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Pellow C, Pichardo S, Pike GB. A systematic review of preclinical and clinical transcranial ultrasound neuromodulation and opportunities for functional connectomics. Brain Stimul 2024; 17:734-751. [PMID: 38880207 DOI: 10.1016/j.brs.2024.06.005] [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: 03/01/2024] [Revised: 05/21/2024] [Accepted: 06/05/2024] [Indexed: 06/18/2024] Open
Abstract
BACKGROUND Low-intensity transcranial ultrasound has surged forward as a non-invasive and disruptive tool for neuromodulation with applications in basic neuroscience research and the treatment of neurological and psychiatric conditions. OBJECTIVE To provide a comprehensive overview and update of preclinical and clinical transcranial low intensity ultrasound for neuromodulation and emphasize the emerging role of functional brain mapping to guide, better understand, and predict responses. METHODS A systematic review was conducted by searching the Web of Science and Scopus databases for studies on transcranial ultrasound neuromodulation, both in humans and animals. RESULTS 187 relevant studies were identified and reviewed, including 116 preclinical and 71 clinical reports with subjects belonging to diverse cohorts. Milestones of ultrasound neuromodulation are described within an overview of the broader landscape. General neural readouts and outcome measures are discussed, potential confounds are noted, and the emerging use of functional magnetic resonance imaging is highlighted. CONCLUSION Ultrasound neuromodulation has emerged as a powerful tool to study and treat a range of conditions and its combination with various neural readouts has significantly advanced this platform. In particular, the use of functional magnetic resonance imaging has yielded exciting inferences into ultrasound neuromodulation and has the potential to advance our understanding of brain function, neuromodulatory mechanisms, and ultimately clinical outcomes. It is anticipated that these preclinical and clinical trials are the first of many; that transcranial low intensity focused ultrasound, particularly in combination with functional magnetic resonance imaging, has the potential to enhance treatment for a spectrum of neurological conditions.
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Affiliation(s)
- Carly Pellow
- Department of Radiology, Cumming School of Medicine, University of Calgary, Alberta, T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Alberta, T2N 4N1, Canada.
| | - Samuel Pichardo
- Department of Radiology, Cumming School of Medicine, University of Calgary, Alberta, T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Alberta, T2N 4N1, Canada; Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, T2N 1N4, Canada
| | - G Bruce Pike
- Department of Radiology, Cumming School of Medicine, University of Calgary, Alberta, T2N 1N4, Canada; Hotchkiss Brain Institute, University of Calgary, Alberta, T2N 4N1, Canada; Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta, T2N 1N4, Canada
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Borges C Diniz J, Alfonso Rodriguez Elvir F, Silva Santana L, Michaela de Oliveira H, Laura Lima Larcipretti A, Muniz Vieira de Melo T, Carneiro Barroso D, Cotrim Gomes F, Dias Polverini A, Milanese V. Asleep versus awake GPi DBS surgery for Parkinson's disease: A systematic review and meta-analysis. J Clin Neurosci 2024; 123:196-202. [PMID: 38604023 DOI: 10.1016/j.jocn.2024.03.033] [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: 09/28/2023] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Patients with Parkinson's Disease (PD) who receive either asleep image-guided subthalamic nucleus deep brain stimulation (DBS) or the traditional awake technique have comparable motor outcomes. However, there are fewer studies regarding which technique should be chosen for globus pallidus internus (GPi) DBS. This systematic review and meta-analysis aims to compare the accuracy of lead placement and motor outcomes of asleep versus awake GPi DBS PD population. METHODS We systematically searched PubMed, Embase, and Cochrane for studies comparing asleep vs. awake GPi DBS lead placement in patients with PD. Outcomes were spatial accuracy of lead placement, measured by radial error between intended and actual location, motor improvement measured using (UPDRS III), and postoperative stimulation parameters. Statistical analysis was performed with Review Manager 5.1.7. and OpenMeta [Analyst]. RESULTS Three studies met inclusion criteria with a total of 247 patients. Asleep DBS was used to treat 192 (77.7 %) patients. Follow-up ranged from 6 to 48 months. Radial error was not statistically different between groups (MD -0.49 mm; 95 % CI -1.0 to 0.02; I2 = 86 %; p = 0.06), with a tendency for higher target accuracy with the asleep technique. There was no significant difference between groups in change on motor function, as measured by UPDRS III, from pre- to postoperative (MD 8.30 %; 95 % CI -4.78 to 21.37; I2 = 67 %, p = 0.2). There was a significant difference in postoperative stimulation voltage, with the asleep group requiring less voltage than the awake group (MD -0.27 V; 95 % CI -0.46 to - 0.08; I2 = 0 %; p = 0.006). CONCLUSION Our meta-analysis indicates that asleep image-guided GPi DBS presents a statistical tendency suggesting superior target accuracy when compared with the awake standard technique. Differences in change in motor function were not statistically significant between groups.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Allan Dias Polverini
- Neurosurgical Oncology Division, Hospital de Amor, Fundação Pio XII, Barretos, Sao Paulo, Brazil.
| | - Vanessa Milanese
- Neurosurgical Division, A Beneficência Portuguesa de São Paulo, São Paulo, Brazil; Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
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3
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Rissardo JP, Vora NM, Tariq I, Mujtaba A, Caprara ALF. Deep Brain Stimulation for the Management of Refractory Neurological Disorders: A Comprehensive Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1991. [PMID: 38004040 PMCID: PMC10673515 DOI: 10.3390/medicina59111991] [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: 10/17/2023] [Revised: 11/04/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023]
Abstract
In recent decades, deep brain stimulation (DBS) has been extensively studied due to its reversibility and significantly fewer side effects. DBS is mainly a symptomatic therapy, but the stimulation of subcortical areas by DBS is believed to affect the cytoarchitecture of the brain, leading to adaptability and neurogenesis. The neurological disorders most commonly studied with DBS were Parkinson's disease, essential tremor, obsessive-compulsive disorder, and major depressive disorder. The most precise approach to evaluating the location of the leads still relies on the stimulus-induced side effects reported by the patients. Moreover, the adequate voltage and DBS current field could correlate with the patient's symptoms. Implantable pulse generators are the main parts of the DBS, and their main characteristics, such as rechargeable capability, magnetic resonance imaging (MRI) safety, and device size, should always be discussed with patients. The safety of MRI will depend on several parameters: the part of the body where the device is implanted, the part of the body scanned, and the MRI-tesla magnetic field. It is worth mentioning that drug-resistant individuals may have different pathophysiological explanations for their resistance to medications, which could affect the efficacy of DBS therapy. Therefore, this could explain the significant difference in the outcomes of studies with DBS in individuals with drug-resistant neurological conditions.
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Affiliation(s)
| | - Nilofar Murtaza Vora
- Medicine Department, Terna Speciality Hospital and Research Centre, Navi Mumbai 400706, India;
| | - Irra Tariq
- Medicine Department, United Medical & Dental College, Karachi 75600, Pakistan;
| | - Amna Mujtaba
- Medicine Department, Karachi Medical & Dental College, Karachi 74700, Pakistan;
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AlMajali M, Patel MS, Patel NK, Zhang JK, Tapia C, Bucholz RD, Chand P. A Technique of Deep Brain Stimulation of the Globus Pallidus Interna for Dystonia Under General Anesthesia With Sevoflurane. Cureus 2023; 15:e40819. [PMID: 37485182 PMCID: PMC10362972 DOI: 10.7759/cureus.40819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 07/25/2023] Open
Abstract
Background Globus pallidus interna (GPi) deep brain stimulation (DBS) is an established surgical procedure that confers a benefit in medication refractory dystonia. Patients with generalized dystonia require general anesthesia (GA) for the surgery as their movements may hinder the surgical procedure. General anesthetics tend to dampen the microelectrode recordings (MERs) from the GPi. Methods We describe our experience with a series of consecutive patients with dystonia who underwent bilateral GPi DBS using standard DBS and MER under GA using sevoflurane as the maintenance general anesthetic drug. All patients had Medtronic 3,387 leads implanted and connected to an RC battery. Patients underwent sequential programming of the DBS after the surgery. Results The mean age of the 13 patients who underwent DBS of the GPi for dystonia was 46.5 years with a range from 29 to 71 years. Every patient in our case series received various doses of (1.37% to 2.11%) inhaled sevoflurane for anesthesia maintenance. Sevoflurane provided adequate anesthesia and allowed accurate MERs from the GPi. No adverse effects were encountered. On follow-up and sequential DBS programming, patients had significant improvements in dystonia attesting to the accuracy of the electrode placements. Conclusions We report our experience using sevoflurane for maintenance of GA for bilateral GPi DBS for dystonia. The main benefits identified have been adequate anesthesia and reduction of dystonia-related movements to allow the performance of the DBS surgery. The MER signals from the GPi were not suppressed by sevoflurane. This allowed accurate mapping and placement of the DBS implants in the GPi.
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Affiliation(s)
| | - Mayur S Patel
- Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Niel K Patel
- Internal Medicine, University of California San Diego, San Diego, USA
- Internal Medicine, Saint Louis University School of Medicine, St. Louis, USA
| | | | | | - Richard D Bucholz
- Neurological Surgery, Saint Louis University School of Medicine, Saint Louis, USA
| | - Pratap Chand
- Neurology, Saint Louis University School of Medicine, Saint Louis, USA
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Ling Y, Liu L, Wang S, Guo Q, Xiao Q, Liu Y, Qu B, Wen Z, Li Y, Zhang C, Wu B, Huang Z, Chu J, Chen L, Liu J, Jiang N. Characteristics of Electroencephalogram in the Prefrontal Cortex during Deep Brain Stimulation of Subthalamic Nucleus in Parkinson's Disease under Propofol General Anesthesia. Brain Sci 2022; 13:brainsci13010062. [PMID: 36672044 PMCID: PMC9856588 DOI: 10.3390/brainsci13010062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/14/2022] [Accepted: 12/20/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Monitoring the depth of anesthesia by electroencephalogram (EEG) based on the prefrontal cortex is an important means to achieve accurate regulation of anesthesia for subthalamic nucleus (STN) deep brain stimulation (DBS) under general anesthesia in patients with Parkinson's disease (PD). However, no previous study has conducted an in-depth investigation into this monitoring data. Here, we aimed to analyze the characteristics of prefrontal cortex EEG during DBS with propofol general anesthesia in patients with PD and determine the reference range of parameters derived from the depth of anesthesia monitoring. Additionally, we attempted to explore whether the use of benzodiazepines in the 3 days during hospitalization before surgery impacted the interpretation of the EEG parameters. MATERIALS AND METHODS We included the data of 43 patients with PD who received STN DBS treatment and SedLine monitoring during the entire course of general anesthesia with propofol in a single center. Eighteen patients (41.86%) took benzodiazepines during hospitalization. We divided the anesthesia process into three stages: awake state before anesthesia, propofol anesthesia state, and shallow anesthesia state during microelectrode recording (MER). We analyzed the power spectral density (PSD) and derived parameters of the patients' prefrontal EEG, including the patient state index (PSI), spectral edge frequency (SEF) of the left and right sides, and the suppression ratio. The baseline characteristics, preoperative medication, preoperative frontal lobe image characteristics, preoperative motor and non-motor evaluation, intraoperative vital signs, internal environment and anesthetic information, and postoperative complications are listed. We also compared the groups according to whether they took benzodiazepines before surgery during hospitalization. RESULTS The average PSI of the awake state, propofol anesthesia state, and MER state were 89.86 ± 6.89, 48.68 ± 12.65, and 62.46 ± 13.08, respectively. The preoperative administration of benzodiazepines did not significantly affect the PSI or SEF, but did reduce the total time of suppression, maximum suppression ratio, and the PSD of beta and gamma during MER. Regarding the occurrence of postoperative delirium and mini-mental state examination (MMSE) scores, there was no significant difference between the two groups (chi-square test, p = 0.48; Mann-Whitney U test, p = 0.30). CONCLUSION For the first time, we demonstrate the reference range of the derived parameters of the depth of anesthesia monitoring and the characteristics of the prefrontal EEG of patients with PD in the awake state, propofol anesthesia state, and shallow anesthesia during MER. Taking benzodiazepines in the 3 days during hospitalization before surgery reduces suppression and the PSD of beta and gamma during MER, but does not significantly affect the observation of anesthesiologists on the depth of anesthesia, nor affect the postoperative delirium and MMSE scores.
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Affiliation(s)
- Yuting Ling
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Lige Liu
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Simin Wang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Qianqian Guo
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Qingyuan Xiao
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Yi Liu
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Bo Qu
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Zhishuang Wen
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Yongfu Li
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Changming Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Bin Wu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Zihuan Huang
- Department of Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Jianping Chu
- Department of Radiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Ling Chen
- Department of Neurology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Jinlong Liu
- Department of Neurosurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
| | - Nan Jiang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou 510080, China
- Correspondence: ; Tel.: +86-137-2540-7606
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6
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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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7
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Lu Y, Chang L, Li J, Luo B, Dong W, Qiu C, Zhang W, Ruan Y. The Effects of Different Anesthesia Methods on the Treatment of Parkinson’s Disease by Bilateral Deep Brain Stimulation of the Subthalamic Nucleus. Front Neurosci 2022; 16:917752. [PMID: 35692425 PMCID: PMC9178204 DOI: 10.3389/fnins.2022.917752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/26/2022] [Indexed: 11/21/2022] Open
Abstract
Background Subthalamic nucleus deep brain stimulation (STN–DBS) surgery for Parkinson’s disease (PD) is routinely performed at medical centers worldwide. However, it is debated whether general anesthesia (GA) or traditional local anesthetic (LA) is superior. Purpose This study aims to compare the effects of LA and GA operation methods on clinical improvement in patients with PD, such as motor and non-motor symptoms, after STN–DBS surgery at our center. Method A total of 157 patients with PD were retrospectively identified as having undergone surgery under LA (n = 81) or GA (n = 76) states. In this study, the Unified Parkinson’s Disease Rating Scale Motor Score (UPDRS-III) in three states, levodopa-equivalent-daily-dose (LEDD), surgical duration, intraoperative microelectrode recording (iMER) signal length, postoperative intracranial volume, electrode implantation error, neuropsychological function, quality of life scores, and complication rates were collected and compared. All patients with PD were routinely followed up at 6, 12, 18, and 24 months postoperatively. Result Overall improvement in UPDRS-III was demonstrated at postoperative follow-up, and there was no significant difference between the two groups in medication-off, stimulation-off state and medication-off, stimulation-on state. However, UPDRS-III scores in medication-on, stimulation-on state under GA was significantly lower than that in the LA group. During postoperative follow-up, LEDD in the LA group (6, 12, 18, and 24 months, postoperatively) was significantly lower than in the GA group. However, there were no significant differences at baseline or 1-month between the two groups. The GA group had a shorter surgical duration, lower intracranial volume, and longer iMER signal length than the LA group. However, there was no significant group difference in electrode implantation accuracy and complication rates. Additionally, the Hamilton Anxiety Scale (HAMA) was significantly lower in the GA group than the LA group at 1-month follow-up, but this difference disappeared at longer follow-up. Besides, there was no significant group difference in the 39-item Parkinson’s Disease Questionnaire (PDQ-39) scale scores. Conclusion Although both groups showed overall motor function improvement without a significant postoperative difference, the GA group seemed superior in surgical duration, intracranial volume, and iMER signal length. As the accuracy of electrode implantation can be ensured by iMER monitoring, DBS with GA will become more widely accepted.
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Affiliation(s)
- Yue Lu
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Lei Chang
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Jinwen Li
- Department of Anesthesiology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Bei Luo
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Wenwen Dong
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Chang Qiu
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
| | - Wenbin Zhang
- Department of Functional Neurosurgery, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Wenbin Zhang,
| | - Yifeng Ruan
- Department of Anesthesiology, The Affiliated Brain Hospital of Nanjing Medical University, Nanjing, China
- Yifeng Ruan,
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Goyal A, Goetz S, Stanslaski S, Oh Y, Rusheen AE, Klassen B, Miller K, Blaha CD, Bennet KE, Lee K. The development of an implantable deep brain stimulation device with simultaneous chronic electrophysiological recording and stimulation in humans. Biosens Bioelectron 2021; 176:112888. [PMID: 33395569 PMCID: PMC7953342 DOI: 10.1016/j.bios.2020.112888] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/01/2020] [Accepted: 12/09/2020] [Indexed: 01/26/2023]
Abstract
Deep brain stimulation (DBS) is used to treat a wide array of neurologic conditions. However, traditional programming of stimulation parameters relies upon short term subjective observation of patient symptoms and undesired stimulation effects while in the clinic. To gain a more objective measure of the neuronal activity that contributes to patient symptoms and response to treatment, there is a clear need for a fully-implantable DBS system capable of chronically recording patient-specific electrophysiological biomarker signals over time. By providing an objective correlate of a patient's disease and response to treatment, this capability has the potential to improve therapeutic benefit while preventing undesirable side effects. Herein, the engineering and capabilities of the Percept PC, the first FDA-approved, fully-implantable DBS device capable of nearly-simultaneous electrophysiological recordings and stimulation, are discussed. The device's ability to chronically record local field potentials (LFPs) at implanted DBS leads was validated in patients with neurological disorders. Lastly, the electrophysiological activity correlates of clinically relevant patient-reported events are presented. While FDA approved for conditions such as Parkinson's disease, essential tremor, dystonia, obsessive-compulsive disorder, and epilepsy, chronic electrophysiological recordings in humans has broad applications within basic science and clinical practice beyond DBS, offering a wealth of information related to normal and abnormal neurophysiology within distinct brain areas.
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Affiliation(s)
- Abhinav Goyal
- Mayo Clinic Medical Scientist Training Program, Mayo Clinic, Rochester, MN, 55905, USA
| | - Steve Goetz
- Medtronic PLC Brain Modulation, Minneapolis, MN, USA
| | | | - Yoonbae Oh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA; Department of Biomedical Engineering, Mayo Clinic, Rochester, MN, 55905, USA
| | - Aaron E Rusheen
- Mayo Clinic Medical Scientist Training Program, Mayo Clinic, Rochester, MN, 55905, USA
| | - Bryan Klassen
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kai Miller
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Charles D Blaha
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kevin E Bennet
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA; Division of Engineering, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Kendall Lee
- Mayo Clinic Medical Scientist Training Program, Mayo Clinic, Rochester, MN, 55905, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
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9
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Ronde EM, Silvasti-Lundell M, Pekkola J, Tallgren M, Kivisaari R. Preoperative Magnetic Resonance Image Quality in Motion Disorder Patients Scheduled for Deep Brain Stimulation Surgery. Stereotact Funct Neurosurg 2020; 98:363-370. [PMID: 32957096 DOI: 10.1159/000506998] [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: 10/15/2019] [Accepted: 03/02/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND To obtain magnetic resonance (MR) images of good quality for accurate target localization in deep brain stimulation (DBS) surgery, sedation or anesthesia may be used, although their usefulness has not been proven. OBJECTIVE To assess whether sedation or general anesthesia (GA) improve the quality of MR imaging (MRI). METHODS The records of DBS procedures for Parkinson's disease (PD), dystonia, and essential tremor in our tertiary neurosurgical unit between January 2011 and June 2016 were reviewed. Adult patients with preoperative MR images were included. Patient records concerning MRI, surgery, adverse events, and clinical outcome were retrospectively scrutinized and analyzed. MR image quality was assessed by two independent radiologists. RESULTS A total of 215 preoperative MR images for 177 DBS procedures were analyzed. The MRI sequences performed under GA were superior to those performed without anesthesia or under sedation (p < 0.01). Virtually all images captured under GA were of good quality, while the proportions among those captured with sedation or without anesthesia were <65%. Good image quality was not associated with better clinical outcome (>50% improvement in the Unified Parkinson's Disease Rating Scale III score) among patients with PD. CONCLUSION GA was associated with better MRI sequences than intravenous sedation or no anesthesia.
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Affiliation(s)
- Elsa M Ronde
- Department of Anesthesia, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marja Silvasti-Lundell
- Department of Anesthesia, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Johanna Pekkola
- Department of Radiology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Minna Tallgren
- Department of Anesthesia, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Riku Kivisaari
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland,
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10
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Benady A, Zadik S, Eimerl D, Heymann S, Bergman H, Israel Z, Raz A. Sedative drugs modulate the neuronal activity in the subthalamic nucleus of parkinsonian patients. Sci Rep 2020; 10:14536. [PMID: 32884017 PMCID: PMC7471283 DOI: 10.1038/s41598-020-71358-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 08/10/2020] [Indexed: 11/09/2022] Open
Abstract
Microelectrode recording (MER) is often used to identify electrode location which is critical for the success of deep brain stimulation (DBS) treatment of Parkinson’s disease. The usage of anesthesia and its’ impact on MER quality and electrode placement is controversial. We recorded neuronal activity at a single depth inside the Subthalamic Nucleus (STN) before, during, and after remifentanil infusion. The root mean square (RMS) of the 250–6000 Hz band-passed signal was used to evaluate the regional spiking activity, the power spectrum to evaluate the oscillatory activity and the coherence to evaluate synchrony between two microelectrodes. We compare those to new frequency domain (spectral) analysis of previously obtained data during propofol sedation. Results showed Remifentanil decreased the normalized RMS by 9% (P < 0.001), a smaller decrease compared to propofol. Regarding the beta range oscillatory activity, remifentanil depressed oscillations (drop from 25 to 5% of oscillatory electrodes), while propofol did not (increase from 33.3 to 41.7% of oscillatory electrodes). In the cases of simultaneously recorded oscillatory electrodes, propofol did not change the synchronization while remifentanil depressed it. In conclusion, remifentanil interferes with the identification of the dorsolateral oscillatory region, whereas propofol interferes with RMS identification of the STN borders. Thus, both have undesired effect during the MER procedure. Trial registration: NCT00355927 and NCT00588926.
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Affiliation(s)
- Amit Benady
- St George's University of London Medical School, Sheba Medical Center, Ramat Gan, Israel.,Center of Advanced Technologies in Rehabilitation, Sheba Medical Center, Ramat Gan, Israel
| | - Sean Zadik
- St George's University of London Medical School, Sheba Medical Center, Ramat Gan, Israel
| | - Dan Eimerl
- Department of Anesthesia, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Sami Heymann
- Department of Neurosurgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Hagai Bergman
- Department of Medical Neurobiology, Hebrew University - Hadassah Medical Scholl, Jerusalem, Israel
| | - Zvi Israel
- Department of Neurosurgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Aeyal Raz
- Department of Anesthesiology, Rambam Health Care Center affiliated with the Ruth and Bruce Rappaport Faculty of Medicine, Rambam Health Care Campus, Technion - Israel Institute of Technology, 8 HaAliya HaShniya St., 3109601, Haifa, Israel.
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Kamimura HAS, Conti A, Toschi N, Konofagou EE. Ultrasound neuromodulation: mechanisms and the potential of multimodal stimulation for neuronal function assessment. FRONTIERS IN PHYSICS 2020; 8:150. [PMID: 32509757 PMCID: PMC7274478 DOI: 10.3389/fphy.2020.00150] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Focused ultrasound (FUS) neuromodulation has shown that mechanical waves can interact with cell membranes and mechanosensitive ion channels, causing changes in neuronal activity. However, the thorough understanding of the mechanisms involved in these interactions are hindered by different experimental conditions for a variety of animal scales and models. While the lack of complete understanding of FUS neuromodulation mechanisms does not impede benefiting from the current known advantages and potential of this technique, a precise characterization of its mechanisms of action and their dependence on experimental setup (e.g., tuning acoustic parameters and characterizing safety ranges) has the potential to exponentially improve its efficacy as well as spatial and functional selectivity. This could potentially reach the cell type specificity typical of other, more invasive techniques e.g., opto- and chemogenetics or at least orientation-specific selectivity afforded by transcranial magnetic stimulation. Here, the mechanisms and their potential overlap are reviewed along with discussions on the potential insights into mechanisms that magnetic resonance imaging sequences along with a multimodal stimulation approach involving electrical, magnetic, chemical, light, and mechanical stimuli can provide.
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Affiliation(s)
- Hermes A. S. Kamimura
- Ultrasound Elasticity Imaging Laboratory, Department of Biomedical Engineering, Columbia University, New Yor, NY, USA
| | - Allegra Conti
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Nicola Toschi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
- Athinoula A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, MA, USA
| | - Elisa E. Konofagou
- Ultrasound Elasticity Imaging Laboratory, Department of Biomedical Engineering, Columbia University, New Yor, NY, USA
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Thevathasan W, Sinclair NC, Bulluss KJ, McDermott HJ. Tailoring Subthalamic Nucleus Deep Brain Stimulation for Parkinson's Disease Using Evoked Resonant Neural Activity. Front Hum Neurosci 2020; 14:71. [PMID: 32180711 PMCID: PMC7059818 DOI: 10.3389/fnhum.2020.00071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/18/2020] [Indexed: 01/15/2023] Open
Affiliation(s)
- Wesley Thevathasan
- Bionics Institute, East Melbourne, VIC, Australia
- Department of Neurology, The Royal Melbourne and Austin Hospitals, Melbourne, VIC, Australia
- Department of Medicine, The University of Melbourne, Melbourne, VIC, Australia
| | - Nicholas C. Sinclair
- Bionics Institute, East Melbourne, VIC, Australia
- Medical Bionics Department, The University of Melbourne, East Melbourne, VIC, Australia
| | - Kristian J. Bulluss
- Bionics Institute, East Melbourne, VIC, Australia
- Department of Neurosurgery, St Vincent's and Austin Hospitals, Melbourne, VIC, Australia
- Department of Surgery, The University of Melbourne, Melbourne, VIC, Australia
| | - Hugh J. McDermott
- Bionics Institute, East Melbourne, VIC, Australia
- Medical Bionics Department, The University of Melbourne, East Melbourne, VIC, Australia
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Lin YS, Liu KD, Chang C, Yang HZ, Tsou MY, Chu YC. Inhibitory concentration of propofol in combination with dexmedetomidine during microelectrode recording for deep brain stimulator insertion surgeries under general anesthesia. J Chin Med Assoc 2020; 83:188-193. [PMID: 31972830 DOI: 10.1097/jcma.0000000000000248] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Microelectrode recording (MER) for target refinement is widely used in deep brain stimulator insertion for Parkinson disease. Signals may be influenced by anesthetics when patients receive general anesthesia (GA). This study determined the inhibitory concentration (IC) of propofol on MER signals when it was coadministered with dexmedetomidine. METHODS Patients were anesthetized with dexmedetomidine (0.5 μg·kg loading, followed by infusion at 0.4 μg·kgh) and propofol through target-controlled infusion for GA with tracheal intubation. The surgeon conducted the online scoring of the background signals, spiking frequency, amplitude, and pattern of single-unit activities by using a 0-10 verbal numerical rating scale (NRS; 0, maximal suppression; 10, minimal suppression), and responses were grouped into suppression (NRS ≤ 6) and nonsuppression (NRS > 6). The median inhibitory concentration (IC50) of propofol (as target effect-site concentrations: Ceprop) was determined using modified Dixon's up-and-down method. Probit regression analysis was further used to obtain the dose-response relationship, and IC05 and IC95 were calculated. RESULTS Twenty-three adult patients participated in this study. Under the concomitant infusion of dexmedetomidine, the predicted IC50 value (95% CI) of Ceprop for neuronal suppression during MER was 1.29 (1.24-1.34) μg·mL as calculated using modified Dixon's up-and-down method. Using probit analysis, the estimated IC05, IC50, and IC95 values (95% CIs) were 1.17 (0.87-1.23), 1.28 (1.21-1.34), and 1.40 (1.33-1.85) μg·mL, respectively. CONCLUSION Our data provided reference values of propofol for dosage adjustment to avoid interference on MER under GA when anesthetics have to be continuously infused during recording.
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Affiliation(s)
- Yu-Shan Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan, ROC
| | - Kang-Du Liu
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan, ROC
| | - Chi Chang
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan, ROC
| | - Huai-Zhe Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan, ROC
| | - Mei-Yung Tsou
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan, ROC
| | - Ya-Chun Chu
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang-Ming University, Taipei, Taiwan, ROC
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Wardell K, Zsigmond P, Hemm S. A System for Combined Laser Doppler Flowmetry and Microelectrode Recording during Deep Brain Stimulation Implantation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2019:3758-3761. [PMID: 31946692 DOI: 10.1109/embc.2019.8856373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Microelectrode recording (MER) and intraoperative test stimulations are commonly used during stereotactic implantation of deep brain stimulation (DBS) electrodes but they can increase the risk of hemorrhage. The aim of the study is to present and evaluate a system combining laser Doppler flowmetry (LDF) and MER. An optical probe was designed with an inner metal tube for the microelectrode. Calibration of the MER-LDF probe in a standard microsphere solution showed expected LDF pattern. No interferences of the MER probe with the LDF signals could be observed. LDF was also acquired in one Parkinson patient undergoing DBS implantation. LDF data were obtained along the precalculated trajectory i.e. from cortex towards the target in the subthalamic nucleus (STN). Results demonstrated the technical feasibility of the combined MER-LDF probe during in-vitro experiences and in one patient. The perfusion signal representing the microcirculation showed stable values with clear peaks from each heartbeat. This agreed with previous investigation using an optical probe without the MER function. Due to the forward-looking probe design, this new technology has a high potential to avoid vessels during MER recording. In addition, it could be possible to detect changes in microcirculatory blood flow during stimulation.
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Toossi A, Everaert DG, Uwiera RRE, Hu DS, Robinson K, Gragasin FS, Mushahwar VK. Effect of anesthesia on motor responses evoked by spinal neural prostheses during intraoperative procedures. J Neural Eng 2019; 16:036003. [PMID: 30790787 DOI: 10.1088/1741-2552/ab0938] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The overall goal of this study was to investigate the effects of various anesthetic protocols on the intraoperative responses to intraspinal microstimulation (ISMS). ISMS is a neuroprosthetic approach that targets the motor networks in the ventral horns of the spinal cord to restore function after spinal cord injury. In preclinical studies, ISMS in the lumbosacral enlargement produced standing and walking by activating networks controlling the hindlimb muscles. ISMS implants are placed surgically under anesthesia, and refinements in placement are made based on the evoked responses. Anesthesia can have a significant effect on the responses evoked by spinal neuroprostheses; therefore, in preparation for clinical testing of ISMS, we compared the evoked responses under a common clinical neurosurgical anesthetic protocol with those evoked under protocols commonly used in preclinical studies. APPROACH Experiments were conducted in seven pigs. An ISMS microelectrode array was implanted in the lumbar enlargement and responses to ISMS were measured under three anesthetic protocols: (1) isoflurane, an agent used pre-clinically and clinically, (2) total intravenous anesthesia (TIVA) with propofol as the main agent commonly used in clinical neurosurgical procedures, (3) TIVA with sodium pentobarbital, an anesthetic agent used mostly preclinically. Responses to ISMS were evaluated based on stimulation thresholds, movement kinematics, and joint torques. Motor evoked potentials (MEP) and plasma concentrations of propofol were also measured. MAIN RESULTS ISMS under propofol anesthesia produced large and functional responses that were not statistically different from those produced under pentobarbital anesthesia. Isoflurane, however, significantly suppressed the ISMS-evoked responses. SIGNIFICANCE This study demonstrated that the choice of anesthesia is critical for intraoperative assessments of motor responses evoked by spinal neuroprostheses. Propofol and pentobarbital anesthesia did not overly suppress the effects of ISMS; therefore, propofol is expected to be a suitable anesthetic agent for clinical intraoperative testing of an intraspinal neuroprosthetic system.
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Affiliation(s)
- Amirali Toossi
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada. Sensory Motor Adaptive Rehabilitative Technology (SMART) Network, University of Alberta, Edmonton, AB, Canada
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Guo L, Yu Y, Xin N, Sun J, Chen Y, Yu M. Clonidine Protects Against Neurotoxicity Induced by Sevoflurane Through NF-κB Signaling Inhibition and Proinflammatory Cytokine Release in Rats. J Mol Neurosci 2018; 65:507-513. [DOI: 10.1007/s12031-018-1117-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 07/10/2018] [Indexed: 12/16/2022]
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Zech N, Seemann M, Seyfried T, Lange M, Schlaier J, Hansen E. Deep Brain Stimulation Surgery without Sedation. Stereotact Funct Neurosurg 2018; 96:370-378. [DOI: 10.1159/000494803] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/07/2018] [Indexed: 11/19/2022]
Abstract
<b><i>Background:</i></b> Sedatives and opioids used during deep brain stimulation (DBS) surgery interfere with optimal target localization and add to side effects and risks, and thus should be minimized. <b><i>Objective:</i></b> To retrospectively test the actual need for sedatives and opioids when cranial nerve blocks and specific therapeutic communication are applied. <b><i>Methods:</i></b> In a case series, 64 consecutive patients treated with a strong rapport, constant contact, non-verbal communication and hypnotic suggestions, such as dissociation to a “safe place,” reframing of disturbing noises and self-confirmation, were compared to 22 preceding patients under standard general anaesthesia or conscious sedation. <b><i>Results:</i></b> With introduction of the protocol the need for sedation dropped from 100% in the control group to 5%, and from a mean dose of 444 mg to 40 mg in 3 patients. Remifentanil originally used in 100% of the patients in an average dose of 813 µg was reduced in the study group to 104 µg in 31% of patients. There were no haemodynamic reactions indicative of stress during incision, trepanation, electrode insertion and closure. <b><i>Conclusion:</i></b> With adequate therapeutic communication, patients do not require sedation and no or only low-dose opioid treatment during DBS surgery, leaving patients fully awake and competent during surgery and testing.
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Chowdhury T, Wilkinson M, Cappellani RB. Hemodynamic Perturbations in Deep Brain Stimulation Surgery: First Detailed Description. Front Neurosci 2017; 11:477. [PMID: 28894414 PMCID: PMC5581352 DOI: 10.3389/fnins.2017.00477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 08/10/2017] [Indexed: 11/13/2022] Open
Abstract
Background: Hemodynamic perturbations can be anticipated in deep brain stimulation (DBS) surgery and may be attributed to multiple factors. Acute changes in hemodynamics may produce rare but severe complications such as intracranial bleeding, transient ischemic stroke and myocardium infarction. Therefore, this retrospective study attempts to determine the incidence of hemodynamic perturbances (rate) and related risk factors in patients undergoing DBS surgery. Materials and Methods: After institutional approval, all patients undergoing DBS surgery for the past 10 years were recruited for this study. Demographic characteristics, procedural characteristics and intraoperative hemodynamic changes were noted. Event rate was calculated and the effect of all the variables on hemodynamic perturbations was analyzed by regression model. Results: Total hemodynamic adverse events during DBS surgery was 10.8 (0–42) and treated in 57% of cases. Conclusion: Among all the perioperative variables, the baseline blood pressure including systolic, diastolic, and mean arterial pressure was found to have highly significant effect on these intraoperative hemodynamic perturbations.
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Field evoked potentials in the globus pallidus of non-human primates. Neurosci Res 2017; 120:18-27. [PMID: 28159649 DOI: 10.1016/j.neures.2017.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 01/12/2017] [Accepted: 01/31/2017] [Indexed: 11/20/2022]
Abstract
Stimulation-induced field evoked potentials (fEPs) have been described in the basal ganglia output nuclei of patients with Parkinson's disease and dystonia. The aim of this study was to ascertain whether fEPs were inducible in the external (GPe) and internal (GPi) segments of the globus pallidus in normal non-human primates (NHPs). Microelectrode recording and stimulation was performed in the GPe and GPi of 2 healthy NHPs. Stimulus response curves of the fEP response to changing pulse width and amplitude examined strength-duration relationships and allowed for calculation of fEP chronaxie in the GPe and GPi. Traditional localization techniques were also used, including comparison of neuronal firing rates, optic tract activation, and internal capsule activation. Notable differences were seen in the fEPs found in GPe compared to the fEPs found in GPi. The GPe fEP had a smaller chronaxie time and larger positive deflection amplitude compared to GPi. In addition, an earlier negative deflection was identified in both nuclei and a late negative deflection was observed in the GPe in contrast to reported fEPs in patients with movement disorders. fEPs proved valuable as an ancillary method in localizing the GPe and GPi in NHPs and may be useful in the operating room during human GPi deep brain stimulation or pallidotomy procedures.
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Sedation During Surgery for Movement Disorders and Perioperative Neurologic Complications: An Observational Study Comparing Local Anesthesia, Remifentanil, and Dexmedetomidine. World Neurosurg 2017; 101:114-121. [PMID: 28179174 DOI: 10.1016/j.wneu.2017.01.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 01/25/2017] [Accepted: 01/25/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND The anesthetic management of patients requiring surgery for movement disorders needs to balance microrecording quality and patient cooperation with safety and comfort. Anesthetics can alter microrecording, although the effect on outcome is debatable. They also provide a rested and cooperative patient and minimize complications such as intracranial hemorrhage by providing better hemodynamic control. Most teams use local anesthesia with monitored anesthesia care or conscious sedation with propofol. Recently, dexmedetomidine has emerged as an alternative that, at low doses, does not affect microrecording, and that does not impair respiratory drive. METHODS In the past 15 years, we have used in our institution local anesthesia, remifentanil, or dexmedetomidine sedation. We compared functional outcome and rate of complications in a group of 145 patients with similar characteristics. RESULTS We found 5 (3.4%) intracranial hemorrhages. Two (1.4%) were symptomatic. The remifentanil group had the highest risk of having systolic blood pressure >160 mm Hg during surgery (odds ratio [OR], 2.8; 95% confidence interval [CI], 0.9-9.9), whereas the dexmedetomidine group had the lowest (OR, 0.7; 95% CI, 0.2-1.8), compared with the local anesthesia group. Surgical time was shortest with dexmedetomidine (mean, 283 minutes) and longest with local anesthesia only (mean, 328 minutes). Functional outcome (Unified Parkinson's Disease Rating Scale, Part III motor component scale) was similar among groups. The dexmedetomidine group had a statistically significant lower risk of perioperative neurologic events compared with the local anesthesia group (OR, 0.09; 95% CI, 0.002-0.68). CONCLUSIONS Sedation can be used safely without affecting outcome, and dexmedetomidine provides better hemodynamic management. Clinical significance remains unclear and larger studies need to be undertaken.
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Mathews L, Camalier CR, Kla KM, Mitchell MD, Konrad PE, Neimat JS, Smithson KG. The Effects of Dexmedetomidine on Microelectrode Recordings of the Subthalamic Nucleus during Deep Brain Stimulation Surgery: A Retrospective Analysis. Stereotact Funct Neurosurg 2017; 95:40-48. [PMID: 28132061 DOI: 10.1159/000453326] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 10/18/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND The placement of subthalamic nucleus (STN) deep brain stimulation (DBS) electrodes can be facilitated by intraoperative microelectrode recording (MER) of the STN. OBJECTIVES Optimal anesthetic management during surgery remains unclear because of a lack of quantitative data of the effect of anesthetics on MER. Therefore, we measured the effects of dexmedetomidine (DEX) on MER measures of the STN commonly taken intraoperatively. METHODS MER from 45 patients was retrospectively compared between patients treated with remifentanil (REMI) alone or both REMI and DEX, which are the 2 main standards of care at our center. The measures examined were population activity, such as root mean square, STN length, and number of passes yielding STN, and the single-neuron measures of firing rate and variability. RESULTS The addition of DEX does not affect population measures (number of passes: DEX+REMI, n = 68, REMI only, n = 154), or neuronal firing rates (number of neurons: DEX+REMI, n = 64, REMI only, n = 72), but firing rate variability was reduced. CONCLUSIONS In this cohort, population-based measures routinely used for electrode placement in the STN were unaffected by DEX when added to REMI. Neuronal firing rates were also unaffected, but their variability was reduced, even beyond 20 min after cessation.
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Affiliation(s)
- Letha Mathews
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Vadera S, Chan A, Lo T, Gill A, Morenkova A, Phielipp NM, Hermanowicz N, Hsu FP. Frameless Stereotactic Robot-Assisted Subthalamic Nucleus Deep Brain Stimulation: Case Report. World Neurosurg 2017; 97:762.e11-762.e14. [DOI: 10.1016/j.wneu.2015.11.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 11/04/2015] [Accepted: 11/05/2015] [Indexed: 11/27/2022]
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Maiti TK, Konar S, Bir S, Kalakoti P, Nanda A. Intra-operative micro-electrode recording in functional neurosurgery: Past, present, future. J Clin Neurosci 2016; 32:166-72. [PMID: 27396672 DOI: 10.1016/j.jocn.2016.03.028] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Revised: 03/24/2016] [Accepted: 03/28/2016] [Indexed: 11/25/2022]
Abstract
The field of functional neurosurgery has experienced a rise, fall and lastly a renaissance over the past 75years. Micro-electrode recording (MER) played a key role during this eventful journey. However, as the intra-operative MRI continues to evolve, a pertinent question about the utility of MER has been raised in recent years. In this article, we critically review these current controversies. The English literature is reviewed and the complex technique of MER is discussed in a simplified manner. The improvement of neuroimaging and its application in functional neurosurgery, especially in deep brain stimulation, is discussed. Finally, the current controversies and technical advances which can direct the future are reviewed. The results of existing meta-analyses addressing the controversies are summarized. Wide variations of pre-operative and intra-operative targeting methods have been described in the literature. Though functional neurosurgery is generally safe, complications do occur and multiple passes during MER can certainly add to the risk of inadvertent hemorrhage and infection. Additionally, the recent introduction of newer MRI modalities has ensured better delineation of the target. However, MER is still useful to address brain shift, for mapping of newer targets, for ablative surgeries and in centers without an intra-operative imaging facility. In the current scenario, it is nearly impossible to conduct a prospective study to decide the utility of MER. The importance of MER may further diminish in the future as a routine procedure, but its role as a gold standard procedure may still persist.
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Affiliation(s)
- Tanmoy K Maiti
- Department of Neurosurgery, LSU Health-Shreveport, 1501 Kings Highway, Shreveport, LA 71130-3932, USA
| | - Subhas Konar
- Department of Neurosurgery, LSU Health-Shreveport, 1501 Kings Highway, Shreveport, LA 71130-3932, USA
| | - Shyamal Bir
- Department of Neurosurgery, LSU Health-Shreveport, 1501 Kings Highway, Shreveport, LA 71130-3932, USA
| | - Piyush Kalakoti
- Department of Neurosurgery, LSU Health-Shreveport, 1501 Kings Highway, Shreveport, LA 71130-3932, USA
| | - Anil Nanda
- Department of Neurosurgery, LSU Health-Shreveport, 1501 Kings Highway, Shreveport, LA 71130-3932, USA.
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Abstract
PURPOSE OF REVIEW Deep brain stimulation (DBS) is a well tolerated and efficacious surgical treatment for movement disorders, chronic pain, psychiatric disorder, and a growing number of neurological disorders. Given that the brain targets are deep and small, accurate electrode placement is commonly accomplished by utilizing frame-based systems. DBS electrode placement is confirmed by microlectrode recordings and macrostimulation to optimize and verify target placement. With a reliance on electrophysiology, proper anaesthetic management is paramount to balance patient comfort without interfering with neurophysiology. RECENT FINDINGS To achieve optimal pain control, generous amounts of local anaesthesia are instilled into the planned incision. During the opening and closing states, conscious sedation is the prevailing method of anaesthesia. The preferred agents are dexmedetomidine, propofol, and remifentanil, as they affect neurocognitive testing the least, and shorter acting. All the agents are turned off 15-30 min prior to microelectrode recording. Dexmedetomidine has gained popularity in DBS procedures, but has some considerations at higher doses. The addition of ketamine is helpful for pediatric cases. SUMMARY DBS is a robust surgical treatment for a variety of neurological disorders. Appropriate anaesthetic agents that achieve patient comfort without interfering with electrophysiology are paramount.
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Lee WW, Ehm G, Yang HJ, Song IH, Lim YH, Kim MR, Kim YE, Hwang JH, Park HR, Lee JM, Kim JW, Kim HJ, Kim C, Kim HC, Park E, Kim IY, Kim DG, Jeon B, Paek SH. Bilateral Deep Brain Stimulation of the Subthalamic Nucleus under Sedation with Propofol and Fentanyl. PLoS One 2016; 11:e0152619. [PMID: 27018855 PMCID: PMC4809591 DOI: 10.1371/journal.pone.0152619] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 03/16/2016] [Indexed: 11/18/2022] Open
Abstract
Awakening during deep brain stimulation (DBS) surgery may be stressful to patients. The aim of the current study was to evaluate the effect on MER signals and their applicability to subthalmic nucleus (STN) DBS surgery for patients with Parkinson’s disease (PD) under sedation with propofol and fentanyl. Sixteen consecutive patients with PD underwent STN-DBS surgery with propofol and fentanyl. Their MER signals were achieved during the surgery. To identify the microelectrodes positions, the preoperative MRI and postoperative CT were used. Clinical profiles were also collected at the baseline and at 6 months after surgery. All the signals were slightly attenuated and contained only bursting patterns, compared with our previous report. All electrodes were mostly located in the middle one third part of the STN on both sides of the brain in the fused images. Six months later, the patients were improved significantly in the medication-off state and they met with less dyskinesia and less off-duration. Our study revealed that the sedation with propofol and fentanyl was applicable to STN-DBS surgery. There were no significant problems in precise positioning of bilateral electrodes. The surgery also improved significantly clinical outcomes in 6-month follow-up.
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Affiliation(s)
- Woong-Woo Lee
- Department of Neurology, Eulji General Hospital, Seoul, Republic of Korea
| | - Gwanhee Ehm
- Department of Neurology, Myongji Hospital, Gyeonggi, Republic of Korea
| | - Hui-Jun Yang
- Department of Neurology, Ulsan University Hospital, Ulsan, Republic of Korea
| | - In Ho Song
- Medical Device Development Center, Osong Medical Innovation Foundation, Chungcheong, Republic of Korea
| | - Yong Hoon Lim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Mi-Ryoung Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Eun Kim
- Department of Neurology, Hallym University Sacred Heart Hospital, Gyeonggi, Republic of Korea
| | - Jae Ha Hwang
- Department of Neurosurgery, Daejeon Woori Hospital, Gyeonggi, Republic of Korea
| | - Hye Ran Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae Min Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jin Wook Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Han-Joon Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Cheolyoung Kim
- Medical Imaging Laboratory, CyberMed Inc., Seoul, Republic of Korea
| | - Hee Chan Kim
- Department of Medical Engineering, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eunkyoung Park
- Department of Biomedical Engineering, Han Yang University, Seoul, Republic of Korea
| | - In Young Kim
- Department of Biomedical Engineering, Han Yang University, Seoul, Republic of Korea
| | - Dong Gyu Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Beomseok Jeon
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University College of Medicine, Seoul, Republic of Korea
- * E-mail:
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27
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Vadivelu N, Kai AM, Tran D, Kodumudi G, Legler A, Ayrian E. Options for perioperative pain management in neurosurgery. J Pain Res 2016; 9:37-47. [PMID: 26929661 PMCID: PMC4755467 DOI: 10.2147/jpr.s85782] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Moderate-to-severe pain following neurosurgery is common but often does not get attention and is therefore underdiagnosed and undertreated. Compounding this problem is the traditional belief that neurosurgical pain is inconsequential and even dangerous to treat. Concerns about problematic effects associated with opioid analgesics such as nausea, vomiting, oversedation, and increased intracranial pressure secondary to elevated carbon dioxide tension from respiratory depression have often led to suboptimal postoperative analgesic strategies in caring for neurosurgical patients. Neurosurgical patients may have difficulty or be incapable of communicating their need for analgesics due to neurologic deficits, which poses an additional challenge. Postoperative pain control should be a priority, because pain adversely affects recovery and patient outcomes. Inconsistent practices and the quality of current analgesic strategies for neurosurgical patients still leave room for improvement. Given the complexity of postoperative pain management for these patients, multimodal strategies are often required to optimize pain control and at the same time limit undesired side effects.
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Affiliation(s)
- Nalini Vadivelu
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Alice M Kai
- Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Daniel Tran
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Gopal Kodumudi
- California Northstate University College of Medicine, Elk Grove, CA, USA
| | - Aron Legler
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT, USA
| | - Eugenia Ayrian
- Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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