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Kornilov E, Baker Erdman H, Kahana E, Fireman S, Zarchi O, Israelashvili M, Reiner J, Glik A, Weiss P, Paz R, Bergman H, Tamir I. Interleaved Propofol-Ketamine Maintains DBS Physiology and Hemodynamic Stability: A Double-Blind Randomized Controlled Trial. Mov Disord 2024; 39:694-705. [PMID: 38396358 DOI: 10.1002/mds.29746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/18/2023] [Accepted: 02/06/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The gold standard anesthesia for deep brain stimulation (DBS) surgery is the "awake" approach, using local anesthesia alone. Although it offers high-quality microelectrode recordings and therapeutic-window assessment, it potentially causes patients extreme stress and might result in suboptimal surgical outcomes. General anesthesia or deep sedation is an alternative, but may reduce physiological testing reliability and lead localization accuracy. OBJECTIVES The aim is to investigate a novel anesthesia regimen of ketamine-induced conscious sedation for the physiological testing phase of DBS surgery. METHODS Parkinson's patients undergoing subthalamic DBS surgery were randomly divided into experimental and control groups. During physiological testing, the groups received 0.25 mg/kg/h ketamine infusion and normal saline, respectively. Both groups had moderate propofol sedation before and after physiological testing. The primary outcome was recording quality. Secondary outcomes included hemodynamic stability, lead accuracy, motor and cognitive outcome, patient satisfaction, and adverse events. RESULTS Thirty patients, 15 from each group, were included. Intraoperatively, the electrophysiological signature and lead localization were similar under ketamine and saline. Tremor amplitude was slightly lower under ketamine. Postoperatively, patients in the ketamine group reported significantly higher satisfaction with anesthesia. The improvement in Unified Parkinson's disease rating scale part-III was similar between the groups. No negative effects of ketamine on hemodynamic stability or cognition were reported perioperatively. CONCLUSIONS Ketamine-induced conscious sedation provided high quality microelectrode recordings comparable with awake conditions. Additionally, it seems to allow superior patient satisfaction and hemodynamic stability, while maintaining similar post-operative outcomes. Therefore, it holds promise as a novel alternative anesthetic regimen for DBS. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Evgeniya Kornilov
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Halen Baker Erdman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
| | - Eilat Kahana
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Shlomo Fireman
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Omer Zarchi
- Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | | | - Johnathan Reiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Amir Glik
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Cognitive Neurology Clinic, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Penina Weiss
- Occupational Therapy Department, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Rony Paz
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
- The Edmond and Lily Safra Center for Brain Sciences, Hebrew University, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
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Aldred J, Freire-Alvarez E, Amelin AV, Antonini A, Bergmans B, Bergquist F, Bouchard M, Budur K, Carroll C, Chaudhuri KR, Criswell SR, Danielsen EH, Gandor F, Jia J, Kimber TE, Mochizuki H, Robieson WZ, Spiegel AM, Standaert DG, Talapala S, Facheris MF, Fung VSC. Continuous Subcutaneous Foslevodopa/Foscarbidopa in Parkinson's Disease: Safety and Efficacy Results From a 12-Month, Single-Arm, Open-Label, Phase 3 Study. Neurol Ther 2023; 12:1937-1958. [PMID: 37632656 PMCID: PMC10630297 DOI: 10.1007/s40120-023-00533-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/07/2023] [Indexed: 08/28/2023] Open
Abstract
INTRODUCTION Foslevodopa/foscarbidopa, a soluble formulation of levodopa/carbidopa (LD/CD) prodrugs for the treatment of Parkinson's disease (PD), is administered as a 24-hour/day continuous subcutaneous infusion (CSCI) with a single infusion site. The efficacy and safety of foslevodopa/foscarbidopa versus oral immediate-release LD/CD was previously demonstrated in patients with PD in a 12-week, randomized, double-blind, phase 3 trial (NCT04380142). We report the results of a separate 52-week, open-label, phase 3 registrational trial (NCT03781167) that evaluated the safety/tolerability and efficacy of 24-hour/day foslevodopa/foscarbidopa CSCI in patients with advanced PD. METHODS Male and female patients with levodopa-responsive PD and ≥ 2.5 hours of "Off" time/day received 24-hour/day foslevodopa/foscarbidopa CSCI at individually optimized therapeutic doses (approximately 700-4250 mg of LD per 24 hours) for 52 weeks. The primary endpoint was safety/tolerability. Secondary endpoints included changes from baseline in normalized "Off" and "On" time, percentage of patients reporting morning akinesia, Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS), Parkinson's Disease Sleep Scale-2 (PDSS-2), 39-item Parkinson's Disease Questionnaire (PDQ-39), and EuroQol 5-dimension questionnaire (EQ-5D-5L). RESULTS Of 244 enrolled patients, 107 discontinued, and 137 completed treatment. Infusion site events were the most common adverse events (AEs). AEs were mostly nonserious (25.8% of patients reported serious AEs) and mild/moderate in severity. At week 52, "On" time without troublesome dyskinesia and "Off" time were improved from baseline (mean [standard deviation (SD)] change in normalized "On" time without troublesome dyskinesia, 3.8 [3.3] hours; normalized "Off" time, -3.5 [3.1] hours). The percentage of patients experiencing morning akinesia dropped from 77.7% at baseline to 27.8% at week 52. Sleep quality (PDSS-2) and quality of life (PDQ-39 and EQ-5D-5L) also improved. CONCLUSION Foslevodopa/foscarbidopa has the potential to provide a safe and efficacious, individualized, 24-hour/day, nonsurgical alternative for patients with PD. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier NCT03781167.
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Affiliation(s)
- Jason Aldred
- Selkirk Neurology and Inland Northwest Research, 610 S Sherman St, Spokane, WA, 99202, USA.
| | - Eric Freire-Alvarez
- Neurology Department, University General Hospital of Elche, Carrer Almazara, 11, 03203, Elche, Spain
| | - Alexander V Amelin
- Department of Neurology and Neurosurgery, Pavlov First Saint Petersburg State Medical University, Ulitsa L'va Tolstogo, 6-8, St. Petersburg, 197022, Russia
| | - Angelo Antonini
- Parkinson and Movement Disorders Unit, Department of Neuroscience, Padua University, Via VIII Febbraio, 2, 35122, Padua, Italy
| | - Bruno Bergmans
- Department of Neurology, AZ St-Jan Brugge-Oostende AV, Ruddershove 10, 8000, Brugge, Belgium
- Department of Neurology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Filip Bergquist
- Department of Pharmacology, University of Gothenburg, Universitetsplatsen 1, 405 30, Gothenburg, Sweden
| | - Manon Bouchard
- Clinique Neuro-Lévis, 1190 A Rue de Courchevel #301, Lévis, QC, G6W 0M5, Canada
| | - Kumar Budur
- AbbVie Inc., 1 N. Waukegan Road, North Chicago, IL, 60064, USA
| | - Camille Carroll
- Faculty of Health, University of Plymouth, Drake Circus, Plymouth, PL4 8AA, UK
| | - K Ray Chaudhuri
- Parkinson's Foundation International Centre of Excellence, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
- King's College Institute of Psychiatry, Psychology and Neuroscience, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Susan R Criswell
- Department of Neurology, Washington University in St. Louis, 1 Brookings Dr, St. Louis, MO, 63130, USA
| | - Erik H Danielsen
- Department of Neurology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus, Denmark
| | - Florin Gandor
- Movement Disorders Hospital, Straße Nach Fichtenwalde 16, 14547, Beelitz-Heilstätten, Germany
- Department of Neurology, Otto-Von-Guericke University Magdeburg, Universitätspl. 2, 39106, Magdeburg, Germany
| | - Jia Jia
- AbbVie Inc., 1 N. Waukegan Road, North Chicago, IL, 60064, USA
| | - Thomas E Kimber
- Department of Neurology, Royal Adelaide Hospital, Port Road, Adelaide, SA, 5000, Australia
- Department of Medicine, University of Adelaide, 4 North Terrace, Adelaide, SA, 5000, Australia
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka, 565-0871, Japan
| | | | - Amy M Spiegel
- AbbVie Inc., 1 N. Waukegan Road, North Chicago, IL, 60064, USA
| | - David G Standaert
- Department of Neurology, Heersink School of Medicine, University of Alabama at Birmingham, 1670 University Blvd, Birmingham, AL, 35233, USA
| | | | | | - Victor S C Fung
- Movement Disorders Unit, Westmead Hospital, Cnr Hawkesbury Road and Darcy Rd, Westmead, NSW, 2145, Australia
- Faculty of Medicine and Health, Sydney Medical School, University of Sydney, Sydney, NSW, 2006, Australia
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Auffret M, Weiss D, Stocchi F, Vérin M, Jost WH. Access to device-aided therapies in advanced Parkinson's disease: navigating clinician biases, patient preference, and prognostic uncertainty. J Neural Transm (Vienna) 2023; 130:1411-1432. [PMID: 37436446 PMCID: PMC10645670 DOI: 10.1007/s00702-023-02668-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 06/24/2023] [Indexed: 07/13/2023]
Abstract
Device-aided therapies (DAT), which include deep brain stimulation and pump-based continuous dopaminergic stimulation with either levodopa or apomorphine, are among the major advances in the clinical management of Parkinson's disease (PD). Although DAT are being increasingly offered earlier in the disease course, their classical indication remains advanced PD. Theoretically, every patient should be offered transition to DAT when faced with refractory motor and nonmotor fluctuations and functional decline. Worldwide clinical reality is far from these ideal, and, therefore, question the "real-world" equal opportunity of access to DAT for PD patients with advanced PD-even within a single health care system. Differences in access to care, referral pattern (timing and frequency), as well as physician biases (unconscious/implicit or conscious/explicit bias), and patients' preferences or health-seeking behaviour are to be considered. Compared to DBS, little information is available concerning infusion therapies, as well as neurologists' and patients' attitudes towards them. This viewpoint aims to be thought-provoking and to assist clinicians in moving through the process of DAT selection, by including in their decision algorithm their own biases, patient perspective, ethical concerns as well as the current unknowns surrounding PD prognosis and DAT-related long-term side effects for a given patient.
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Affiliation(s)
- Manon Auffret
- France Développement Electronique (FDE), Monswiller, France.
- Institut des Neurosciences Cliniques de Rennes (INCR), Rennes, France.
- Behavior and Basal Ganglia Research Unit, CIC-IT, CIC1414, Pontchaillou University Hospital and University of Rennes, Rennes, France.
| | - Daniel Weiss
- Centre for Neurology, Department for Neurodegenerative Diseases, Hertie-Institute for Clinical Brain Research, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany
| | - Fabrizio Stocchi
- University San Raffaele Roma and Institute of Research and Medical Care IRCCS San Raffaele Roma, Rome, Italy
| | - Marc Vérin
- Institut des Neurosciences Cliniques de Rennes (INCR), Rennes, France
- Behavior and Basal Ganglia Research Unit, CIC-IT, CIC1414, Pontchaillou University Hospital and University of Rennes, Rennes, France
- Neurology Department, Pontchaillou University Hospital, rue Henri Le Guilloux, 35000, Rennes, France
| | - Wolfgang H Jost
- Parkinson-Klinik Ortenau, Kreuzbergstr. 12-16, 77709, Wolfach, Germany
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Harding L, McFarlane J, Honey CR, McDonald PJ, Illes J. Mapping the Landscape of Equitable Access to Advanced Neurotechnologies in Canada. Can J Neurol Sci 2023; 50:s17-s25. [PMID: 37160675 PMCID: PMC10172973 DOI: 10.1017/cjn.2023.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Geographic, social, political, and economic factors shape access to advanced neurotechnologies, yet little previous research has explored the barriers, enablers, and areas of opportunity for equitable and meaningful access for diverse patient communities across Canada. We applied a mixed-mode approach involving semi-structured interviews and rating scale questions to consult with 24 medical experts who are involved in the care of patients who undergo functional neurosurgery targeting the brain. Seven major themes emerged from the qualitative analysis: Health care system, Neurotechnology features, Patient demographics, Target condition features, Ethics, Upstream barriers and enablers, and Areas of opportunity. Descriptive statistics of the Likert-scale responses suggest that interviewees perceive a disparity between the imperative of access to advanced neurotechnologies for people living in rural and remote areas and the likelihood of achieving such access. The results depict a complex picture of access to functional neurosurgery in Canada with pockets of excellence and a motivation to improve the availability of care for vulnerable populations through the expansion of distributed care models, improved health care system efficiencies, increasing funding and support for patient travel, and increasing awareness about and advocacy for advanced neurotechnologies.
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Affiliation(s)
- Louise Harding
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jacob McFarlane
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Christopher R. Honey
- Faculty of Medicine, Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Patrick J. McDonald
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Faculty of Medicine, Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
- Section of Neurosurgery, Departments of Surgery and Pediatrics and Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Judy Illes
- Neuroethics Canada, Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Immunity orchestrates a bridge in gut-brain axis of neurodegenerative diseases. Ageing Res Rev 2023; 85:101857. [PMID: 36669690 DOI: 10.1016/j.arr.2023.101857] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/15/2023] [Accepted: 01/15/2023] [Indexed: 01/18/2023]
Abstract
Neurodegenerative diseases, in particular for Alzheimer's disease (AD), Parkinson's disease (PD) and Multiple sclerosis (MS), are a category of diseases with progressive loss of neuronal structure or function (encompassing neuronal death) leading to neuronal dysfunction, whereas the underlying pathogenesis remains to be clarified. As the microbiological ecosystem of the intestinal microbiome serves as the second genome of the human body, it is strongly implicated as an essential element in the initiation and/or progression of neurodegenerative diseases. Nevertheless, the precise underlying principles of how the intestinal microflora impact on neurodegenerative diseases via gut-brain axis by modulating the immune function are still poorly characterized. Consequently, an overview of initiating the development of neurodegenerative diseases and the contribution of intestinal microflora on immune function is discussed in this review.
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Erdman HB, Kornilov E, Kahana E, Zarchi O, Reiner J, Socher A, Strauss I, Firman S, Israel Z, Bergman H, Tamir I. Asleep DBS under ketamine sedation: Proof of concept. Neurobiol Dis 2022; 170:105747. [PMID: 35550159 DOI: 10.1016/j.nbd.2022.105747] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/28/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is commonly and safely performed for selective Parkinson's disease patients. Many centers perform DBS lead positioning exclusively under local anesthesia, to optimize brain microelectrode recordings (MER) and testing of stimulation-related therapeutic and side effects. These measures enable physiological identification of the DBS borders and subdomains based on electrophysiological properties like firing rates and patterns, intra-operative evaluation of therapeutic window, and improvement of lead placement accuracy. Nevertheless, due to the challenges of awake surgery, some centers use sedation or general anesthesia, despite the distortion of discharge properties and interference with clinical testing, resulting in potential impact on surgical outcomes. Thus, there is a need for a novel anesthesia regimen that enables sedation without compromising intra-operative monitoring. OBJECTIVE This open-label study investigates the use of low-dose ketamine for conscious sedation during microelectrode recordings and lead positioning in subthalamic nucleus (STN) DBS for Parkinson's disease patients. METHODS Three anesthetic regimens were retrospectively compared in 38 surgeries (74 MER trajectories, 5962 recording sites) across three DBS centers: 1) Interleaved propofol-ketamine (PK), 2) Interleaved propofol-awake (PA), and 3) Fully awake (AA). RESULTS All anesthesia regimens achieved satisfactory MER. Detection of STN borders and subdomains by expert electrophysiologist was similar between the groups. Electrophysiological signature of the STN under ketamine was not inferior to either control group. All patients completed stimulation testing. CONCLUSIONS This study supports a low-dose ketamine anesthesia regimen for DBS which allows microelectrode recordings and stimulation testing that are not inferior to those conducted under awake and propofol-awake regimens and may optimize patient experience. A prospective double-blind study that would also compare patients' satisfaction level and clinical outcome should be performed to confirm these findings.
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Affiliation(s)
- Halen Baker Erdman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel.
| | - Evgeniya Kornilov
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel; Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Eilat Kahana
- Department of Anesthesiology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Omer Zarchi
- Intraoperative Neurophysiology Unit, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Johnathan Reiner
- Department of Neurology, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel
| | - Achinoam Socher
- Department of Neurology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Strauss
- Department of Neurosurgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Shimon Firman
- Department of Anesthesiology, Critical Care Medicine, and Pain Management, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Zvi Israel
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University, Jerusalem, Israel; Department of Neurosurgery, Hadassah Medical Center, Hebrew University, Jerusalem, Israel; The Edmond and Lily Safra Center for Brain Sciences, Hebrew University, Jerusalem, Israel
| | - Idit Tamir
- Department of Neurosurgery, Rabin Medical Center, Beilinson Hospital, Petach Tikvah, Israel.
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Guang J, Baker H, Ben-Yishay Nizri O, Firman S, Werner-Reiss U, Kapuller V, Israel Z, Bergman H. Toward asleep DBS: cortico-basal ganglia spectral and coherence activity during interleaved propofol/ketamine sedation mimics NREM/REM sleep activity. NPJ PARKINSONS DISEASE 2021; 7:67. [PMID: 34341348 PMCID: PMC8329235 DOI: 10.1038/s41531-021-00211-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 07/09/2021] [Indexed: 12/20/2022]
Abstract
Deep brain stimulation (DBS) is currently a standard procedure for advanced Parkinson's disease. Many centers employ awake physiological navigation and stimulation assessment to optimize DBS localization and outcome. To enable DBS under sedation, asleep DBS, we characterized the cortico-basal ganglia neuronal network of two nonhuman primates under propofol, ketamine, and interleaved propofol-ketamine (IPK) sedation. Further, we compared these sedation states in the healthy and Parkinsonian condition to those of healthy sleep. Ketamine increases high-frequency power and synchronization while propofol increases low-frequency power and synchronization in polysomnography and neuronal activity recordings. Thus, ketamine does not mask the low-frequency oscillations used for physiological navigation toward the basal ganglia DBS targets. The brain spectral state under ketamine and propofol mimicked rapid eye movement (REM) and Non-REM (NREM) sleep activity, respectively, and the IPK protocol resembles the NREM-REM sleep cycle. These promising results are a meaningful step toward asleep DBS with nondistorted physiological navigation.
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Affiliation(s)
- Jing Guang
- Edmond and Lily Safra Center for Brain Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Halen Baker
- Department of Medical Neurobiology, The Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Shimon Firman
- Department of Anesthesiology, Critical Care Medicine, and Pain Management, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Uri Werner-Reiss
- Edmond and Lily Safra Center for Brain Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Vadim Kapuller
- Department of Pediatric Surgery, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel.,Asuta-Ashdod University Medical Center, Ashdod, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Zvi Israel
- Department of Neurosurgery, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hagai Bergman
- Edmond and Lily Safra Center for Brain Sciences, The Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Medical Neurobiology, The Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Neurosurgery, Hadassah Medical Center, The Hebrew University of Jerusalem, Jerusalem, Israel
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