor impairment. However, the neuronal origin of HFO and its usefulness as a potential target for deep brain stimulation remain to be established. For example, it is unclear whether HFO arise from the same neural populations as beta oscillations. We intraoperatively recorded local field potentials from the subthalamic nucleus while advancing DBS electrodes in 2 mm steps from 4 mm above the surgical target point until 2 mm below, resulting in 4 recording sites. Data from 26 nuclei from 14 patients were analysed. For each trajectory, we identified the recording site with the largest spectral peak in the beta range (13–30 Hz), and the largest peak in the HFO range separately. In addition, we identified the recording site with the largest beta-HFO PAC. Recording sites with largest beta power and largest HFO power coincided in 50% of cases. In the other 50%, HFO was more likely to be detected at a more superior recording site in the target area. PAC followed more closely the site with largest HFO (45%) than beta power (27%). HFO are likely to arise from spatially close, but slightly more superior neural populations than beta oscillations. Further work is necessary to determine whether the different activities can help fine-tune deep brain stimulation targeting. LFPs were recorded from multiple sites within and around the subthalamic nucleus. Sites with largest beta and high-frequency oscillations (HFO) were identified. HFO were located slightly more superior than beta oscillations. Phase-amplitude coupling more closely followed the site with largest HFO. This work hints at different neural generators for beta and HFO.
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Affiliation(s)
- B C M van Wijk
- Department of Neurology, Charité - University Medicine Berlin, Berlin, Germany.,Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, London, United Kingdom
| | - A Pogosyan
- Nuffield Department of Clinical Neuroscience, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - M I Hariz
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom.,Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - H Akram
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom.,Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - T Foltynie
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom
| | - P Limousin
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom
| | - A Horn
- Department of Neurology, Charité - University Medicine Berlin, Berlin, Germany.,Berenson-Allen Center for Non-Invasive Brain Stimulation and Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - S Ewert
- Department of Neurology, Charité - University Medicine Berlin, Berlin, Germany.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - P Brown
- Nuffield Department of Clinical Neuroscience, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.,Medical Research Council Brain Network Dynamics Unit at the University of Oxford, Oxford, United Kingdom
| | - V Litvak
- Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, London, United Kingdom
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Dopamine Release in the Nonhuman Primate Caudate and Putamen Depends upon Site of Stimulation in the Subthalamic Nucleus. J Neurosci 2017; 36:6022-9. [PMID: 27251623 DOI: 10.1523/jneurosci.0403-16.2016] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/20/2016] [Indexed: 12/20/2022] Open
Abstract
UNLABELLED Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is an effective treatment for medically refractory Parkinson's disease. Although DBS has recognized clinical utility, its biologic mechanisms are not fully understood, and whether dopamine release is a potential factor in those mechanisms is in dispute. We tested the hypothesis that STN DBS-evoked dopamine release depends on the precise location of the stimulation site in the STN and the site of recording in the caudate and putamen. We conducted DBS with miniature, scaled-to-animal size, multicontact electrodes and used functional magnetic resonance imaging to identify the best dopamine recording site in the brains of nonhuman primates (rhesus macaques), which are highly representative of human brain anatomy and circuitry. Real-time stimulation-evoked dopamine release was monitored using in vivo fast-scan cyclic voltammetry. This study demonstrates that STN DBS-evoked dopamine release can be reduced or increased by redirecting STN stimulation to a slightly different site. SIGNIFICANCE STATEMENT Electrical stimulation of deep structures of the brain, or deep brain stimulation (DBS), is used to modulate pathological brain activity. However, technological limitations and incomplete understanding of the therapeutic mechanisms of DBS prevent personalization of this therapy and may contribute to less-than-optimal outcomes. We have demonstrated that DBS coincides with changes in dopamine neurotransmitter release in the basal ganglia. Here we mapped relationships between DBS and changes in neurochemical activity. Importantly, this study shows that DBS-evoked dopamine release can be reduced or increased by refocusing the DBS on a slightly different stimulation site.
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Themistocleous MS, Sakas DE, Boviatsis E, Tagaris G, Kouyialis A, Psachoulia C, Stathis P. The Insertion of Electrodes in the Brain for Electrophysiological Recording or Chronic Stimulation Is Not Associated With Any Biochemically Detectable Neuronal Injury. Neuromodulation 2017; 20:424-428. [PMID: 28393415 DOI: 10.1111/ner.12598] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Revised: 01/29/2017] [Accepted: 02/15/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the degree of brain tissue injury that could be potentially induced by the introduction of a) microrecording electrodes, b) macrostimulation electrodes, or c) chronic stimulation electrodes. We aimed to evaluate whether the use of five simultaneous microrecording tracks is associated with any brain injury not detectable by conventional imaging such as CT or MRI. MATERIALS AND METHODS The study included 61 patients who underwent surgery for implantation of 121 DBS leads. In all cases, five simultaneous tracts were utilized for microelectrode recordings. All patients underwent measurements of serum S-100b at specific time points as follows: a) prior to the operation, and b) intraoperatively at specific stages of the procedure: 1) after opening the burr hole, 2) after the insertion of microrecording electrodes, 3) during macrostimulation, 4) at the end of the operation, and 5) on the first postoperative day. RESULTS The levels of serum S-100B protein remained within the normal range during the entire period of investigation in all patients with the exception of two cases. In both patients, the procedure was complicated by intraparenchymal hemorrhage visible in neuro-imaging. The first patient developed a small intraparenchymal hemorrhage, visible on the postoperative MRI, with no neurological deficit. The second patient experienced a focal epileptic seizure after the insertion of the right DBS chronic lead and the postoperative CT scan revealed a right frontal lobe hemorrhage. CONCLUSION These results strongly indicate that the insertion of either multiple recording electrodes or the implantation of chronic electrodes in DBS does not increase the risk of brain hemorrhage or of other intracranial complications, and furthermore it does not cause any biochemically detectable brain tissue damage.
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Affiliation(s)
- Marios S Themistocleous
- Department of Neurosurgery, University of Athens Medical School, "Evangelismos" Hospital, Athens, Greece.,P. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
| | - Damianos E Sakas
- Department of Neurosurgery, University of Athens Medical School, "Evangelismos" Hospital, Athens, Greece.,P. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
| | - Efstathios Boviatsis
- Department of Neurosurgery, University of Athens Medical School, "Evangelismos" Hospital, Athens, Greece.,P. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
| | - George Tagaris
- Department of Neurosurgery, University of Athens Medical School, "Evangelismos" Hospital, Athens, Greece.,P. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
| | - Andreas Kouyialis
- Department of Neurosurgery, University of Athens Medical School, "Evangelismos" Hospital, Athens, Greece
| | | | - Pantelis Stathis
- Department of Neurosurgery, University of Athens Medical School, "Evangelismos" Hospital, Athens, Greece.,P. Kokkalis Hellenic Center for Neurosurgical Research, Athens, Greece
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Sammartino F, Krishna V, Sankar T, Fisico J, Kalia SK, Hodaie M, Kucharczyk W, Mikulis DJ, Crawley A, Lozano AM. 3-Tesla MRI in patients with fully implanted deep brain stimulation devices: a preliminary study in 10 patients. J Neurosurg 2016; 127:892-898. [PMID: 28009238 DOI: 10.3171/2016.9.jns16908] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the safety of 3-T MRI in patients with implanted deep brain stimulation (DBS) systems. METHODS This study was performed in 2 phases. In an initial phantom study, a Lucite phantom filled with tissue-mimicking gel was assembled. The system was equipped with a single DBS electrode connected to an internal pulse generator. The tip of the electrode was coupled to a fiber optic thermometer with a temperature resolution of 0.1°C. Both anatomical (T1- and T2-weighted) and functional MRI sequences were tested. A temperature change within 2°C from baseline was considered safe. After findings from the phantom study suggested safety, 10 patients with implanted DBS systems targeting various brain areas provided informed consent and underwent 3-T MRI using the same imaging sequences. Detailed neurological evaluations and internal pulse generator interrogations were performed before and after imaging. RESULTS During phantom testing, the maximum temperature increase was registered using the T2-weighted sequence. The maximal temperature changes at the tip of the DBS electrode were < 1°C for all sequences tested. In all patients, adequate images were obtained with structural imaging, although a significant artifact from lead connectors interfered with functional imaging quality. No heating, warmth, or adverse neurological effects were observed. CONCLUSIONS To the authors' knowledge, this was the first study to assess the clinical safety of 3-T MRI in patients with a fully implanted DBS system (electrodes, extensions, and pulse generator). It provided preliminary data that will allow further examination and assessment of the safety of 3-T imaging studies in patients with implanted DBS systems. The authors cannot advocate widespread use of this type of imaging in patients with DBS implants until more safety data are obtained.
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Affiliation(s)
| | | | - Tejas Sankar
- Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jason Fisico
- Department of Medical Imaging, University of Toronto, Ontario; and
| | | | - Mojgan Hodaie
- Division of Neurosurgery, Department of Surgery, and
| | | | - David J Mikulis
- Department of Medical Imaging, University of Toronto, Ontario; and
| | - Adrian Crawley
- Department of Medical Imaging, University of Toronto, Ontario; and
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Rabie A, Verhagen Metman L, Slavin KV. Using "Functional" Target Coordinates of the Subthalamic Nucleus to Assess the Indirect and Direct Methods of the Preoperative Planning: Do the Anatomical and Functional Targets Coincide? Brain Sci 2016; 6:brainsci6040065. [PMID: 28009826 PMCID: PMC5187579 DOI: 10.3390/brainsci6040065] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 12/04/2016] [Accepted: 12/12/2016] [Indexed: 11/16/2022] Open
Abstract
Objective: To answer the question of whether the anatomical center of the subthalamic nucleus (STN), as calculated indirectly from stereotactic atlases or by direct visualization on magnetic resonance imaging (MRI), corresponds to the best functional target. Since the neighboring red nucleus (RN) is well visualized on MRI, we studied the relationships of the final target to its different borders. Methods: We analyzed the data of 23 PD patients (46 targets) who underwent bilateral frame-based STN deep brain stimulation (DBS) procedure with microelectrode recording guidance. We calculated coordinates of the active contact on DBS electrode on postoperative MRI, which we referred to as the final “functional/optimal” target. The coordinates calculated by the atlas-based “indirect” and “direct” methods, as well as the coordinates of the different RN borders were compared to these final coordinates. Results: The mean ± SD of the final target coordinates was 11.7 ± 1.5 mm lateral (X), 2.4 ± 1.5 mm posterior (Y), and 6.1 ± 1.7 mm inferior to the mid-commissural point (Z). No significant differences were found between the “indirect” X, Z coordinates and those of the final targets. The “indirect” Y coordinate was significantly posterior to Y of the final target, with mean difference of 0.6 mm (p = 0.014). No significant differences were found between the “direct” X, Y, and Z coordinates and those of the final targets. Conclusions: The functional STN target is located in direct proximity to its anatomical center. During preoperative targeting, we recommend using the “direct” method, and taking into consideration the relationships of the final target to the mid-commissural point (MCP) and the different RN borders.
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Affiliation(s)
- Ahmed Rabie
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA.
- Department of Neurosurgery, Alexandria University, Alexandria, Egypt.
| | - Leo Verhagen Metman
- Department of Neurological Sciences, Rush University Medical Center, Chicago, IL 60612, USA.
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Shah A, Coste J, Lemaire JJ, Schkommodau E, Taub E, Guzman R, Derost P, Hemm S. A novel assistive method for rigidity evaluation during deep brain stimulation surgery using acceleration sensors. J Neurosurg 2016; 127:602-612. [PMID: 27982769 DOI: 10.3171/2016.8.jns152770] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite the widespread use of deep brain stimulation (DBS) for movement disorders such as Parkinson's disease (PD), the exact anatomical target responsible for the therapeutic effect is still a subject of research. Intraoperative stimulation tests by experts consist of performing passive movements of the patient's arm or wrist while the amplitude of the stimulation current is increased. At each position, the amplitude that best alleviates rigidity is identified. Intrarater and interrater variations due to the subjective and semiquantitative nature of such evaluations have been reported. The aim of the present study was to evaluate the use of an acceleration sensor attached to the evaluator's wrist to assess the change in rigidity, hypothesizing that such a change will alter the speed of the passive movements. Furthermore, the combined analysis of such quantitative results with anatomy would generate a more reproducible description of the most effective stimulation sites. METHODS To test the reliability of the method, it was applied during postoperative follow-up examinations of 3 patients. To study the feasibility of intraoperative use, it was used during 9 bilateral DBS operations in patients suffering from PD. Changes in rigidity were calculated by extracting relevant outcome measures from the accelerometer data. These values were used to identify rigidity-suppressing stimulation current amplitudes, which were statistically compared with the amplitudes identified by the neurologist. Positions for the chronic DBS lead implantation that would have been chosen based on the acceleration data were compared with clinical choices. The data were also analyzed with respect to the anatomical location of the stimulating electrode. RESULTS Outcome measures extracted from the accelerometer data were reproducible for the same evaluator, thus providing a reliable assessment of rigidity changes during intraoperative stimulation tests. Of the 188 stimulation sites analyzed, the number of sites where rigidity-suppressing amplitudes were found increased from 144 to 170 when the accelerometer evaluations were considered. In general, rigidity release could be observed at significantly lower amplitudes with accelerometer evaluation (mean 0.9 ± 0.6 mA) than with subjective evaluation (mean 1.4 ± 0.6 mA) (p < 0.001). Of 14 choices for the implant location of the DBS lead, only 2 were the same for acceleration-based and subjective evaluations. The comparison across anatomical locations showed that stimulation in the fields of Forel ameliorates rigidity at similar amplitudes as stimulation in the subthalamic nucleus, but with fewer side effects. CONCLUSIONS This article describes and validates a new assistive method for assessing rigidity with acceleration sensors during intraoperative stimulation tests in DBS procedures. The initial results indicate that the proposed method may be a clinically useful aid for optimal DBS lead placement as well as a new tool in the ongoing scientific search for the optimal DBS target for PD.
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Affiliation(s)
- Ashesh Shah
- Institute for Medical and Analytical Technologies, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland, Muttenz
| | - Jérôme Coste
- Image-Guided Clinical Neuroscience and Connectomics, and.,Service de Neurochirurgie and
| | - Jean-Jacques Lemaire
- Image-Guided Clinical Neuroscience and Connectomics, and.,Service de Neurochirurgie and
| | - Erik Schkommodau
- Institute for Medical and Analytical Technologies, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland, Muttenz
| | - Ethan Taub
- Departments of Neurosurgery and Biomedicine, University Hospital of Basel, Switzerland
| | - Raphael Guzman
- Departments of Neurosurgery and Biomedicine, University Hospital of Basel, Switzerland
| | - Philippe Derost
- Neuro-Psycho-Pharmacologie des Systèmes Dopaminergiques Sous-Corticaux, Université Clermont Auvergne, Université d'Auvergne; and.,Service de Neurologie, CHU Clermont-Ferrand, France
| | - Simone Hemm
- Institute for Medical and Analytical Technologies, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland, Muttenz
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Hemm S, Pison D, Alonso F, Shah A, Coste J, Lemaire JJ, Wårdell K. Patient-Specific Electric Field Simulations and Acceleration Measurements for Objective Analysis of Intraoperative Stimulation Tests in the Thalamus. Front Hum Neurosci 2016; 10:577. [PMID: 27932961 PMCID: PMC5122591 DOI: 10.3389/fnhum.2016.00577] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 11/01/2016] [Indexed: 11/25/2022] Open
Abstract
Despite an increasing use of deep brain stimulation (DBS) the fundamental mechanisms of action remain largely unknown. Simulation of electric entities has previously been proposed for chronic DBS combined with subjective symptom evaluations, but not for intraoperative stimulation tests. The present paper introduces a method for an objective exploitation of intraoperative stimulation test data to identify the optimal implant position of the chronic DBS lead by relating the electric field (EF) simulations to the patient-specific anatomy and the clinical effects quantified by accelerometry. To illustrate the feasibility of this approach, it was applied to five patients with essential tremor bilaterally implanted in the ventral intermediate nucleus (VIM). The VIM and its neighborhood structures were preoperatively outlined in 3D on white matter attenuated inversion recovery MR images. Quantitative intraoperative clinical assessments were performed using accelerometry. EF simulations (n = 272) for intraoperative stimulation test data performed along two trajectories per side were set-up using the finite element method for 143 stimulation test positions. The resulting EF isosurface of 0.2 V/mm was superimposed to the outlined anatomical structures. The percentage of volume of each structure’s overlap was calculated and related to the corresponding clinical improvement. The proposed concept has been successfully applied to the five patients. For higher clinical improvements, not only the VIM but as well other neighboring structures were covered by the EF isosurfaces. The percentage of the volumes of the VIM, of the nucleus intermediate lateral of the thalamus and the prelemniscal radiations within the prerubral field of Forel increased for clinical improvements higher than 50% compared to improvements lower than 50%. The presented new concept allows a detailed and objective analysis of a high amount of intraoperative data to identify the optimal stimulation target. First results indicate agreement with published data hypothesizing that the stimulation of other structures than the VIM might be responsible for good clinical effects in essential tremor. (Clinical trial reference number: Ref: 2011-A00774-37/AU905)
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Affiliation(s)
- Simone Hemm
- Institute for Medical and Analytical Technologies, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland FHNWMuttenz, Switzerland; Department of Biomedical Engineering, Linköping UniversityLinköping, Sweden
| | - Daniela Pison
- Institute for Medical and Analytical Technologies, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland FHNW Muttenz, Switzerland
| | - Fabiola Alonso
- Department of Biomedical Engineering, Linköping University Linköping, Sweden
| | - Ashesh Shah
- Institute for Medical and Analytical Technologies, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland FHNW Muttenz, Switzerland
| | - Jérôme Coste
- Université Clermont Auvergne, Université d'Auvergne, EA 7282, Image Guided Clinical Neurosciences and Connectomics (IGCNC)Clermont-Ferrand, France; Service de Neurochirurgie, Hôpital Gabriel-Montpied, Centre Hospitalier Universitaire de Clermont-FerrandClermont-Ferrand, France
| | - Jean-Jacques Lemaire
- Université Clermont Auvergne, Université d'Auvergne, EA 7282, Image Guided Clinical Neurosciences and Connectomics (IGCNC)Clermont-Ferrand, France; Service de Neurochirurgie, Hôpital Gabriel-Montpied, Centre Hospitalier Universitaire de Clermont-FerrandClermont-Ferrand, France
| | - Karin Wårdell
- Department of Biomedical Engineering, Linköping University Linköping, Sweden
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Targeting of the Subthalamic Nucleus for Deep Brain Stimulation: A Survey Among Parkinson Disease Specialists. World Neurosurg 2016; 99:41-46. [PMID: 27838430 DOI: 10.1016/j.wneu.2016.11.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/30/2016] [Accepted: 11/01/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Deep brain stimulation within or adjacent to the subthalamic nucleus (STN) represents the most common stereotactic procedure performed for Parkinson disease. Better STN imaging is often regarded as a requirement for improving stereotactic targeting. However, it is unclear whether there is consensus about the optimal target. METHODS To obtain an expert opinion on the site regarded optimal for "STN stimulation," movement disorder specialists were asked to indicate their preferred position for an active contact on hard copies of the Schaltenbrand and Wahren atlas depicting the STN in all 3 planes. This represented an idealized setting, and it mimicked optimal imaging for direct target definition in a perfectly delineated STN. RESULTS The suggested targets were heterogeneous, although some clustering was observed in the dorsolateral STN and subthalamic area. In particular, in the anteroposterior direction, the intended targets differed to a great extent. Most of the indicated targets are thought to also result in concomitant stimulation of structures adjacent to the STN, including the zona incerta, fields of Forel, and internal capsule. CONCLUSIONS This survey illustrates that most sites regarded as optimal for STN stimulation are close to each other, but there appears to be no uniform perception of the optimal anatomic target, possibly influencing surgical results. The anatomic sweet zone for STN stimulation needs further specification, as this information is likely to make magnetic resonance imaging-based target definition less variable when applied to individual patients.
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Garcia-Garcia D, Guridi J, Toledo JB, Alegre M, Obeso JA, Rodríguez-Oroz MC. Stimulation sites in the subthalamic nucleus and clinical improvement in Parkinson's disease: a new approach for active contact localization. J Neurosurg 2016; 125:1068-1079. [DOI: 10.3171/2015.9.jns15868] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE
Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is widely used in patients with Parkinson's disease (PD). However, which target area of this region results in the highest antiparkinsonian efficacy is still a matter of debate. The aim of this study was to develop a more accurate methodology to locate the electrodes and the contacts used for chronic stimulation (active contacts) in the subthalamic region, and to determine the position at which stimulation conveys the greatest clinical benefit.
METHODS
The study group comprised 40 patients with PD in whom bilateral DBS electrodes had been implanted in the STN. Based on the Morel atlas, the authors created an adaptable 3D atlas that takes into account individual anatomical variability and divides the STN into functional territories. The locations of the electrodes and active contacts were obtained from an accurate volumetric assessment of the artifact using preoperative and postoperative MR images. Active contacts were positioned in the 3D atlas using stereotactic coordinates and a new volumetric method based on an ellipsoid representation created from all voxels that belong to a set of contacts. The antiparkinsonian benefit of the stimulation was evaluated by the reduction in the Unified Parkinson's Disease Rating Scale Part III (UPDRS-III) score and in the levodopa equivalent daily dose (LEDD) at 6 months. A homogeneous group classification for contact position and the respective clinical improvement was applied using a hierarchical clustering method.
RESULTS
Subthalamic stimulation induced a significant reduction of 58.0% ± 16.5% in the UPDRS-III score (p < 0.001) and 64.9% ± 21.0% in the LEDD (p < 0.001). The greatest reductions in the total and contralateral UPDRS-III scores (64% and 76%, respectively) and in the LEDD (73%) were obtained when the active contacts were placed approximately 12 mm lateral to the midline, with no influence of the position being observed in the anteroposterior and dorsoventral axes. In contrast, contacts located about 10 mm from the midline only reduced the global and contralateral UPDRS-III scores by 47% and 41%, respectively, and the LEDD by 33%. Using the ellipsoid method of location, active contacts with the highest benefit were positioned in the rostral and most lateral portion of the STN and at the interface between this subthalamic region, the zona incerta, and the thalamic fasciculus. Contacts placed in the most medial regions of the motor STN area provided the lowest clinical efficacy.
CONCLUSIONS
The authors report an accurate new methodology to assess the position of electrodes and contacts used for chronic subthalamic stimulation. Using this approach, the highest antiparkinsonian benefit is achieved when active contacts are located within the rostral and the most lateral parts of the motor region of the STN and at the interface of this region and adjacent areas (zona incerta and thalamic fasciculus).
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Affiliation(s)
- David Garcia-Garcia
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
- 2Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED); and
| | - Jorge Guridi
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
- 2Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED); and
| | - Jon B. Toledo
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
| | - Manuel Alegre
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
| | - José A. Obeso
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
- 2Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED); and
| | - María C. Rodríguez-Oroz
- 1Neurosciences Area, CIMA, Department of Neurology and Neurosurgery, Clínica Universidad de Navarra Medical School, Pamplona
- 2Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED); and
- 3Neuroscience Unit, BioDonostia Research Institute, University Hospital Donostia, Basque Center on Cognition, Brain and Language (BCBL), San Sebastián; Ikerbasque, Basque Foundation for Science, Bilbao, Spain
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Verhagen R, Schuurman PR, van den Munckhof P, Contarino MF, de Bie RMA, Bour LJ. Comparative study of microelectrode recording-based STN location and MRI-based STN location in low to ultra-high field (7.0 T) T2-weighted MRI images. J Neural Eng 2016; 13:066009. [DOI: 10.1088/1741-2560/13/6/066009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Electrophysiological interpretations of the clinical response to stimulation parameters of pallidal deep brain stimulation for cervical dystonia. Acta Neurochir (Wien) 2016; 158:2029-38. [PMID: 27562682 DOI: 10.1007/s00701-016-2942-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/17/2016] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) at the posterolateral ventral portion of the globus pallidus internus (GPi) has been regarded as a good therapeutic modality. Because the theoretical principle behind the stimulation parameters is yet to be determined, this study aimed to interpret analyses of the stimulation parameters used in our department based on an electrophysiological review. METHODS Nineteen patients with medically refractory idiopathic cervical dystonia who underwent GPi DBS were enrolled. The baseline and follow-up parameters were analyzed according to their dependence on time after DBS. The pattern of changes in the stimulation parameters over time, the differences across the four active contacts, and the relationship between the stimulation parameters and clinical benefits were evaluated. RESULTS Mean age and disease duration were 50.9 years and 54.7 months, respectively. Mean follow-up duration was 22.6 months. The amplitude and frequency exhibited significant increasing temporal patterns, i.e., a mean amplitude and frequency of 3.1 V and 132.2 Hz at the initial setting and 4.0 V and 142.6 Hz at the last follow-up, respectively. The better clinical response group (clinical improvement rate of 65-100 %) used a narrower pulse width (mean value of 78.4 μs) than the worse clinical response group (clinical improvement rate of 5-60 %, mean of value of 88.6 μs). Active contact at the GPe was used more often in the worse clinical response group than in the better response group. CONCLUSIONS Based on electrophysiological considerations, these patterns of stimulation parameters could be interpreted. This interpretation was based on a theoretical understanding of the mechanisms of action of DBS, i.e., that the abnormal neural signal is substituted by an induced neural signal, which is generated by therapeutic DBS.
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Saleh C, Dooms G, Berthold C, Hertel F. Post-operative imaging in deep brain stimulation: A controversial issue. Neuroradiol J 2016; 29:244-9. [PMID: 27029393 PMCID: PMC4978322 DOI: 10.1177/1971400916639960] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
In deep brain stimulation (DBS), post-operative imaging has been used on the one hand to assess complications, such as haemorrhage; and on the other hand, to detect misplaced contacts. The post-operative determination of the accurate location of the final electrode plays a critical role in evaluating the precise area of effective stimulation and for predicting the potential clinical outcome; however, safety remains a priority in postoperative DBS imaging. A plethora of diverse post-operative imaging methods have been applied at different centres. There is neither a consensus on the most efficient post-operative imaging methodology, nor is there any standardisation for the automatic or manual analysis of the images within the different imaging modalities. In this article, we give an overview of currently applied post-operative imaging modalities and discuss the current challenges in post-operative imaging in DBS.
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Affiliation(s)
- Christian Saleh
- Department of Neurology, Centre Hospitalier de Luxembourg, Luxembourg
| | - Georges Dooms
- Department of Neuroradiology, Centre Hospitalier de Luxembourg, Luxembourg
| | | | - Frank Hertel
- Department of Neurosurgery, Centre Hospitalier de Luxembourg, Luxembourg
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Chansakul T, Chen PN, Lee TC, Tierney T. Interventional MR Imaging for Deep-Brain Stimulation Electrode Placement. Radiology 2016; 281:940-946. [PMID: 27326663 DOI: 10.1148/radiol.2015151136] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To investigate the safety and targeting errors of deep-brain stimulation (DBS) electrodes placed under interventional magnetic resonance (MR) imaging, which allows near real-time anatomic placement without physiologic mapping. Materials and Methods Retrospectively evaluated were 10 consecutive patients (five women, five men) with a mean age of 59.9 years (age range, 17-79 years). These patients underwent interventional MR imaging-guided DBS placement for movement disorders from September 2013 to August 2014 for placement of 19 DBS electrodes in cases where traditional frame-based surgery may be challenging because of the following: dystonia resulting in difficulty in placing the patients in frame, patient's inability or unwillingness to tolerate awake surgery, or anatomic anomaly or variant that could increase the risk of bleeding from microelectrode mapping. Outcomes measured included perioperative hemorrhage, death, and stroke, and electrode functionality assessed at 2 weeks after the operation. In addition, the mean radial error and mean trajectory error were calculated. Results No intraoperative neurologic complications (n = 10 [95% confidence interval: 0%, 31%]) were observed. One patient developed aspiration pneumonia in the postoperative period. Mean radial error was 0.7 mm ± 0.4 (standard deviation) and mean trajectory error was 0.5 mm ± 0.4. All leads delivered clinically effective stimulation. Conclusion Interventional MR imaging-guided DBS electrode placement may be a safe and effective alternative to conventional frame-based surgery in well-selected patients. © RSNA, 2016.
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Affiliation(s)
- Thanissara Chansakul
- From the Department of Radiology, Division of Neuroradiology (T.C., P.N.C., T.C.L.), and Department of Neurosurgery (T.T.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Paul N Chen
- From the Department of Radiology, Division of Neuroradiology (T.C., P.N.C., T.C.L.), and Department of Neurosurgery (T.T.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Thomas C Lee
- From the Department of Radiology, Division of Neuroradiology (T.C., P.N.C., T.C.L.), and Department of Neurosurgery (T.T.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
| | - Travis Tierney
- From the Department of Radiology, Division of Neuroradiology (T.C., P.N.C., T.C.L.), and Department of Neurosurgery (T.T.), Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115
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Picillo M, Lozano AM, Kou N, Puppi Munhoz R, Fasano A. Programming Deep Brain Stimulation for Parkinson's Disease: The Toronto Western Hospital Algorithms. Brain Stimul 2016; 9:425-437. [DOI: 10.1016/j.brs.2016.02.004] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/02/2016] [Accepted: 02/03/2016] [Indexed: 12/19/2022] Open
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Picillo M, Lozano AM, Kou N, Munhoz RP, Fasano A. Programming Deep Brain Stimulation for Tremor and Dystonia: The Toronto Western Hospital Algorithms. Brain Stimul 2016; 9:438-452. [DOI: 10.1016/j.brs.2016.02.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/02/2016] [Accepted: 02/03/2016] [Indexed: 10/22/2022] Open
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Zibetti M, Moro E, Krishna V, Sammartino F, Picillo M, Munhoz RP, Lozano AM, Fasano A. Low-frequency Subthalamic Stimulation in Parkinson's Disease: Long-term Outcome and Predictors. Brain Stimul 2016; 9:774-779. [PMID: 27198578 DOI: 10.1016/j.brs.2016.04.017] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 03/24/2016] [Accepted: 04/26/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Parkinson's disease patients undergoing subthalamic nucleus deep brain stimulation (STN DBS) at standard frequency (>100 Hz) often develop gait impairment, postural instability and speech difficulties. Low frequency stimulation (<100 Hz, LFS) can improve such axial symptoms, but there are concerns that improvement may be transient. OBJECTIVE To identify long-term outcome and predictors of low-frequency subthalamic stimulation in Parkinson's disease. METHODS Through a chart review we identified 85 out of 324 STN DBS patients who received a trial of LFS and describe their characteristics and outcome predictors. RESULTS Patients were switched to LFS (<100 Hz) 3.8 ± 3.3 years after surgery. Most patients (64%) attained a subjective improvement of gait, speech or balance for 2.0 ± 1.9 years. Motor scores improved within the first year after the stimulation change and showed a slower progression over time when compared to patients switched back to high frequency stimulation. UPDRS III axial score on medication before surgery and the y-axis coordinate of the active contact were independent predictors of LFS retention. CONCLUSIONS This report provides evidence that the use of LFS yields an enduring benefit in a considerable percentage of patients who develop axial motor symptoms during conventional stimulation.
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Affiliation(s)
- Maurizio Zibetti
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy
| | - Elena Moro
- Service de Neurologie, CHU Grenoble, Joseph Fourier University, INSERM U836, Grenoble, France
| | - Vibhor Krishna
- Division of Neurosurgery, Toronto Western Hospital - UHN, University of Toronto, Toronto, Ontario, Canada
| | - Francesco Sammartino
- Division of Neurosurgery, Toronto Western Hospital - UHN, University of Toronto, Toronto, Ontario, Canada
| | - Marina Picillo
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital - UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Centre for Neurodegenerative Diseases (CEMAND), Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Renato P Munhoz
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital - UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital - UHN, University of Toronto, Toronto, Ontario, Canada
| | - Alfonso Fasano
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J. Safra Program in Parkinson's Disease, Toronto Western Hospital - UHN, Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Krembil Research Institute, Toronto, Ontario, Canada.
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Velasco F, Carrillo-Ruiz JD, Salcido V, Castro G, Soto J, Velasco AL. Unilateral Stimulation of Prelemniscal Radiations for the Treatment of Acral Symptoms of Parkinson's Disease: Long-Term Results. Neuromodulation 2016; 19:357-64. [DOI: 10.1111/ner.12433] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/22/2016] [Accepted: 02/22/2016] [Indexed: 12/14/2022]
Affiliation(s)
- Francisco Velasco
- Unit for Stereotactic and Functional Neurosurgery and Radiosurgery; Mexico General Hospital; Mexico D.F. Mexico
| | - José D. Carrillo-Ruiz
- Unit for Stereotactic and Functional Neurosurgery and Radiosurgery; Mexico General Hospital; Mexico D.F. Mexico
| | - Víctor Salcido
- Unit for Stereotactic and Functional Neurosurgery and Radiosurgery; Mexico General Hospital; Mexico D.F. Mexico
| | - Guillermo Castro
- Unit for Stereotactic and Functional Neurosurgery and Radiosurgery; Mexico General Hospital; Mexico D.F. Mexico
| | - Julián Soto
- Unit for Stereotactic and Functional Neurosurgery and Radiosurgery; Mexico General Hospital; Mexico D.F. Mexico
| | - Ana Luisa Velasco
- Unit for Stereotactic and Functional Neurosurgery and Radiosurgery; Mexico General Hospital; Mexico D.F. Mexico
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Mirzadeh Z, Chapple K, Lambert M, Evidente VG, Mahant P, Ospina MC, Samanta J, Moguel-Cobos G, Salins N, Lieberman A, Tröster AI, Dhall R, Ponce FA. Parkinson’s disease outcomes after intraoperative CT-guided “asleep” deep brain stimulation in the globus pallidus internus. J Neurosurg 2016; 124:902-7. [DOI: 10.3171/2015.4.jns1550] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Recent studies show that deep brain stimulation can be performed safely and accurately without microelectrode recording ortest stimulation but with the patient under general anesthesia. The procedure couples techniques for direct anatomical targeting on MRI with intraoperative imaging to verify stereotactic accuracy. However, few authors have examined the clinical outcomes of Parkinson’s disease (PD) patients after this procedure. The purpose of this study was to evaluate PD outcomes following “asleep” deep brain stimulation in the globus pallidus internus (GPi).
METHODS
The authors prospectively examined all consecutive patients with advanced PD who underwent bilateral GPi electrode placement while under general anesthesia. Intraoperative CT was used to assess lead placement accuracy. The primary outcome measure was the change in the off-medication Unified Parkinson’s Disease Rating Scale motor score 6 months after surgery. Secondary outcomes included effects on the 39-Item Parkinson’s Disease Questionnaire (PDQ-39) scores, on-medication motor scores, and levodopa equivalent daily dose. Lead locations, active contact sites, stimulation parameters, and adverse events were documented.
RESULTS
Thirty-five patients (24 males, 11 females) had a mean age of 61 years at lead implantation. The mean radial error off plan was 0.8 mm. Mean coordinates for the active contact were 21.4 mm lateral, 4.7 mm anterior, and 0.4 mm superior to the midcommissural point. The mean off-medication motor score improved from 48.4 at baseline to 28.9 (40.3% improvement) at 6 months (p < 0.001). The PDQ-39 scores improved (50.3 vs 42.0; p = 0.03), and the levodopa equivalent daily dose was reduced (1207 vs 1035 mg; p = 0.004). There were no significant adverse events.
CONCLUSIONS
Globus pallidus internus leads placed with the patient under general anesthesia by using direct anatomical targeting resulted in significantly improved outcomes as measured by the improvement in the off-medication motor score at 6 months after surgery.
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Affiliation(s)
| | | | | | | | - Padma Mahant
- 4Banner Good Samaritan Medical Center, Phoenix, Arizona
| | | | - Johan Samanta
- 4Banner Good Samaritan Medical Center, Phoenix, Arizona
| | | | | | | | - Alexander I. Tröster
- 5Clinical Neuropsychology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix
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Pallavaram S, DʼHaese PF, Lake W, Konrad PE, Dawant BM, Neimat JS. Fully automated targeting using nonrigid image registration matches accuracy and exceeds precision of best manual approaches to subthalamic deep brain stimulation targeting in Parkinson disease. Neurosurgery 2015; 76:756-65. [PMID: 25988929 DOI: 10.1227/neu.0000000000000714] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Finding the optimal location for the implantation of the electrode in deep brain stimulation (DBS) surgery is crucial for maximizing the therapeutic benefit to the patient. Such targeting is challenging for several reasons, including anatomic variability between patients as well as the lack of consensus about the location of the optimal target. OBJECTIVE To compare the performance of popular manual targeting methods against a fully automatic nonrigid image registration-based approach. METHODS In 71 Parkinson disease subthalamic nucleus (STN)-DBS implantations, an experienced functional neurosurgeon selected the target manually using 3 different approaches: indirect targeting using standard stereotactic coordinates, direct targeting based on the patient magnetic resonance imaging, and indirect targeting relative to the red nucleus. Targets were also automatically predicted by using a leave-one-out approach to populate the CranialVault atlas with the use of nonrigid image registration. The different targeting methods were compared against the location of the final active contact, determined through iterative clinical programming in each individual patient. RESULTS Targeting by using standard stereotactic coordinates corresponding to the center of the motor territory of the STN had the largest targeting error (3.69 mm), followed by direct targeting (3.44 mm), average stereotactic coordinates of active contacts from this study (3.02 mm), red nucleus-based targeting (2.75 mm), and nonrigid image registration-based automatic predictions using the CranialVault atlas (2.70 mm). The CranialVault atlas method had statistically smaller variance than all manual approaches. CONCLUSION Fully automatic targeting based on nonrigid image registration with the use of the CranialVault atlas is as accurate and more precise than popular manual methods for STN-DBS.
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Affiliation(s)
- Srivatsan Pallavaram
- *Department of Electrical Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee; ‡Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Li B, Jiang C, Li L, Zhang J, Meng D. Automated Segmentation and Reconstruction of the Subthalamic Nucleus in Parkinson's Disease Patients. Neuromodulation 2015; 19:13-9. [DOI: 10.1111/ner.12350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 07/23/2015] [Accepted: 08/17/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Bo Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace, Tsinghua University, Beijing, China
| | - Changqing Jiang
- National Engineering Laboratory for Neuromodulation, School of Aerospace, Tsinghua University, Beijing, China
| | - Luming Li
- National Engineering Laboratory for Neuromodulation, School of Aerospace, Tsinghua University, Beijing, China.,Center of Epilepsy, Beijing Institute for Brain Disorders, Beijing, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dawei Meng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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