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Martin T, Jannin P, Baxter JSH. Generalisation capabilities of machine-learning algorithms for the detection of the subthalamic nucleus in micro-electrode recordings. Int J Comput Assist Radiol Surg 2024:10.1007/s11548-024-03202-2. [PMID: 38951363 DOI: 10.1007/s11548-024-03202-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 05/27/2024] [Indexed: 07/03/2024]
Abstract
PURPOSE Micro-electrode recordings (MERs) are a key intra-operative modality used during deep brain stimulation (DBS) electrode implantation, which allow for a trained neurophysiologist to infer the anatomy in which the electrode is placed. As DBS targets are small, such inference is necessary to confirm that the electrode is correctly positioned. Recently, machine learning techniques have been used to augment the neurophysiologist's capability. The goal of this paper is to investigate the generalisability of these methods with respect to different clinical centres and training paradigms. METHODS Five deep learning algorithms for binary classification of MER signals have been implemented. Three databases from two different clinical centres have also been collected with differing size, acquisition hardware, and annotation protocol. Each algorithm has initially been trained on the largest database, then either directly tested or fine-tuned on the smaller databases in order to estimate their generalisability. As a reference, they have also been trained from scratch on the smaller databases as well in order to estimate the effect of the differing database sizes and annotation systems. RESULTS Each network shows significantly reduced performance (on the order of a 6.5% to 16.0% reduction in balanced accuracy) when applied out-of-distribution. This reduction can be ameliorated through fine-tuning the network on the new database through transfer learning. Although, even for these small databases, it appears that retraining from scratch may still offer equivalent performance as fine-tuning with transfer learning. However, this is at the expense of significantly longer training times. CONCLUSION Generalisability is an important criterion for the success of machine learning algorithms in clinic. We have demonstrated that a variety of recent machine learning algorithms for MER classification are negatively affected by domain shift, but that this can be quickly ameliorated through simple transfer learning procedures that can be readily performed for new centres.
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Affiliation(s)
- Thibault Martin
- Laboratoire Traitement du Signal et de l'Image (LTSI, INSERM UMR 1099), Université de Rennes, Rennes, France
| | - Pierre Jannin
- Laboratoire Traitement du Signal et de l'Image (LTSI, INSERM UMR 1099), Université de Rennes, Rennes, France
| | - John S H Baxter
- Laboratoire Traitement du Signal et de l'Image (LTSI, INSERM UMR 1099), Université de Rennes, Rennes, France.
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Kesarwani R, Mahajan UV, Wang AS, Kilbane C, Shaikh AG, Miller JP, Sweet JA. Improved Side-Effect Stimulation Thresholds and Postoperative Transient Confusion With Asleep, Image-Guided Deep Brain Stimulation. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01042. [PMID: 38305427 DOI: 10.1227/ons.0000000000001076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 12/01/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Asleep, image-guided deep brain stimulation (DBS) is a modern alternative to awake, microelectrode recording (MER) guidance. Studies demonstrate comparable efficacy and complications between techniques, although some report lower stimulation thresholds for side effects with image guidance. In addition, few studies directly compare the risk of postoperative transient confusion (pTC) across techniques. The purpose of this study was to compare clinical efficacy, stimulation thresholds for side effects, and rates of pTC with MER-guided DBS vs intraoperative 3D-fluoroscopy (i3D-F) guidance in Parkinson's disease and essential tremor. METHODS Consecutive patients from 2006 to 2021 were identified from the departmental database and grouped as having either MER-guided DBS or i3D-F-guided DBS insertion. Directional leads were used once commercially available. Changes in Unified Parkinson's Disease Rating Scale (UPDRS)-III scores, levodopa equivalent daily dose, Fahn-Tolosa-Marin scores, and stimulation thresholds were assessed, as were rates of complications including pTC. RESULTS MER guidance was used to implant 487 electrodes (18 globus pallidus interna, GPi; 171 subthalamic nucleus; 76 ventrointermediate thalamus, VIM) in 265 patients. i3D-F guidance was used in 167 electrodes (19 GPi; 25 subthalamic nucleus; 41 VIM) in 85 patients. There were no significant differences in Unified Parkinson's Disease Rating III Scale, levodopa equivalent daily dose, or Fahn-Tolosa-Marin between groups. Stimulation thresholds for side effects were higher with i3D-F guidance in the subthalamic nucleus (MER, 2.80 mA ± 0.98; i3D-F, 3.46 mA ± 0.92; P = .002) and VIM (MER, 2.81 mA ± 1.00; i3D-F, 3.19 mA ± 1.03; P = .0018). Less pTC with i3D-F guidance (MER, 7.5%; i3D-F, 1.2%; P = .034) was also found. CONCLUSION Although clinical efficacy between MER-guided and i3D-F-guided DBS was comparable, thresholds for stimulation side effects were higher with i3D-F guidance and the rate of pTC was lower. This suggests that image-guided DBS may affect long-term side effects and pose a decreased risk of pTC.
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Affiliation(s)
- Rohit Kesarwani
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Current Affiliation: Meritas Health Neurosurgery, North Kansas City Hospital, North Kansas City, Missouri, USA
| | - Uma V Mahajan
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Alexander S Wang
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Camilla Kilbane
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Aasef G Shaikh
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- United States Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Jonathan P Miller
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jennifer A Sweet
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Acevedo N, Rossell S, Castle D, Groves C, Cook M, McNeill P, Olver J, Meyer D, Perera T, Bosanac P. Clinical outcomes of deep brain stimulation for obsessive-compulsive disorder: Insight as a predictor of symptom changes. Psychiatry Clin Neurosci 2024; 78:131-141. [PMID: 37984432 PMCID: PMC10952286 DOI: 10.1111/pcn.13619] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 10/18/2023] [Accepted: 11/11/2023] [Indexed: 11/22/2023]
Abstract
AIM Deep brain stimulation (DBS) is a safe and effective treatment option for people with refractory obsessive-compulsive disorder (OCD). Yet our understanding of predictors of response and prognostic factors remains rudimentary, and long-term comprehensive follow-ups are lacking. We aim to investigate the efficacy of DBS therapy for OCD patients, and predictors of clinical response. METHODS Eight OCD participants underwent DBS stimulation of the nucleus accumbens (NAc) in an open-label longitudinal trial, duration of follow-up varied between 9 months and 7 years. Post-operative care involved comprehensive fine tuning of stimulation parameters and adjunct multidisciplinary therapy. RESULTS Six participants achieved clinical response (35% improvement in obsessions and compulsions on the Yale Brown Obsessive Compulsive Scale (YBOCS)) within 6-9 weeks, response was maintained at last follow up. On average, the YBOCS improved by 45% at last follow up. Mixed linear modeling elucidated directionality of symptom changes: insight into symptoms strongly predicted (P = 0.008) changes in symptom severity during DBS therapy, likely driven by initial changes in depression and anxiety. Precise localization of DBS leads demonstrated that responders most often had their leads (and active contacts) placed dorsal compared to non-responders, relative to the Nac. CONCLUSION The clinical efficacy of DBS for OCD is demonstrated, and mediators of changes in symptoms are proposed. The symptom improvements within this cohort should be seen within the context of the adjunct psychological and biopsychosocial care that implemented a shared decision-making approach, with flexible iterative DBS programming. Further research should explore the utility of insight as a clinical correlate of response. The trial was prospectively registered with the ANZCTR (ACTRN12612001142820).
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Affiliation(s)
- Nicola Acevedo
- Centre for Mental HealthSwinburne University of TechnologyMelbourneVictoriaAustralia
- St Vincent's HospitalMelbourneVictoriaAustralia
| | - Susan Rossell
- Centre for Mental HealthSwinburne University of TechnologyMelbourneVictoriaAustralia
- St Vincent's HospitalMelbourneVictoriaAustralia
| | - David Castle
- St Vincent's HospitalMelbourneVictoriaAustralia
- Centre for Addiction and Mental HealthUniversity of TorontoTorontoOntarioCanada
| | | | - Mark Cook
- St Vincent's HospitalMelbourneVictoriaAustralia
| | | | - James Olver
- Department of PsychiatryUniversity of MelbourneMelbourneVictoriaAustralia
| | - Denny Meyer
- Centre for Mental HealthSwinburne University of TechnologyMelbourneVictoriaAustralia
| | - Thushara Perera
- Bionics InstituteEast MelbourneVictoriaAustralia
- Department of Medical BionicsThe University of MelbourneMelbourneVictoriaAustralia
| | - Peter Bosanac
- St Vincent's HospitalMelbourneVictoriaAustralia
- Department of PsychiatryUniversity of MelbourneMelbourneVictoriaAustralia
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Chuang TC, Tan JQ, Chen SM. Comparison of intraoperative imaging guided versus microelectrode recording guided deep brain stimulation for Parkinson's disease: A meta-analysis. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:228-237. [PMID: 36931932 DOI: 10.1016/j.neucie.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 09/12/2022] [Indexed: 03/17/2023]
Abstract
BACKGROUND Traditionally, most centers would use microelectrode recording (MER) to refine targeting in deep brain stimulation (DBS) surgery. In recent years, intraoperative imaging (IMG) guided DBS has become an alternative way to verify lead placement. Currently, there is still controversy surrounding the necessity of MER or IMG for DBS. This meta-analysis aims to explore lead accuracy, clinical efficacy and safety between IMG and MER guided DBS for Parkinson's disease (PD). METHODS PubMed, Embase, Web of Science, Cochrane Library were searched up to Mar, 2021 for studies reporting comparisons between IMG and MER guided DBS for PD. Subgroup analysis was conducted to assess effects of different IMG technology and DBS targeting site. RESULTS Six studies, comprising of 478 patients were included in our analysis. The mean difference between the two implantation techniques in stereotactic accuracy, lead passes per trajectory, improvement% of Unified Parkinson's Disease Rating Scale part III and levodopa equivalent daily dose were -0.45 (95% confidence interval, CI=-1.11 to 0.20), -0.18 (95% CI=-0.41 to 0.06), 3.40 (95% CI=-5.36 to 12.16), and 5.00 (95% CI=-1.40 to 11.39), respectively. No significant differences were observed in each adverse event and operation/procedure time between the two implantation techniques. CONCLUSIONS Both IMG and MER guided DBS offered effective control of motor symptoms for PD. Besides, IMG guided is comparable to MER guided DBS, in terms of safety, accuracy and efficiency. It is recommended for each hospital to select DBS guidance technology based on available resources and equipment.
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Affiliation(s)
- Tsung-Che Chuang
- Department of Primary Medicine, Shuang-Ho Hospital, New Taipei, Taiwan
| | - Jia-Qi Tan
- Department of Primary Medicine, Shuang-Ho Hospital, New Taipei, Taiwan
| | - Shu-Mei Chen
- Department of Surgery, School of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Neurosurgery, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan.
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5
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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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DePaoli D, Côté DC, Bouma BE, Villiger M. Endoscopic imaging of white matter fiber tracts using polarization-sensitive optical coherence tomography. Neuroimage 2022; 264:119755. [PMID: 36400379 PMCID: PMC9802682 DOI: 10.1016/j.neuroimage.2022.119755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/29/2022] [Accepted: 11/14/2022] [Indexed: 11/17/2022] Open
Abstract
Polarization sensitive optical coherence tomography (PSOCT) has been shown to image and delineate white matter fibers in a label-free manner by revealing optical birefringence within the myelin sheath using a microscope setup. In this proof-of-concept study, we adapt recent advancements in endoscopic PSOCT to perform depth-resolved imaging of white matter structures deep inside intact porcine brain tissue ex-vivo, through a small, rotational fiber probe. The probe geometry is comparable to microelectrodes currently used in neurosurgical interventions. The presented imaging system is mobile, robust, and uses biologically safe levels of optical radiation making it well suited for clinical translation. In neurosurgery, where accuracy is imperative, endoscopic PSOCT through a narrow-gauge fiber probe could provide intra-operative feedback on the location of critical white matter structures.
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Affiliation(s)
- Damon DePaoli
- Harvard Medical School, Boston, MA 02115, USA,Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Daniel C. Côté
- CERVO Brain Research Center, Université Laval, Quebec City, Quebec G1E 1T2, Canada
| | - Brett E. Bouma
- Harvard Medical School, Boston, MA 02115, USA,Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA 02142, USA
| | - Martin Villiger
- Harvard Medical School, Boston, MA 02115, USA,Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA 02114, USA,Corresponding author. (M. Villiger)
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7
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Comparison of intraoperative imaging guided versus microelectrode recording guided deep brain stimulation for Parkinson's disease: A meta-analysis. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
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8
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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: 4] [Impact Index Per Article: 2.0] [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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Sinclair NC, McDermott HJ, Lee WL, Xu SS, Acevedo N, Begg A, Perera T, Thevathasan W, Bulluss KJ. Electrically evoked and spontaneous neural activity in the subthalamic nucleus under general anesthesia. J Neurosurg 2022; 137:449-458. [PMID: 34891136 DOI: 10.3171/2021.8.jns204225] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 08/09/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) surgery is commonly performed with the patient awake to facilitate assessments of electrode positioning. However, awake neurosurgery can be a barrier to patients receiving DBS. Electrode implantation can be performed with the patient under general anesthesia (GA) using intraoperative imaging, although such techniques are not widely available. Electrophysiological features can also aid in the identification of target neural regions and provide functional evidence of electrode placement. Here we assess the presence and positional variation under GA of spontaneous beta and high-frequency oscillation (HFO) activity, and evoked resonant neural activity (ERNA), a novel evoked response localized to the subthalamic nucleus. METHODS ERNA, beta, and HFO were intraoperatively recorded from DBS leads comprising four individual electrodes immediately after bilateral awake implantation into the subthalamic nucleus of 21 patients with Parkinson's disease (42 hemispheres) and after subsequent GA induction deep enough to perform pulse generator implantation. The main anesthetic agent was either propofol (10 patients) or sevoflurane (11 patients). RESULTS GA reduced the amplitude of ERNA, beta, and HFO activity (p < 0.001); however, ERNA amplitudes remained large in comparison to spontaneous local field potentials. Notably, a moderately strong correlation between awake ERNA amplitude and electrode distance to an "ideal" therapeutic target within dorsal STN was preserved under GA (awake: ρ = -0.73, adjusted p value [padj] < 0.001; GA: ρ = -0.69, padj < 0.001). In contrast, correlations were diminished under GA for beta (awake: ρ = -0.45, padj < 0.001; GA: ρ = -0.13, padj = 0.12) and HFO (awake: ρ = -0.69, padj < 0.001; GA: ρ = -0.33, padj < 0.001). The largest ERNA occurred at the same electrode (awake vs GA) for 35/42 hemispheres (83.3%) and corresponded closely to the electrode selected by the clinician for chronic therapy at 12 months (awake ERNA 77.5%, GA ERNA 82.5%). The largest beta amplitude occurred at the same electrode (awake vs GA) for only 17/42 (40.5%) hemispheres and 21/42 (50%) for HFO. The electrode measuring the largest awake beta and HFO amplitudes corresponded to the electrode selected by the clinician for chronic therapy at 12 months in 60% and 70% of hemispheres, respectively. However, this correspondence diminished substantially under GA (beta 20%, HFO 35%). CONCLUSIONS ERNA is a robust electrophysiological signal localized to the dorsal subthalamic nucleus subregion that is largely preserved under GA, indicating it could feasibly guide electrode implantation, either alone or in complementary use with existing methods.
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Affiliation(s)
- Nicholas C Sinclair
- 1Bionics Institute, East Melbourne
- 2Medical Bionics Department, The University of Melbourne, East Melbourne
| | - Hugh J McDermott
- 1Bionics Institute, East Melbourne
- 2Medical Bionics Department, The University of Melbourne, East Melbourne
| | | | - San San Xu
- 1Bionics Institute, East Melbourne
- 3Department of Neurology, Austin Hospital, Heidelberg
| | | | | | - Thushara Perera
- 1Bionics Institute, East Melbourne
- 2Medical Bionics Department, The University of Melbourne, East Melbourne
| | - Wesley Thevathasan
- 1Bionics Institute, East Melbourne
- 3Department of Neurology, Austin Hospital, Heidelberg
- 5Department of Medicine, The University of Melbourne, Parkville
| | - Kristian J Bulluss
- 1Bionics Institute, East Melbourne
- 6Department of Neurosurgery, St. Vincent's and Austin Hospitals, Melbourne; and
- 7Department of Surgery, The University of Melbourne, Heidelberg, Victoria, Australia
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10
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Zheng Z, Zhu Z, Ying Y, Jiang H, Wu H, Tian J, Luo W, Zhu J. The Accuracy of Imaging Guided Targeting with Microelectrode Recoding in Subthalamic Nucleus for Parkinson's Disease: A Single-Center Experience. JOURNAL OF PARKINSON'S DISEASE 2022; 12:897-903. [PMID: 35124576 PMCID: PMC9108556 DOI: 10.3233/jpd-213095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: Accurate electrode targeting was essential for the efficacy of deep brain stimulation (DBS). There is ongoing debate about the necessary of microelectrode recording (MER) in subthalamic nucleus (STN)-DBS surgery for accurate targeting. Objective: This study aimed to analyze the accuracy of imaging-guided awake DBS with MER in STN for Parkinson’s disease in a single center. Methods: The authors performed a retrospective analysis of 161 Parkinson’s disease patients undergoing STN-DBS at our center from March 2013 to June 2021. The implantation was performed by preoperative magnetic resonance imaging (MRI)-based direct targeting with intraoperative MER and macrostimulation testing. 285 electrode tracks with preoperative and postoperative coordinates were included to calculate the placement error in STN targeting. Results: 85.9% of electrodes guided by preoperative MRI were implanted without intraoperative adjustment. 31 (10.2%) and 12 (3.9%) electrodes underwent intraoperative adjustment due to MER and intraoperative testing, respectively. We found 86.2% (245/285) of electrodes with trajectory error ≤2 mm. The MER physiological signals length < 4 mm and ≥4 mm group showed trajectory error > 2 mm in 38.0% and 8.8% of electrodes, respectively. Compared to non-adjustment electrodes, the final positioning of MER-adjusted electrodes deviated from the center of STN. Conclusion: The preoperative MRI guided STN targeting results in approximately 14% cases that require electrode repositioning. MER physiological signals length < 4 mm at first penetration implied deviation off planned target. MER combined with intraoperative awake testing served to rescue such deviation based on MRI alone.
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Affiliation(s)
- Zhe Zheng
- Department of Neurosurgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang Province, China
| | - Zhoule Zhu
- Department of Neurosurgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang Province, China
| | - Yuqi Ying
- Department of Neurosurgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang Province, China
| | - Hongjie Jiang
- Department of Neurosurgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang Province, China
| | - Hemmings Wu
- Department of Neurosurgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang Province, China
| | - Jun Tian
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang Province, China
| | - Wei Luo
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang Province, China
| | - Junming Zhu
- Department of Neurosurgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang Province, China
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11
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Wang S, Gong S, Tao Y, Liang G, Sha R, Xie A, Li Z, Yuan L. A Modified Power-on Programming Method after Deep Brain Stimulation for Parkinson Disease. World Neurosurg 2022; 160:e152-e158. [PMID: 34979288 DOI: 10.1016/j.wneu.2021.12.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/26/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To explore the feasibility of using a modified power-on programming method in deep brain stimulation (DBS) for Parkinson disease (PD). METHODS We conducted a retrospective cohort study including 151 PD patients with bilateral robot-assisted DBS surgery from July 2017 to June 2020. Ninety-seven patients were adopted to the modified power-on programming method (Group I) and 54 patients were adopted to the traditional power-on programming method (Group II). In one-year follow-up, power-on programming duration, stimulation parameters, scores of Unified PD Rating Scale (UPDRS) and UPDRS-III of the 2 groups were recorded and compared. RESULTS There were no significant differences in the postoperative UPDRS, UPDRS-III improvement rate, and stimulation parameters between the 2 groups. The duration of power-on programming of Group I (1.7 ± 1.1 hours) was significantly less than that of Group II (3.5 ± 1.8 hours, P < 0.0001). CONCLUSIONS The modified power-on programming method can achieve a similar clinical effect to the traditional method, with the advantage of more efficiency.
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Affiliation(s)
- Shimiao Wang
- Department of Neurosurgery, The General Hospital of Northern Theater Command, Shenyang, China
| | - Shun Gong
- Department of Neurosurgery, The General Hospital of Northern Theater Command, Shenyang, China
| | - Yingqun Tao
- Department of Neurosurgery, The General Hospital of Northern Theater Command, Shenyang, China.
| | - Guobiao Liang
- Department of Neurosurgery, The General Hospital of Northern Theater Command, Shenyang, China
| | - Rong Sha
- Department of Neurosurgery, The General Hospital of Northern Theater Command, Shenyang, China
| | - Aotan Xie
- Department of Neurosurgery, The General Hospital of Northern Theater Command, Shenyang, China
| | - Zirui Li
- Department of Clinical Medicine (105K-Class 83), China Medical University, Shenyang, China
| | - Lijia Yuan
- Department of Neurosurgery, The General Hospital of Northern Theater Command, Shenyang, China
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12
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Frey J, Cagle J, Johnson KA, Wong JK, Hilliard JD, Butson CR, Okun MS, de Hemptinne C. Past, Present, and Future of Deep Brain Stimulation: Hardware, Software, Imaging, Physiology and Novel Approaches. Front Neurol 2022; 13:825178. [PMID: 35356461 PMCID: PMC8959612 DOI: 10.3389/fneur.2022.825178] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
Deep brain stimulation (DBS) has advanced treatment options for a variety of neurologic and neuropsychiatric conditions. As the technology for DBS continues to progress, treatment efficacy will continue to improve and disease indications will expand. Hardware advances such as longer-lasting batteries will reduce the frequency of battery replacement and segmented leads will facilitate improvements in the effectiveness of stimulation and have the potential to minimize stimulation side effects. Targeting advances such as specialized imaging sequences and "connectomics" will facilitate improved accuracy for lead positioning and trajectory planning. Software advances such as closed-loop stimulation and remote programming will enable DBS to be a more personalized and accessible technology. The future of DBS continues to be promising and holds the potential to further improve quality of life. In this review we will address the past, present and future of DBS.
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Affiliation(s)
- Jessica Frey
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Jackson Cagle
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Kara A. Johnson
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Joshua K. Wong
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Justin D. Hilliard
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Christopher R. Butson
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Michael S. Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Coralie de Hemptinne
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
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13
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Hyperdirect connectivity of opercular speech network to the subthalamic nucleus. Cell Rep 2022; 38:110477. [PMID: 35263607 PMCID: PMC8971827 DOI: 10.1016/j.celrep.2022.110477] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 01/10/2022] [Accepted: 02/11/2022] [Indexed: 12/18/2022] Open
Abstract
How the basal ganglia participate in the uniquely human behavior of speech is poorly understood, despite their known role in modulating critical aspects of cognitive and motor behavior. The subthalamic nucleus (STN) is well positioned to facilitate basal ganglia functions critical for speech. Using electrocorticography in patients undergoing awake deep brain stimulation (DBS) surgery, evidence is reported for a left opercular hyperdirect pathway in humans via stimulating the STN and examining antidromic-evoked activity in the left temporal, parietal, and frontal opercular cortex. These high-resolution cortical and subcortical mapping data provide evidence for hyperdirect connectivity between the inferior frontal gyrus and the STN. In addition, evoked potential data are consistent with the presence of monosynaptic projections from areas of the opercular ections may be unique to humans, evolving alongside the ability for speech. Using electrical stimulation of the subthalamic nucleus and simultaneous cortical recordings in individuals undergoing deep brain stimulation, Jorge et al. provide electrophysiological evidence for a hyperdirect pathway to the basal ganglia from cortical areas that control sensory and motor-planning aspects of speech.
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14
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Chrabaszcz A, Wang D, Lipski W, Bush A, Crammond D, Shaiman S, Dickey M, Holt L, Turner R, Fiez J, Richardson R. Simultaneously recorded subthalamic and cortical LFPs reveal different lexicality effects during reading aloud. JOURNAL OF NEUROLINGUISTICS 2021; 60:101019. [PMID: 34305315 PMCID: PMC8294107 DOI: 10.1016/j.jneuroling.2021.101019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Many language functions are traditionally assigned to cortical brain areas, leaving the contributions of subcortical structures to language processing largely unspecified. The present study examines a potential role of the subthalamic nucleus (STN) in lexical processing, specifically, reading aloud of words (e.g., 'fate') and pseudowords (e.g., 'fape'). We recorded local field potentials simultaneously from the STN and the cortex (precentral, postcentral, and superior temporal gyri) of 13 people with Parkinson's disease undergoing awake deep brain stimulation and compared STN's lexicality-related neural activity with that of the cortex. Both STN and cortical activity demonstrated significant task-related modulations, but the lexicality effects were different in the two brain structures. In the STN, an increase in gamma band activity (31-70 Hz) was present in pseudoword trials compared to word trials during subjects' spoken response. In the cortex, a greater decrease in beta band activity (12-30 Hz) was observed for pseudowords in the precentral gyrus. Additionally, 11 individual cortical sites showed lexicality effects with varying temporal and topographic characteristics in the alpha and beta frequency bands. These findings suggest that the STN and the sampled cortical regions are involved differently in the processing of lexical distinctions.
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Affiliation(s)
- A. Chrabaszcz
- Department of Psychology, University of Pittsburgh, Pittsburgh, USA, 15213
| | - D. Wang
- School of Medicine, Tsinghua University, Beijing, China, 100084
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA, 15213
| | - W.J. Lipski
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA, 15213
| | - A. Bush
- Brain Modulation Lab, Department of Neurosurgery, Massachusetts General Hospital, Boston, USA, 02114
- Harvard Medical School, Boston, USA, 02115
| | - D.J. Crammond
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, USA, 15213
| | - S. Shaiman
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, USA, 15213
| | - M.W. Dickey
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, USA, 15213
| | - L.L. Holt
- Department of Psychology, Carnegie Mellon University, Pittsburgh, USA, 15213
| | - R.S. Turner
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, USA, 15213
- University of Pittsburgh Brain Institute, Pittsburgh, USA, 15213
| | - J.A. Fiez
- Department of Psychology, University of Pittsburgh, Pittsburgh, USA, 15213
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, USA, 15213
- University of Pittsburgh Brain Institute, Pittsburgh, USA, 15213
| | - R.M. Richardson
- Brain Modulation Lab, Department of Neurosurgery, Massachusetts General Hospital, Boston, USA, 02114
- Harvard Medical School, Boston, USA, 02115
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15
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A novel deep recurrent convolutional neural network for subthalamic nucleus localization using local field potential signals. Biocybern Biomed Eng 2021. [DOI: 10.1016/j.bbe.2021.09.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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16
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Verhagen Metman L, Slavin KV, Rosenow JM, Vitek JL, van den Munckhof P. More Than Just the Level of Consciousness: Comparing Asleep and Awake Deep Brain Stimulation. Mov Disord 2021; 36:2763-2766. [PMID: 34585783 DOI: 10.1002/mds.28806] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 08/27/2021] [Accepted: 09/11/2021] [Indexed: 02/01/2023] Open
Affiliation(s)
- Leo Verhagen Metman
- Department of Neurological Sciences, Rush University, Chicago, Illinois, USA
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Joshua M Rosenow
- Departments of Neurosurgery, Neurology, and Physical Medicine and Rehabilitation, Northwestern University, Chicago, Illinois, USA
| | - Jerrold L Vitek
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota, USA
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, Amsterdam, North Holland, USA
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17
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Koh EJ, Golubovsky JL, Rammo R, Momin A, Walter B, Fernandez HH, Machado A, Nagel SJ. Estimating the Risk of Deep Brain Stimulation in the Modern Era: 2008 to 2020. Oper Neurosurg (Hagerstown) 2021; 21:277-290. [PMID: 34392372 DOI: 10.1093/ons/opab261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 05/16/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) was first approved by the United States Food and Drug Administration in 1997. Although the fundamentals of DBS remain the same, hardware, software, and imaging have evolved significantly. OBJECTIVE To test our hypothesis that the aggregate complication rate in the medical literature in the past 12 years would be lower than what is often cited based on early experience with DBS surgery. METHODS PubMed, PsycINFO, and EMBASE were queried for studies from 2008 to 2020 that included patients treated with DBS from 2007 to 2019. This yielded 34 articles that evaluated all complications of DBS surgery, totaling 2249 patients. RESULTS The overall complication rate in this study was 16.7% per patient. There was found to be a systemic complication rate of 0.89%, intracranial complication rate of 2.7%, neurological complication rate of 4.6%, hardware complication rate of 2.2%, and surgical site complication rate of 3.4%. The infection and erosion rate was 3.0%. CONCLUSION This review suggests that surgical complication rates have decreased since the first decade after DBS was first FDA approved. Understanding how to minimize complications from the inception of a technique should receive more attention.
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Affiliation(s)
- Eun Jeong Koh
- Department of Neurosurgery, Jeonbuk National University Medical School, Jeonju, Jeonbuk, Republic of Korea
| | - Joshua L Golubovsky
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Richard Rammo
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Arbaz Momin
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Benjamin Walter
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Hubert H Fernandez
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Andre Machado
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sean J Nagel
- Center for Neurological Restoration, Cleveland Clinic, Cleveland, Ohio, USA
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18
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Merola A, Singh J, Reeves K, Changizi B, Goetz S, Rossi L, Pallavaram S, Carcieri S, Harel N, Shaikhouni A, Sammartino F, Krishna V, Verhagen L, Dalm B. New Frontiers for Deep Brain Stimulation: Directionality, Sensing Technologies, Remote Programming, Robotic Stereotactic Assistance, Asleep Procedures, and Connectomics. Front Neurol 2021; 12:694747. [PMID: 34367055 PMCID: PMC8340024 DOI: 10.3389/fneur.2021.694747] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/14/2021] [Indexed: 11/21/2022] Open
Abstract
Over the last few years, while expanding its clinical indications from movement disorders to epilepsy and psychiatry, the field of deep brain stimulation (DBS) has seen significant innovations. Hardware developments have introduced directional leads to stimulate specific brain targets and sensing electrodes to determine optimal settings via feedback from local field potentials. In addition, variable-frequency stimulation and asynchronous high-frequency pulse trains have introduced new programming paradigms to efficiently desynchronize pathological neural circuitry and regulate dysfunctional brain networks not responsive to conventional settings. Overall, these innovations have provided clinicians with more anatomically accurate programming and closed-looped feedback to identify optimal strategies for neuromodulation. Simultaneously, software developments have simplified programming algorithms, introduced platforms for DBS remote management via telemedicine, and tools for estimating the volume of tissue activated within and outside the DBS targets. Finally, the surgical accuracy has improved thanks to intraoperative magnetic resonance or computerized tomography guidance, network-based imaging for DBS planning and targeting, and robotic-assisted surgery for ultra-accurate, millimetric lead placement. These technological and imaging advances have collectively optimized DBS outcomes and allowed “asleep” DBS procedures. Still, the short- and long-term outcomes of different implantable devices, surgical techniques, and asleep vs. awake procedures remain to be clarified. This expert review summarizes and critically discusses these recent innovations and their potential impact on the DBS field.
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Affiliation(s)
- Aristide Merola
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Jaysingh Singh
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Kevin Reeves
- Department of Psychiatry, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Barbara Changizi
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Steven Goetz
- Medtronic PLC Neuromodulation, Minneapolis, MN, United States
| | | | | | | | - Noam Harel
- Center for Magnetic Resonance Research, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Ammar Shaikhouni
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Francesco Sammartino
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Vibhor Krishna
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Leo Verhagen
- Movement Disorder Section, Department of Neurological Sciences, Rush University, Chicago, IL, United States
| | - Brian Dalm
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, United States
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19
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Acevedo N, Bosanac P, Pikoos T, Rossell S, Castle D. Therapeutic Neurostimulation in Obsessive-Compulsive and Related Disorders: A Systematic Review. Brain Sci 2021; 11:brainsci11070948. [PMID: 34356182 PMCID: PMC8307974 DOI: 10.3390/brainsci11070948] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/09/2021] [Accepted: 07/10/2021] [Indexed: 01/16/2023] Open
Abstract
Invasive and noninvasive neurostimulation therapies for obsessive-compulsive and related disorders (OCRD) were systematically reviewed with the aim of assessing clinical characteristics, methodologies, neuroanatomical substrates, and varied stimulation parameters. Previous reviews have focused on a narrow scope, statistical rather than clinical significance, grouped together heterogenous protocols, and proposed inconclusive outcomes and directions. Herein, a comprehensive and transdiagnostic evaluation of all clinically relevant determinants is presented with translational clinical recommendations and novel response rates. Electroconvulsive therapy (ECT) studies were limited in number and quality but demonstrated greater efficacy than previously identified. Targeting the pre-SMA/SMA is recommended for transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation (TMS). TMS yielded superior outcomes, although polarity findings were conflicting, and refinement of frontal/cognitive control protocols may optimize outcomes. For both techniques, standardization of polarity, more treatment sessions (>20), and targeting multiple structures are encouraged. A deep brain stimulation (DBS) 'sweet spot' of the striatum for OCD was proposed, and CBT is strongly encouraged. Tourette's patients showed less variance and reliance on treatment optimization. Several DBS targets achieved consistent, rapid, and sustained clinical response. Analysis of fiber connectivity, as opposed to precise neural regions, should be implemented for target selection. Standardization of protocols is necessary to achieve translational outcomes.
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Affiliation(s)
- Nicola Acevedo
- Centre for Mental Health, Swinburne University of Technology, John Street, Melbourne, VIC 3122, Australia; (T.P.); (S.R.)
- Correspondence:
| | - Peter Bosanac
- St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Melbourne, VIC 3065, Australia; (P.B.); (D.C.)
- Department of Psychiatry, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Toni Pikoos
- Centre for Mental Health, Swinburne University of Technology, John Street, Melbourne, VIC 3122, Australia; (T.P.); (S.R.)
| | - Susan Rossell
- Centre for Mental Health, Swinburne University of Technology, John Street, Melbourne, VIC 3122, Australia; (T.P.); (S.R.)
- St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Melbourne, VIC 3065, Australia; (P.B.); (D.C.)
| | - David Castle
- St. Vincent’s Hospital Melbourne, 41 Victoria Parade, Melbourne, VIC 3065, Australia; (P.B.); (D.C.)
- Department of Psychiatry, University of Melbourne, Melbourne, VIC 3010, Australia
- Centre for Addiction and Mental Health, 252 College Street, Toronto, ON M5T 1R7, Canada
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20
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Faraji AH, Kokkinos V, Sweat JC, Crammond DJ, Richardson RM. Robotic-Assisted Stereotaxy for Deep Brain Stimulation Lead Implantation in Awake Patients. Oper Neurosurg (Hagerstown) 2021; 19:444-452. [PMID: 32147722 DOI: 10.1093/ons/opaa029] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 12/15/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Robotic-assisted stereotaxy has been increasingly adopted for lead implantation in stereoelectroencephalography based on its efficiency, accuracy, and precision. Despite initially being developed for use in deep brain stimulation (DBS) surgery, adoption for this indication has not been widespread. OBJECTIVE To describe a recent robotic-assisted stereotaxy experience and workflow for DBS lead implantation in awake patients with and without microelectrode recording (MER), including considerations for intraoperative research using electrocorticography (ECoG). METHODS A retrospective review of 20 consecutive patients who underwent simultaneous bilateral DBS lead implantation using robotic-assisted stereotaxy was performed. Radial error was determined by comparing the preoperative target with the DBS lead position in the targeting plane on postoperative computed tomography. Information regarding any postoperative complications was obtained by chart review. RESULTS A novel method for robot coregistration was developed. We describe a standard workflow that allows for MER and/or ECoG research, and a streamlined workflow for cases in which MER is not required. The overall radial error for lead placement across all 20 patients was 1.14 ± 0.11 mm. A significant difference (P = .006) existed between the radial error of the first 10 patients (1.46 ± 0.19 mm) as compared with the second 10 patients (0.86 ± 0.09 mm). No complications were encountered. CONCLUSION Robotic-assisted stereotaxy has the potential to increase precision and reduce human error, compared to traditional frame-based DBS surgery, without negatively impacting patient safety or the ability to perform awake neurophysiology research.
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Affiliation(s)
- Amir H Faraji
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Vasileios Kokkinos
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - James C Sweat
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Donald J Crammond
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - R Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
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21
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Chandran AS, Thani NB, Bangash OK, Lind CRP. The Magnetic Resonance Imaging (MRI)-Directed Implantable Guide Tube Technique: Accuracy and Applications in Deep Brain Stimulation. World Neurosurg 2021; 151:e1016-e1023. [PMID: 34044164 DOI: 10.1016/j.wneu.2021.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/11/2021] [Accepted: 05/13/2021] [Indexed: 09/30/2022]
Abstract
OBJECTIVE The magnetic resonance imaging (MRI)-directed implantable guide tube technique allows for direct targeting of deep brain structures without microelectrode recording or intraoperative clinical assessment. This study describes a 10-year institutional experience of this technique including nuances that enable performance of surgery using readily available equipment. METHODS Eighty-seven patients underwent deep brain stimulation surgery using the guide tube technique for Parkinson disease (n = 59), essential tremor (n = 16), and dystonia (n = 12). Preoperative and intraoperative MRI was analyzed to measure lead accuracy, volume of pneumocephalus, and the ability to safely plan a trajectory for multiple electrode contacts. RESULTS Mean target error was measured to be 0.7 mm (95% confidence interval [CI] 0.6-0.8 mm) in the anteroposterior plane, 0.6 mm (95% CI 0.5-0.7 mm) in the mediolateral plane, and 0.8 mm (95% CI 0.7-0.9 mm) in the superoinferior plane. Net deviation (Euclidean error) from the planned target was 1.3 mm (95% CI 1.2-1.4 mm). Mean intracranial air volume per lead was 0.2 mL (95% CI 0.1-0.4 mL). In total, 52 patients had no intracranial air on postoperative imaging. In all patients, a safe trajectory could be planned to target for multiple electrode contacts without violating critical neural structures, the lateral ventricle, sulci, or cerebral blood vessels. CONCLUSIONS The MRI-directed implantable guide tube technique is a highly accurate, low-cost, reliable method for introducing deep brain electrodes. This technique reduces brain shift secondary to pneumocephalus and allows for whole trajectory planning of multiple electrode contacts.
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Affiliation(s)
- Arjun S Chandran
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.
| | - Nova B Thani
- Department of Neurosurgery, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Omar K Bangash
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Christopher R P Lind
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; School of Medicine, University of Western Australia, Perth, Western Australia, Australia
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22
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Martin T, Peralta M, Gilmore G, Sauleau P, Haegelen C, Jannin P, Baxter JS. Extending convolutional neural networks for localizing the subthalamic nucleus from micro-electrode recordings in Parkinson’s disease. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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23
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Bezchlibnyk YB, Sharma VD, Naik KB, Isbaine F, Gale JT, Cheng J, Triche SD, Miocinovic S, Buetefisch CM, Willie JT, Boulis NM, Factor SA, Wichmann T, DeLong MR, Gross RE. Clinical outcomes of globus pallidus deep brain stimulation for Parkinson disease: a comparison of intraoperative MRI- and MER-guided lead placement. J Neurosurg 2021; 134:1072-1082. [PMID: 32114534 DOI: 10.3171/2019.12.jns192010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) lead placement is increasingly performed with the patient under general anesthesia by surgeons using intraoperative MRI (iMRI) guidance without microelectrode recording (MER) or macrostimulation. The authors assessed the accuracy of lead placement, safety, and motor outcomes in patients with Parkinson disease (PD) undergoing DBS lead placement into the globus pallidus internus (GPi) using iMRI or MER guidance. METHODS The authors identified all patients with PD who underwent either MER- or iMRI-guided GPi-DBS lead placement at Emory University between July 2007 and August 2016. Lead placement accuracy and adverse events were determined for all patients. Clinical outcomes were assessed using the Unified Parkinson's Disease Rating Scale (UPDRS) part III motor scores for patients completing 12 months of follow-up. The authors also assessed the levodopa-equivalent daily dose (LEDD) and stimulation parameters. RESULTS Seventy-seven patients were identified (MER, n = 28; iMRI, n = 49), in whom 131 leads were placed. The stereotactic accuracy of the surgical procedure with respect to the planned lead location was 1.94 ± 0.21 mm (mean ± SEM) (95% CI 1.54-2.34) with frame-based MER and 0.84 ± 0.007 mm (95% CI 0.69-0.98) with iMRI. The rate of serious complications was similar, at 6.9% for MER-guided DBS lead placement and 9.4% for iMRI-guided DBS lead placement (RR 0.71 [95% CI 0.13%-3.9%]; p = 0.695). Fifty-seven patients were included in clinical outcome analyses (MER, n = 16; iMRI, n = 41). Both groups had similar characteristics at baseline, although patients undergoing MER-guided DBS had a lower response on their baseline levodopa challenge (44.8% ± 5.4% [95% CI 33.2%-56.4%] vs 61.6% ± 2.1% [95% CI 57.4%-65.8%]; t = 3.558, p = 0.001). Greater improvement was seen following iMRI-guided lead placement (43.2% ± 3.5% [95% CI 36.2%-50.3%]) versus MER-guided lead placement (25.5% ± 6.7% [95% CI 11.1%-39.8%]; F = 5.835, p = 0.019). When UPDRS III motor scores were assessed only in the contralateral hemibody (per-lead analyses), the improvements remained significantly different (37.1% ± 7.2% [95% CI 22.2%-51.9%] and 50.0% ± 3.5% [95% CI 43.1%-56.9%] for MER- and iMRI-guided DBS lead placement, respectively). Both groups exhibited similar reductions in LEDDs (21.2% and 20.9%, respectively; F = 0.221, p = 0.640). The locations of all active contacts and the 2D radial distance from these to consensus coordinates for GPi-DBS lead placement (x, ±20; y, +2; and z, -4) did not differ statistically by type of surgery. CONCLUSIONS iMRI-guided GPi-DBS lead placement in PD patients was associated with significant improvement in clinical outcomes, comparable to those observed following MER-guided DBS lead placement. Furthermore, iMRI-guided DBS implantation produced a similar safety profile to that of the MER-guided procedure. As such, iMRI guidance is an alternative to MER guidance for patients undergoing GPi-DBS implantation for PD.
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Affiliation(s)
- Yarema B Bezchlibnyk
- 1Department of Neurosurgery and Brain Repair, Morsani School of Medicine, University of South Florida, Tampa, Florida
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Vibhash D Sharma
- 3Department of Neurology, University of Kansas Medical Center, Kansas City, Kansas
- 4Department of Neurology, Emory University School of Medicine
| | - Kushal B Naik
- 5Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, and
| | - Faical Isbaine
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - John T Gale
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Jennifer Cheng
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
- 6Department of Neurosurgery, University of Kansas Medical Center, Kansas City, Kansas
| | | | | | | | - Jon T Willie
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
- 4Department of Neurology, Emory University School of Medicine
| | - Nicholas M Boulis
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Thomas Wichmann
- 4Department of Neurology, Emory University School of Medicine
| | - Mahlon R DeLong
- 4Department of Neurology, Emory University School of Medicine
| | - Robert E Gross
- 2Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
- 4Department of Neurology, Emory University School of Medicine
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Almahariq F, Sedmak G, Vuletić V, Dlaka D, Orešković D, Marčinković P, Raguž M, Chudy D. The Accuracy of Direct Targeting Using Fusion of MR and CT Imaging for Deep Brain Stimulation of the Subthalamic Nucleus in Patients with Parkinson's Disease. J Neurol Surg A Cent Eur Neurosurg 2021; 82:518-525. [PMID: 33618414 DOI: 10.1055/s-0040-1715826] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION In 33 consecutive patients with Parkinson's disease (PD) undergoing awake deep brain stimulation (DBS) without microelectrode recording (MER), we assessed and validated the precision and accuracy of direct targeting of the subthalamic nucleus (STN) using preoperative magnetic resonance imaging (MRI) and stereotactic computed tomography (CT) image fusion combined with immediate postoperative stereotactic CT and postoperative MRI, and we report on the side effects and clinical results up to 6 months' follow-up. MATERIALS AND METHODS Preoperative nonstereotactic MRI and stereotactic CT images were merged and used for planning the trajectory and final lead position. Immediate postoperative stereotactic CT and postoperative nonstereotactic MRI provided the validation of the final electrode position. Changes in the Unified Parkinson's Disease Rating Scale III (UPDRS III) scores and the levodopa equivalent daily doses (LEDD) and appearance of adverse side effects were assessed. RESULTS The mean Euclidian distance (ED) error between the planned position and the final position of the lead in the left STN was 1.69 ± 0.82 mm and that in the right STN was 2.12 ± 1.00. The individual differences between planned and final position in each of the three coordinates were less than 2 mm. The UPDRS III scores improved by 75% and LEDD decreased by 45%. Few patients experienced complications, such as postoperative infection (n = 1), or unwanted side effects, such as emotional instability (n = 1). CONCLUSION Our results confirm that direct targeting of an STN on stereotactic CT merged with MRI could be a valid method for placement the DBS electrode. The magnitude of our targeting error is comparable with the reported errors when using MER and other direct targeting approaches.
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Affiliation(s)
- Fadi Almahariq
- Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia.,Center of Excellence in Basic, Clinical and Translational Neuroscience, Zagreb, Croatia
| | - Goran Sedmak
- Center of Excellence in Basic, Clinical and Translational Neuroscience, Zagreb, Croatia.,Croatian Institute for Brain Research, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Vladimira Vuletić
- Department of Neurology, School of Medicine, University of Rijeka, University Hospital Rijeka, Rijeka, Croatia
| | - Domagoj Dlaka
- Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia
| | - Darko Orešković
- Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia
| | - Petar Marčinković
- Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia
| | - Marina Raguž
- Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia
| | - Darko Chudy
- Department of Neurosurgery, Clinical Hospital Dubrava, Zagreb, Croatia.,Center of Excellence in Basic, Clinical and Translational Neuroscience, Zagreb, Croatia.,Department of Surgery, School of Medicine, University of Zagreb, Zagreb, Croatia
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van den Munckhof P, Bot M, Schuurman PR. Targeting of the Subthalamic Nucleus in Patients with Parkinson's Disease Undergoing Deep Brain Stimulation Surgery. Neurol Ther 2021; 10:61-73. [PMID: 33565018 PMCID: PMC8140007 DOI: 10.1007/s40120-021-00233-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 01/20/2021] [Indexed: 11/29/2022] Open
Abstract
Precise stereotactic targeting of the dorsolateral motor part of the subthalamic nucleus (STN) is paramount for maximizing clinical effectiveness and preventing side effects of deep brain stimulation (DBS) in patients with advanced Parkinson's disease. With recent developments in magnetic resonance imaging (MRI) techniques, direct targeting of the dorsolateral part of the STN is now feasible, together with visualization of the motor fibers in the nearby internal capsule. However, clinically relevant discrepancies were reported when comparing STN borders on MRI to electrophysiological STN borders during microelectrode recordings (MER). Also, one should take into account the possibility of a 3D inaccuracy of up to 2 mm of the applied stereotactic technique. Pneumocephalus and image fusion errors may further increase implantation inaccuracy. Even when implantation has been successful, suboptimal lead anchoring on the skull may cause lead migration during follow-up. Meticulous pre- and intraoperative imaging is therefore indispensable, and so is postoperative imaging when the effects of DBS deteriorate during follow-up. Thus far, most DBS centers employ MRI targeting, multichannel MER, and awake test stimulation in STN surgery, but randomized trials comparing surgery under local versus general anesthesia and additional studies comparing MER-STN borders to high-field MRI-STN may change this clinical practice. Further developments in imaging protocols and improvements in image fusion processes are needed to optimize placement of DBS leads in the dorsolateral motor part of the STN in Parkinson's disease.
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Affiliation(s)
- Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands.
| | - Maarten Bot
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - P Richard Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
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26
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Chari A, Budhdeo S, Sparks R, Barone DG, Marcus HJ, Pereira EAC, Tisdall MM. Brain-Machine Interfaces: The Role of the Neurosurgeon. World Neurosurg 2020; 146:140-147. [PMID: 33197630 DOI: 10.1016/j.wneu.2020.11.028] [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: 09/23/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 12/26/2022]
Abstract
Neurotechnology is set to expand rapidly in the coming years as technological innovations in hardware and software are translated to the clinical setting. Given our unique access to patients with neurologic disorders, expertise with which to guide appropriate treatments, and technical skills to implant brain-machine interfaces (BMIs), neurosurgeons have a key role to play in the progress of this field. We outline the current state and key challenges in this rapidly advancing field, including implant technology, implant recipients, implantation methodology, implant function, and ethical, regulatory, and economic considerations. Our key message is to encourage the neurosurgical community to proactively engage in collaborating with other health care professionals, engineers, scientists, ethicists, and regulators in tackling these issues. By doing so, we will equip ourselves with the skills and expertise to drive the field forward and avoid being mere technicians in an industry driven by those around us.
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Affiliation(s)
- Aswin Chari
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom; Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom.
| | - Sanjay Budhdeo
- Department for Clinical and Movement Neurosciences, Queen Square Institute of Neurology, University College London, London, United Kingdom; Department of Neurology, National Hospital for Neurology and Neurosurgery, London, United Kingdom; OwkinInc, New York, New York, USA
| | - Rachel Sparks
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, United Kingdom
| | - Damiano G Barone
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Hani J Marcus
- Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom; Wellcome EPSRC Centre for Interventional and Surgical Sciences, University College London, London, United Kingdom
| | - Erlick A C Pereira
- Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's, University of London, United Kingdom
| | - Martin M Tisdall
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom; Department of Neurosurgery, Great Ormond Street Hospital, London, United Kingdom
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Peralta M, Bui QA, Ackaouy A, Martin T, Gilmore G, Haegelen C, Sauleau P, Baxter JSH, Jannin P. SepaConvNet for Localizing the Subthalamic Nucleus Using One Second Micro-electrode Recordings. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:888-893. [PMID: 33018127 DOI: 10.1109/embc44109.2020.9175294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Micro-electrode recording (MER) is a powerful way of localizing target structures during neurosurgical procedures such as the implantation of deep brain stimulation electrodes, which is a common treatment for Parkinson's disease and other neurological disorders. While Micro-electrode Recording (MER) provides adjunctive information to guidance assisted by pre-operative imaging, it is not unanimously used in the operating room. The lack of standard use of MER may be in part due to its long duration, which can lead to complications during the operation, or due to high degree of expertise required for their interpretation. Over the past decade, various approaches addressing automating MER analysis for target localization have been proposed, which have mainly focused on feature engineering. While the accuracies obtained are acceptable in certain configurations, one issue with handcrafted MER features is that they do not necessarily capture more subtle differences in MER that could be detected auditorily by an expert neurophysiologist. In this paper, we propose and validate a deep learning-based pipeline for subthalamic nucleus (STN) localization with micro-electrode recordings motivated by the human auditory system. Our proposed Convolutional Neural Network (CNN), referred as SepaConvNet, shows improved accuracy over two comparative networks for locating the STN from one second MER samples.
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Gonzalez-Escamilla G, Muthuraman M, Ciolac D, Coenen VA, Schnitzler A, Groppa S. Neuroimaging and electrophysiology meet invasive neurostimulation for causal interrogations and modulations of brain states. Neuroimage 2020; 220:117144. [DOI: 10.1016/j.neuroimage.2020.117144] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/22/2020] [Accepted: 07/02/2020] [Indexed: 12/13/2022] Open
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Nguyen TAK, Schüpbach M, Mercanzini A, Dransart A, Pollo C. Directional Local Field Potentials in the Subthalamic Nucleus During Deep Brain Implantation of Parkinson's Disease Patients. Front Hum Neurosci 2020; 14:521282. [PMID: 33192384 PMCID: PMC7556345 DOI: 10.3389/fnhum.2020.521282] [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: 03/02/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022] Open
Abstract
Segmented deep brain stimulation leads feature directional electrodes that allow for a finer spatial control of electrical stimulation compared to traditional ring-shaped electrodes. These segmented leads have demonstrated enlarged therapeutic windows and have thus the potential to improve the treatment of Parkinson's disease patients. Moreover, they provide a unique opportunity to record directional local field potentials. Here, we investigated whether directional local field potentials can help identify the best stimulation direction to assist device programming. Four Parkinson's disease patients underwent routine implantation of the subthalamic nucleus. Firstly, local field potentials were recorded in three directions for two conditions: In one condition, the patient was at rest; in the other condition, the patient's arm was moved. Secondly, current thresholds for therapeutic and side effects were identified intraoperatively for directional stimulation. Therapeutic windows were calculated from these two thresholds. Thirdly, the spectral power of the total beta band (13-35 Hz) and its sub-bands low, high, and peak beta were analyzed post hoc. Fourthly, the spectral power was used by different algorithms to predict the ranking of directions. The spectral power profiles were patient-specific, and spectral peaks were found both in the low beta band (13-20 Hz) and in the high beta band (20.5-35 Hz). The direction with the highest spectral power in the total beta band was most indicative of the 1st best direction when defined by therapeutic window. Based on the total beta band, the resting condition and the moving condition were similarly predictive about the direction ranking and classified 83.3% of directions correctly. However, different algorithms were needed to predict the ranking defined by therapeutic window or therapeutic current threshold. Directional local field potentials may help predict the best stimulation direction. Further studies with larger sample sizes are needed to better distinguish the informative value of different conditions and the beta sub-bands.
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Affiliation(s)
- T. A. Khoa Nguyen
- Department of Neurosurgery, University Hospital of Bern, Bern, Switzerland
| | - Michael Schüpbach
- Department of Neurology, University Hospital of Bern, Bern, Switzerland
| | - André Mercanzini
- Microsystems Laboratory 4, School of Engineering, EPF Lausanne, Lausanne, Switzerland
- Aleva Neurotherapeutics SA, Lausanne, Switzerland
| | | | - Claudio Pollo
- Department of Neurosurgery, University Hospital of Bern, Bern, Switzerland
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30
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Jorge A, Dastolfo-Hromack C, Lipski WJ, Kratter IH, Smith LJ, Gartner-Schmidt JL, Richardson RM. Anterior Sensorimotor Subthalamic Nucleus Stimulation Is Associated With Improved Voice Function. Neurosurgery 2020; 87:788-795. [PMID: 32199026 PMCID: PMC7490159 DOI: 10.1093/neuros/nyaa024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 12/11/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite the impact of Parkinson disease (PD) on speech communication, there is no consensus regarding the effect of lead location on voice-related outcomes in subthalamic nucleus (STN) deep brain stimulation (DBS). OBJECTIVE To determine the relationship of stimulation location to changes in cepstral analyses of voice following STN DBS. METHODS Speech pathology evaluations were obtained from 14 PD subjects, before and after STN DBS, including audio-perceptual voice ratings (overall severity, loudness, hoarseness changes), measured indices of dysphonia (cepstral peak prominence and cepstral spectral index of dysphonia), and phonatory aerodynamics. The contact locations used for active stimulation at the time of postoperative voice evaluations were determined and assessed in relation to voice outcomes. RESULTS Voice outcomes remained relatively unchanged on average. Stimulation locations in the anterior portion of the sensorimotor region of the left STN, however, were associated with improvements in voice severity scores, cepstral spectral index of dysphonia, shortness of breath, and phonatory airflow during connected speech. Posterior locations were associated with worsening of these outcomes. Variation in the medial-lateral or dorsal-ventral position on the left, and in any direction on the right, did not correlate with any voice outcome. CONCLUSION Active contact placement within the anterior sensorimotor STN was associated with improved perceptual and acoustic-aerodynamic voice-related outcomes. These findings suggest an STN topography for improving airflow for speech, in turn improving how PD patients' voices sound.
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Affiliation(s)
- Ahmed Jorge
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christina Dastolfo-Hromack
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Witold J Lipski
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ian H Kratter
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Libby J Smith
- Department of Otolaryngology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - R Mark Richardson
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Gravbrot N, Burket A, Saranathan M, Kasoff WS. Asleep Deep Brain Stimulation of the Nucleus Ventralis Intermedius for Essential Tremor Using Indirect Targeting and Interventional Magnetic Resonance Imaging: Single-Institution Case Series. Mov Disord Clin Pract 2020; 7:521-530. [PMID: 32626797 PMCID: PMC7328410 DOI: 10.1002/mdc3.12955] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/15/2020] [Accepted: 03/30/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Literature on asleep deep brain stimulation (DBS) of the ventralis intermedius (Vim) nucleus in essential tremor is relatively sparse. Furthermore, controversy exists as to whether indirect ("consensus" or "atlas-based") targeting of the Vim requires physiologic adjustment for effective clinical outcomes in DBS surgery. OBJECTIVES The objective of this study was to evaluate the clinical results of asleep Vim DBS using indirect coordinates and real-time interventional magnetic resonance imaging guidance. METHODS Retrospective review of a prospectively collected database was performed to identify patients with essential tremor undergoing asleep Vim DBS using interventional magnetic resonance imaging guidance. Stereotactic and clinical outcomes were abstracted and analyzed using descriptive statistics. RESULTS A total of 12 consecutive patients were identified, all of whom were available for 6-month clinical follow-up. Stereotactic (radial) error was 0.5 ± 0.2 mm on the left and 0.5 ± 0.3 mm on the right. Fahn-Tolosa-Marin tremor scores in the treated limb(s) decreased by 71.2% ± 31.0% (P = 0.0088), The Essential Tremor Rating Assessment Scale activities of daily living improved by 74.9% ± 23.7% (P < 0.0001), and The Essential Tremor Rating Assessment Scale performance improved by 64.3 ± 16.2% (P = 0.0004). Surgical complications were mild and generally transient. Stimulation-related side effects were similar to those reported in historical series of awake Vim DBS. CONCLUSIONS Asleep Vim DBS using indirect targeting and interventional magnetic resonance imaging-guided placement is safe and effective, with 6-month clinical results similar to those achieved with awake placement. These data support the use of asleep surgery in essential tremor and represent a baseline for comparison with future studies using more advanced targeting techniques.
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Affiliation(s)
- Nicholas Gravbrot
- Department of NeurosurgeryUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - Aaron Burket
- Department of NeurosurgeryUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - Manojkumar Saranathan
- Department of Medical ImagingUniversity of Arizona College of MedicineTucsonArizonaUSA
| | - Willard S. Kasoff
- Department of NeurosurgeryUniversity of Arizona College of MedicineTucsonArizonaUSA
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Janson AP, Anderson DN, Butson CR. Activation robustness with directional leads and multi-lead configurations in deep brain stimulation. J Neural Eng 2020; 17:026012. [PMID: 32116233 PMCID: PMC7405888 DOI: 10.1088/1741-2552/ab7b1d] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Clinical outcomes from deep brain stimulation (DBS) can be highly variable, and two critical factors underlying this variability are the location and type of stimulation. In this study we quantified how robustly DBS activates a target region when taking into account a range of different lead designs and realistic variations in placement. The objective of the study is to assess the likelihood of achieving target activation. APPROACH We performed finite element computational modeling and established a metric of performance robustness to evaluate the ability of directional and multi-lead configurations to activate target fiber pathways while taking into account location variability. A more robust lead configuration produces less variability in activation across all stimulation locations around the target. MAIN RESULTS Directional leads demonstrated higher overall performance robustness compared to axisymmetric leads, primarily 1-2 mm outside of the target. Multi-lead configurations demonstrated higher levels of robustness compared to any single lead due to distribution of electrodes in a broader region around the target. SIGNIFICANCE Robustness measures can be used to evaluate the performance of existing DBS lead designs and aid in the development of novel lead designs to better accommodate known variability in lead location and orientation. This type of analysis may also be useful to understand how DBS clinical outcome variability is influenced by lead location among groups of patients.
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Affiliation(s)
- Andrew P Janson
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States of America. Scientific Computing and Imaging (SCI) Institute, University of Utah, Salt Lake City, UT, United States of America
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Frequin HL, Bot M, Dilai J, Scholten MN, Postma M, Bour LJ, Contarino MF, de Bie RMA, Schuurman PR, van den Munckhof P. Relative Contribution of Magnetic Resonance Imaging, Microelectrode Recordings, and Awake Test Stimulation in Final Lead Placement during Deep Brain Stimulation Surgery of the Subthalamic Nucleus in Parkinson's Disease. Stereotact Funct Neurosurg 2020; 98:118-128. [PMID: 32131066 DOI: 10.1159/000505710] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 12/31/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION For deep brain stimulation (DBS) surgery of the subthalamic nucleus (STN) in Parkinson's disease (PD), many centers employ visualization of the nucleus on magnetic resonance imaging (MRI), intraoperative microelectrode recordings (MER), and test stimulation in awake patients. The value of these steps is a subject for ongoing debate. In the current study, we determined the relative contribution of MRI targeting, multitrack MER, and awake test stimulation in final lead placement during STN DBS surgery for PD. METHODS Data on PD patients undergoing MRI-targeted STN DBS surgery with three-channel MER and awake test stimulation between February 2010 and January 2014 were analyzed to determine in which MER trajectory final leads were implanted and why this tract was chosen. RESULTS Seventy-six patients underwent implantation of 146 DBS leads. In 92% of the STN, the final leads were implanted in one of the three planned channels. In 6%, additional channels were needed. In 2%, surgery was aborted before final lead implantation due to anxiety or fatigue. The final leads were implanted in the channels with the longest STN MER signal trajectory in 60% of the STN (38% of the bilaterally implanted patients). This was the central channel containing the MRI target in 39% of the STN (18% bilaterally). The most frequently noted reasons why another channel than the central channel was chosen for final lead placement were (1) a lower threshold for side effects (54%) and (2) no or a too short trajectory of the STN MER signal (40%) in the central channel. The latter reason correlated with larger 2D (x and y) errors in our stereotactic method. CONCLUSIONS STN DBS leads were often not implanted in the MRI-planned trajectory or in the trajectory with the longest STN MER signal. Thresholds for side effects during awake test stimulation were decisive for final target selection in the majority of patients.
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Affiliation(s)
- Henrieke L Frequin
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands.,Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Maarten Bot
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - José Dilai
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Marije N Scholten
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Miranda Postma
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Lodewijk J Bour
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Maria Fiorella Contarino
- Department of Neurology, Haga Teaching Hospital, The Hague, The Netherlands.,Department of Neurology, Leiden University Medical Center (LUMC), Leiden, The Netherlands
| | - Rob M A de Bie
- Department of Neurology and Clinical Neurophysiology, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - P Rick Schuurman
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands
| | - Pepijn van den Munckhof
- Department of Neurosurgery, Amsterdam University Medical Centers, Academic Medical Center (AMC), Amsterdam, The Netherlands,
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Patel NJ, Gavvala JR, Jimenez-Shahed J. Awake Testing to Confirm Target Engagement. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_10] [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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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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Pope JE, Schu S, Sayed D, Raslan AM, Baranidharan G, Heros RD, Blomme B, Capobianco RA, Deer TR. Anatomic Lead Placement Without Paresthesia Mapping Provides Effective and Predictable Therapy During the Trial Evaluation Period: Results From the Prospective, Multicenter, Randomized, DELIVERY Study. Neuromodulation 2019; 23:109-117. [DOI: 10.1111/ner.13019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 05/15/2019] [Accepted: 06/06/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Jason E. Pope
- Evolve Restorative Center, California Society of Interventional Pain Society Santa Rosa CA USA
| | | | - Dawood Sayed
- Department of Anesthesiology and Pain MedicineThe University of Kansas Medical Center Kansas City KS USA
| | - Ahmed M. Raslan
- Department of Neurological SurgeryOregon Health & Science University Portland Oregon
| | | | | | - Bram Blomme
- Abbott (formerly St. Jude Medical), Neuromodulation division Brussels Belgium
| | - Robyn A. Capobianco
- Abbott (formerly St. Jude Medical), Neuromodulation division Brussels Belgium
| | - Timothy R. Deer
- The Spine and Nerve Center of the Virginias Charleston WV USA
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Chrabaszcz A, Neumann WJ, Stretcu O, Lipski WJ, Bush A, Dastolfo-Hromack CA, Wang D, Crammond DJ, Shaiman S, Dickey MW, Holt LL, Turner RS, Fiez JA, Richardson RM. Subthalamic Nucleus and Sensorimotor Cortex Activity During Speech Production. J Neurosci 2019; 39:2698-2708. [PMID: 30700532 PMCID: PMC6445998 DOI: 10.1523/jneurosci.2842-18.2019] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/11/2019] [Accepted: 01/18/2019] [Indexed: 11/21/2022] Open
Abstract
The sensorimotor cortex is somatotopically organized to represent the vocal tract articulators such as lips, tongue, larynx, and jaw. How speech and articulatory features are encoded at the subcortical level, however, remains largely unknown. We analyzed LFP recordings from the subthalamic nucleus (STN) and simultaneous electrocorticography recordings from the sensorimotor cortex of 11 human subjects (1 female) with Parkinson's disease during implantation of deep-brain stimulation (DBS) electrodes while they read aloud three-phoneme words. The initial phonemes involved either articulation primarily with the tongue (coronal consonants) or the lips (labial consonants). We observed significant increases in high-gamma (60-150 Hz) power in both the STN and the sensorimotor cortex that began before speech onset and persisted for the duration of speech articulation. As expected from previous reports, in the sensorimotor cortex, the primary articulators involved in the production of the initial consonants were topographically represented by high-gamma activity. We found that STN high-gamma activity also demonstrated specificity for the primary articulator, although no clear topography was observed. In general, subthalamic high-gamma activity varied along the ventral-dorsal trajectory of the electrodes, with greater high-gamma power recorded in the dorsal locations of the STN. Interestingly, the majority of significant articulator-discriminative activity in the STN occurred before that in sensorimotor cortex. These results demonstrate that articulator-specific speech information is contained within high-gamma activity of the STN, but with different spatial and temporal organization compared with similar information encoded in the sensorimotor cortex.SIGNIFICANCE STATEMENT Clinical and electrophysiological evidence suggest that the subthalamic nucleus (STN) is involved in speech; however, this important basal ganglia node is ignored in current models of speech production. We previously showed that STN neurons differentially encode early and late aspects of speech production, but no previous studies have examined subthalamic functional organization for speech articulators. Using simultaneous LFP recordings from the sensorimotor cortex and the STN in patients with Parkinson's disease undergoing deep-brain stimulation surgery, we discovered that STN high-gamma activity tracks speech production at the level of vocal tract articulators before the onset of vocalization and often before related cortical encoding.
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Affiliation(s)
- Anna Chrabaszcz
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Wolf-Julian Neumann
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Campus Mitte, Charité, Universitätsmedizin Berlin, Berlin, Germany 10117
| | - Otilia Stretcu
- Machine Learning Department, School of Computer Science, Carnegie Mellon University, Pittsburgh, Pennsylvania 15213
| | - Witold J Lipski
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Alan Bush
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
- Department of Physics, FCEN, University of Buenos Aires and IFIBA-CONICET, Buenos Aires, Argentina 1428
| | - Christina A Dastolfo-Hromack
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Dengyu Wang
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
- School of Medicine, Tsinghua University, Beijing, China 100084
| | - Donald J Crammond
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213
| | - Susan Shaiman
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Michael W Dickey
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
| | - Lori L Holt
- Department of Psychology, Carnegie Mellon University, Pittsburgh, Pennsylvania 15213
| | - Robert S Turner
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, and
- University of Pittsburgh Brain Institute, Pittsburgh, Pennsylvania 15213
| | - Julie A Fiez
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- Department of Communication Science and Disorders, University of Pittsburgh, Pittsburgh, Pennsylvania 15213
- University of Pittsburgh Brain Institute, Pittsburgh, Pennsylvania 15213
| | - R Mark Richardson
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213,
- Department of Neurobiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, and
- University of Pittsburgh Brain Institute, Pittsburgh, Pennsylvania 15213
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Hartmann CJ, Fliegen S, Groiss SJ, Wojtecki L, Schnitzler A. An update on best practice of deep brain stimulation in Parkinson's disease. Ther Adv Neurol Disord 2019; 12:1756286419838096. [PMID: 30944587 PMCID: PMC6440024 DOI: 10.1177/1756286419838096] [Citation(s) in RCA: 78] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 02/01/2019] [Indexed: 11/16/2022] Open
Abstract
During the last 30 years, deep brain stimulation (DBS) has evolved into the clinical standard of care as a highly effective treatment for advanced Parkinson’s disease. Careful patient selection, an individualized anatomical target localization and meticulous evaluation of stimulation parameters for chronic DBS are crucial requirements to achieve optimal results. Current hardware-related advances allow for a more focused, individualized stimulation and hence may help to achieve optimal clinical results. However, current advances also increase the degrees of freedom for DBS programming and therefore challenge the skills of healthcare providers. This review gives an overview of the clinical effects of DBS, the criteria for patient, target, and device selection, and finally, offers strategies for a structured programming approach.
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Affiliation(s)
- Christian J Hartmann
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Sabine Fliegen
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefan J Groiss
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Lars Wojtecki
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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Yin Z, Luo Y, Jin Y, Yu Y, Zheng S, Duan J, Xu R, Zhou D, Hong T, Lu G. Is awake physiological confirmation necessary for DBS treatment of Parkinson's disease today? A comparison of intraoperative imaging, physiology, and physiology imaging-guided DBS in the past decade. Brain Stimul 2019; 12:893-900. [PMID: 30876883 DOI: 10.1016/j.brs.2019.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is a well-established surgical therapy for Parkinson's disease (PD). Intraoperative imaging (IMG), intraoperative physiology (PHY) and their combination (COMB) are the three mainstream DBS guidance methods. OBJECTIVE To comprehensively compare the use of IMG-DBS, PHY-DBS and COMB-DBS in treating PD. METHODS PubMed, Embase, the Cochrane Library and OpenGrey were searched to identify PD-DBS studies reporting guidance techniques published between January 1, 2010, and May 1, 2018. We quantitatively compared the therapeutic effects, surgical time, target error and complication risk and qualitatively compared the patient experience, cost and technical prospects. A meta-regression analysis was also performed. This study is registered with PROSPERO, number CRD42018105995. RESULTS Fifty-nine cohorts were included in the main analysis. The three groups were equivalent in therapeutic effects and infection risks. IMG-DBS (p < 0.001) and COMB-DBS (p < 0.001) had a smaller target error than PHY-DBS. IMG-DBS had a shorter surgical time (p < 0.001 and p = 0.008, respectively) and a lower intracerebral hemorrhage (ICH) risk (p = 0.013 and p = 0.004, respectively) than PHY- and COMB-DBS. The use of intraoperative imaging and microelectrode recording correlated with a higher surgical accuracy (p = 0.018) and a higher risk of ICH (p = 0.049). CONCLUSIONS The comparison of COMB-DBS and PHY-DBS showed intraoperative imaging's superiority (higher surgical accuracy), while the comparison of COMB-DBS and IMG-DBS showed physiological confirmation's inferiority (longer surgical time and higher ICH risk). Combined with previous evidence, the use of intraoperative neuroimaging techniques should become a future trend.
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Affiliation(s)
- Zixiao Yin
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China; The First Clinical Medical College of Nanchang University, Nanchang, Jiangxi, PR China
| | - Yunyun Luo
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China; The First Clinical Medical College of Nanchang University, Nanchang, Jiangxi, PR China
| | - Yanwen Jin
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China; The Second Clinical Medical College of Nanchang University, Nanchang, Jiangxi, PR China
| | - Yaqing Yu
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
| | - Suyue Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
| | - Jian Duan
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
| | - Renxu Xu
- Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
| | - Dongwei Zhou
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
| | - Tao Hong
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China
| | - Guohui Lu
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, PR China.
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Abstract
Gene therapy has the potential to provide therapeutic benefit to millions of people with neurodegenerative diseases through several means, including direct correction of pathogenic mechanisms, neuroprotection, neurorestoration, and symptom control. Therapeutic efficacy is therefore dependent on knowledge of the disease pathogenesis and the required temporal and spatial specificity of gene expression. An additional critical challenge is achieving the most complete transduction of the target structure while avoiding leakage into neighboring regions or perivascular spaces. The gene therapy field has recently entered a new technological era, in which interventional MRI-guided convection-enhanced delivery (iMRI-CED) is the gold standard for verifying accurate vector delivery in real time. The availability of this advanced neurosurgical technique may accelerate the translation of the promising preclinical therapeutics under development for neurodegenerative disorders, including Parkinson's, Huntington's, and Alzheimer's diseases.
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Affiliation(s)
- Vivek Sudhakar
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 15213, USA
| | - R Mark Richardson
- Brain Modulation Laboratory, Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, 15213, USA.
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