RESUMEN
Background: The relationship between the levodopa challenge test (LDCT) and postoperative subthalamic nucleus-deep brain stimulation (STN-DBS) benefits is controversial in patients with Parkinson's disease (PD). We aim to evaluate the value of total levodopa response (TLR) and symptom levodopa response (SLR) in predicting postoperative improvement in different PD motor subtypes. Methods: Studies were split into a training set (147 patients) and a validation set (304 patients). We retrospectively collected data from 147 patients who received the Unified Parkinson's Disease Rating Scale- (UPDRS-) III and the Parkinson's Disease Questionnaire- (PDQ-) 39 evaluation. Patients were classified into tremor-dominant (TD), akinetic-rigid-dominant (AR), and mixed (MX) groups. Clinically important difference (CID) was employed to dichotomize DBS effects. For patients in each subtype group from the training set, we used the correlation and receiver operator characteristic (ROC) curve analyses to explore the strength of their relations. Areas under the curve (AUCs) were calculated and compared through the DeLong test. Results developed from the training set were applied into the validation set to predict postoperative improvement in different PD motor subtypes. Results: In the validation cohort, TLR significantly correlated with postoperative motor (p < 0.001) and quality of life (QOL) (p < 0.001) improvement in the MX group. The AUC between TLR and UPDRS-III (TU) is 0.800. The AUC between TLR and PDQ-39 (TP) is 0.770. An associated criterion in both TU and TP is around 50%. In the AR group, strong correlation was only found in SLR and PDQ-39 (SP) (p < 0.001). And the AUC of SP is significantly larger than that in TLR and PDQ-39 (TP) (p = 0.034). An associated criterion in SP is around 37%. No significant correlation was found in the TD group. Conclusions: We provide a more accurate judgment for LDCT. TLR strongly correlated with postoperative UPDRS-III and PDQ-39 improvement in MX patients. A TLR > 50% may indicate a higher possibility of clinically meaningful benefits from STN-DBS comparing to medication only. SLR can well predict QOL improvement in AR patients. Similarly, a SLR > 37% may indicate a higher possibility of clinically significant benefits from STN-DBS. LDCT provides limited information for TD patients.
Asunto(s)
Antiparkinsonianos/administración & dosificación , Estimulación Encefálica Profunda/normas , Juicio , Levodopa/administración & dosificación , Enfermedad de Parkinson/terapia , Núcleo Subtalámico/fisiología , Anciano , Estudios de Cohortes , Estimulación Encefálica Profunda/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Enfermedad de Parkinson/diagnóstico , Enfermedad de Parkinson/tratamiento farmacológico , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The use of telemedicine in the management of chronic neurological conditions including movement disorders has expanded over time. In addition to enabling remote access to specialized care, telemedicine has also been shown to reduce caregiver burden and to improve patient satisfaction. With the COVID-19 pandemic, implementation of telehealth for patients with movement disorders, particularly those with more severe mobility issues, has increased rapidly. Although telemedicine care has been shown to be effective for patients with various movement disorders, its utilization for patients with device aided therapies such as deep brain stimulation (DBS) is limited due to challenges related to adjusting these devices remotely and to the lack of consensus recommendations for using telemedicine in this patient population. Thus, guidelines for telemedicine and DBS will assist clinicians on the appropriate implementation of telemedicine to provide care to DBS patients. Optimizing the use of telemedicine for DBS will expand this type of therapy to remote locations with limited access to programming expertise, and also reduce the need for patient travel. Telemedicine is particularly important during the ongoing pandemic due to infection risk and limited access to clinic visits. In this article we review the currently available and emerging strategies for telemedicine and remote care for DBS. We then outline common principles and recommendations for telemedicine care in patients with DBS, review patient selection and best practices. Finally, we briefly discuss the current state of reimbursement for DBS telemedicine visits.
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Estimulación Encefálica Profunda/tendencias , Telemedicina/tendencias , COVID-19 , Estimulación Encefálica Profunda/normas , Humanos , Pandemias , Consulta Remota , Telemedicina/normasRESUMEN
INTRODUCTION: Deep brain stimulation (DBS) is a highly efficacious treatment for essential tremor (ET). Still, the optimal anatomical target in the (sub)thalamic area is a matter of debate. The aim of this study was to determine the optimal target of DBS for ET regarding beneficial clinical outcome and impact on activities of daily living as well as stimulation-induced side effects and compare it with previously published coordinates. METHODS: In 30 ET patients undergoing bilateral DBS, severity of tremor was assessed by blinded video ratings before and at 1-year follow-up with DBS ON and OFF. Tremor scores and reported side effects and volumes of tissue activated were used to create a probabilistic map of DBS efficiency and side effects. RESULTS: DBS was effective both in tremor suppression as well as in improving patient reported outcomes, which were positively correlated. The "sweet spot" for tremor suppression was located inferior of the VIM in the subthalamic area, close to the superior margin of the zona incerta. The Euclidean distance of active contacts to this spot as well as to 10 of 13 spots from the literature review was predictive of individual outcome. A cluster associated with the occurrence of ataxia was located in direct vicinity of the "sweet spot". CONCLUSION: Our findings suggest the highest clinical efficacy of DBS in the posterior subthalamic area, lining up with previously published targets likely representing the dentato-rubro-thalamic tract. Side effects may not necessarily indicate lead misplacement, but should encourage clinicians to employ novel DBS programing options.
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Estimulación Encefálica Profunda , Temblor Esencial/terapia , Subtálamo , Anciano , Estimulación Encefálica Profunda/métodos , Estimulación Encefálica Profunda/normas , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Resultado del TratamientoRESUMEN
High frequency deep brain stimulation (DBS) of the internal portion of the globus pallidus has, in the last two decades, become a mainstream therapy for the management of medically-refractory dystonia syndromes. Such increasing uptake places an onus on movement disorder physicians to become familiar with this treatment modality, in particular optimal patient selection for the procedure and how to troubleshoot problems relating to sub-optimal efficacy and therapy-related side effects. Deep brain stimulation for dystonic conditions presents some unique challenges. For example, the frequent lack of immediate change in clinical status following stimulation alterations means that programming often relies on personal experience and local practice rather than real-time indicators of efficacy. Further, dystonia is a highly heterogeneous disorder, making the development of unifying guidelines and programming algorithms for DBS in this population difficult. Consequently, physicians may feel less confident in managing DBS for dystonia as compared to other indications e.g. Parkinson's disease. In this review, we integrate our years of personal experience of the programming of DBS systems for dystonia with a critical appraisal of the literature to produce a practical guide for troubleshooting common issues encountered in patients with dystonia treated with DBS, in the hope of improving the care for these patients.
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Estimulación Encefálica Profunda , Trastornos Distónicos/terapia , Globo Pálido , Guías de Práctica Clínica como Asunto , Estimulación Encefálica Profunda/métodos , Estimulación Encefálica Profunda/normas , Humanos , Guías de Práctica Clínica como Asunto/normasRESUMEN
BACKGROUND: subthalamic nucleus deep brain stimulation (STN-DBS) may have a detrimental effect on speech in Parkinson's disease (PD) patients and new stimulation technologies may help in addressing this issue. OBJECTIVE: to evaluate the STN-DBS acute effect of 30 µs pulse width (30PW) versus conventional 60 µs PW (60PW) on speech and identify the core features of voice modified by 30PW. METHODS: seven STN-DBS treated PD patients participated into a pilot cross-sectional study. Motor and speech performances were tested by means of both automatic analysis and blinded clinical evaluations in four stimulation conditions: 30PW and 60PW both at the usual amplitude and at an amplitude just below the threshold for stimulation-related side effects. RESULTS: at the threshold amplitude, 30PW stimulation improved speech intelligibility for both words (p = 0.02) and sentences (p = 0.04), without worsening motor performance. A lower but not statistically significant voice variability and instability and percentage of stuttering disfluencies was also observed. The beneficial effect of 30PW detected by automatic analysis, was confirmed by patients' perception. CONCLUSIONS: STN-DBS treated patients experiencing low speech intelligibility may benefit from a 30PW stimulation trial at a higher amplitude. Deep characterization of PD speech profiles may help in a better application of recent DBS hardware advances.
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Estimulación Encefálica Profunda/métodos , Disartria/terapia , Enfermedad de Parkinson/terapia , Núcleo Subtalámico , Anciano , Estudios Transversales , Estimulación Encefálica Profunda/normas , Disartria/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Enfermedad de Parkinson/complicaciones , Proyectos PilotoAsunto(s)
Encéfalo/fisiología , Competencia Clínica , Estimulación Transcraneal de Corriente Directa/métodos , Estimulación Magnética Transcraneal/métodos , Competencia Clínica/normas , Estimulación Encefálica Profunda/métodos , Estimulación Encefálica Profunda/normas , Humanos , Técnicas Estereotáxicas/educación , Técnicas Estereotáxicas/normas , Estimulación Transcraneal de Corriente Directa/normas , Estimulación Magnética Transcraneal/normasRESUMEN
INTRODUCTION: Deep brain stimulation (DBS) is an established treatment for Parkinson's disease (PD). Clinicians face various challenges in adjusting stimulation parameters and configurations in clinical DBS settings owing to inexperience, time constraints, and recent advances in DBS technology that have expanded the number of possible contact configurations. We aimed to assess the efficacy of a closed-loop algorithm (CLA) for the DBS-programming method using external motion sensor-based motor assessments in patients with PD. METHODS: In this randomized, double-blind, crossover study, we enrolled 12 patients who underwent eight-ring-contact DBS lead implantations bilaterally in the subthalamic nucleus. The DBS settings of the participants were programmed using a standard of care (SOC) and CLA method. The clinical effects of both programming methods were assessed in a randomized crossover fashion. The outcomes were evaluated using the Unified Parkinson's Disease Scale part III (UPDRS-III) and sensor-based scores for baseline (medication-off/stimulation-off) and both programming methods. The number of programming steps required for each programming method was also recorded. RESULTS: The UPDRS-III scores and sensor-based scores were significantly improved by SOC and CLA settings compared to the baseline. No statistical difference was observed between SOC and CLA. The programming steps were significantly reduced in the CLA settings compared to those in the SOC. No serious adverse events were observed. CONCLUSION: CLA can optimize DBS settings prospectively with similar therapeutic benefits as that of the SOC and reduce the number of programming steps. Automated optimization of DBS settings would reduce the burden of programming for both clinicians and patients.
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Estimulación Encefálica Profunda/métodos , Monitorización Neurofisiológica , Enfermedad de Parkinson/fisiopatología , Enfermedad de Parkinson/terapia , Núcleo Subtalámico , Dispositivos Electrónicos Vestibles , Adulto , Anciano , Algoritmos , Estudios Cruzados , Estimulación Encefálica Profunda/normas , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Procesos y Resultados en Atención de Salud , Enfermedad de Parkinson/diagnóstico , Índice de Severidad de la Enfermedad , Núcleo Subtalámico/cirugíaRESUMEN
BACKGROUND: In 2020, the Guidelines Task Force conducted another systematic review of the relevant literature on deep brain stimulation (DBS) for obsessive-compulsive disorder (OCD) to update the original 2014 guidelines to ensure timeliness and accuracy for clinical practice. OBJECTIVE: To conduct a systematic review of the literature and update the evidence-based guidelines on DBS for OCD. METHODS: The Guidelines Task Force conducted another systematic review of the relevant literature, using the same search terms and strategies as used to search PubMed and Embase for relevant literature. The updated search included studies published between 1966 and December 2019. The same inclusion/exclusion criteria as the original guideline were also applied. Abstracts were reviewed and relevant full-text articles were retrieved and graded. Of 864 articles, 10 were retrieved for full-text review and analysis. Recommendations were updated according to new evidence yielded by this update. RESULTS: Seven studies were included in the original guideline, reporting the use of bilateral DBS as more effective in improving OCD symptoms than sham treatment. An additional 10 studies were included in this update: 1 class II and 9 class III. CONCLUSION: Based on the data published in the literature, the following recommendations can be made: (1) It is recommended that clinicians utilize bilateral subthalamic nucleus DBS over best medical management for the treatment of patients with medically refractory OCD (level I). (2) Clinicians may use bilateral nucleus accumbens or bed nucleus of stria terminalis DBS for the treatment of patients with medically refractory OCD (level II). There is insufficient evidence to make a recommendation for the identification of the most effective target.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/deep-brain-stimulation-obsessive-compulsive-disord.
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Congresos como Asunto/normas , Estimulación Encefálica Profunda/normas , Medicina Basada en la Evidencia/normas , Neurocirujanos/normas , Trastorno Obsesivo Compulsivo/terapia , Guías de Práctica Clínica como Asunto/normas , Estimulación Encefálica Profunda/métodos , Medicina Basada en la Evidencia/métodos , Humanos , Núcleo Accumbens/fisiología , Trastorno Obsesivo Compulsivo/diagnóstico , Núcleo Subtalámico/fisiología , Tálamo/fisiología , Resultado del TratamientoRESUMEN
Deep brain stimulation (DBS) is a complex surgical procedure that requires detailed anatomical knowledge. In many fields of neurosurgery navigation systems are used to display anatomical structures during an operation to aid performing these surgeries. In frame-based DBS, the advantage of visualization has not yet been evaluated during the procedure itself. In this study, we added live visualization to a frame-based DBS system, using a standard navigation system and investigated its accuracy and potential use in DBS surgery. As a first step, a phantom study was conducted to investigate the accuracy of the navigation system in conjunction with a frame-based approach. As a second step, 5 DBS surgeries were performed with this combined approach. Afterwards, 3 neurosurgeons and 2 neurologists with different levels of experience evaluated the potential use of the system with a questionnaire. Moreover, the additional personnel, costs and required set up time were noted and compared to 5 consecutive standard procedures. In the phantom study, the navigation system showed an inaccuracy of 2.1 mm (mean SD 0.69 mm). In the questionnaire, a mean of 9.4/10 points was awarded for the use of the combined approach as a teaching tool, a mean of 8.4/10 for its advantage in creating a 3-dimensional (3-D) map and a mean of 8/10 points for facilitating group discussions. Especially neurosurgeons and neurologists in training found it useful to better interpret clinical results and side effects (mean 9/10 points) and neurosurgeons appreciated its use to better interpret microelectrode recordings (mean 9/10 points). A mean of 6/10 points was awarded when asked if the benefits were worth the additional efforts. Initially 2 persons, then one additional person was required to set up the system with no relevant added time or costs. Using a navigation system for live visualization during frame-based DBS surgery can improve the understanding of the complex 3-D anatomy and many aspects of the procedure itself. For now, we would regard it as an excellent teaching tool rather than a necessity to perform DBS surgeries.
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Estimulación Encefálica Profunda/normas , Neuronavegación/normas , Neurocirujanos/normas , Técnicas Estereotáxicas/normas , Estimulación Encefálica Profunda/métodos , Electrodos Implantados/normas , Femenino , Humanos , Imagenología Tridimensional/métodos , Imagenología Tridimensional/normas , Masculino , Microelectrodos/normas , Trastornos del Movimiento/diagnóstico por imagen , Trastornos del Movimiento/cirugía , Neuronavegación/métodos , Procedimientos Neuroquirúrgicos/métodos , Procedimientos Neuroquirúrgicos/normas , Fantasmas de Imagen/normasRESUMEN
OBJECTIVE: The ongoing coronavirus disease 2019 (COVID-19) pandemic has considerably affected the delivery of postoperative care to patients who have undergone deep brain stimulation (DBS) surgery. DBS teleprogramming technology was developed and deployed in China before the COVID-19 outbreak. In this report, the authors share their experiences with telemedical DBS treatment of patients with psychiatric disorders during the COVID-19 outbreak. METHODS: Four patients (2 with obsessive-compulsive disorder, 1 with major depressive disorder, and 1 with anorexia nervosa) underwent DBS surgery at Ruijin Hospital and received continuous postoperative DBS telemedicine case management from January 2020 to July 2020. DBS teleprogramming, individualized psychological support, and medical consultations were provided via the authors' DBS telemedicine platform, which also incorporated a synchronous real-time video communication system. RESULTS: Forty-five DBS telemedicine sessions were conducted; there was no unexpected loss of network connection during the sessions. Of these, 28 sessions involved DBS teleprogramming. Adjustments were made to the stimulation voltage, frequency, pulse width, and contact site in 21, 12, 9, and 9 sessions, respectively. Psychological support and troubleshooting were provided during the remaining telemedicine sessions. Modest to substantial clinical improvements after DBS surgery were observed in some but not all patients, whereas stimulation-related side effects were reported by 2 patients and included reversible sleep and mood problems, headache, and a sensation of heat. CONCLUSIONS: DBS telemedicine seems to offer a feasible, safe, and efficient strategy for maintaining the delivery of medical care to psychiatric patients during the COVID-19 outbreak. The authors propose that implementation of a comprehensive DBS telemedicine system, which combines DBS teleprogramming with psychological counseling, medical consultations, and medication prescriptions and delivery, could be an efficient and effective approach to manage the mental health and quality of life of patients with psychiatric disorders during future local or global public health crises.
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Anorexia Nerviosa/cirugía , COVID-19/epidemiología , Estimulación Encefálica Profunda/métodos , Trastorno Depresivo Mayor/cirugía , Trastorno Obsesivo Compulsivo/cirugía , Telemedicina/métodos , Anorexia Nerviosa/diagnóstico , Anorexia Nerviosa/psicología , Estimulación Encefálica Profunda/normas , Trastorno Depresivo Mayor/diagnóstico , Trastorno Depresivo Mayor/psicología , Estudios de Seguimiento , Humanos , Trastornos Mentales , Trastorno Obsesivo Compulsivo/diagnóstico , Trastorno Obsesivo Compulsivo/psicología , Estudios Retrospectivos , Telemedicina/normas , Resultado del TratamientoRESUMEN
BACKGROUND: Low-frequency oscillations (LFO) detected in the internal globus pallidus of dystonia patients have been identified as a physiomarker for adaptive Deep Brain Stimulation (aDBS), since LFO correlate with dystonic symptoms and are rapidly suppressed by continuous DBS (cDBS). However, it is as yet unclear how LFO should be incorporated as feedback for aDBS. OBJECTIVES: to test the acute effects of aDBS, using the amplitude of short-lived LFO-bursts to titrate stimulation, to explore the immediate effects of cDBS on LFO-modulation and dystonic symptoms, and to investigate whether a difference in the resting-state LFO is present between DBS-naïve patients and patients with chronic DBS. METHODS: seven patients were assessed during either DBS-implantation (n = 2) or battery replacement surgery (n = 5), and pseudorandomized in three conditions: no stimulation, cDBS, and aDBS. Additionally, resting-state LFP-recordings from patients undergoing battery replacement were compared to those obtained during DBS-implantation; LFP-recordings from a previous cohort of six dystonia patients undergoing DBS-implantation were incorporated into this analysis (total n = 8 newly implanted patients). RESULTS: we corroborated that a mild LFO-suppression rapidly occurs during cDBS. However, no acute changes in clinical symptoms were observed after cDBS or aDBS. Remarkably, we observed that resting-state LFO were significantly lower in patients who had been effectively treated with chronic cDBS compared to those of newly implanted patients, even when stimulation was suspended. CONCLUSIONS: our results indicate that LFO-suppression in dystonia, similar to symptom response to cDBS, might be gradual, and remain after stimulation is suspended. Therefore, tracking gradual changes in LFO may be required for aDBS implementation.
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Ondas Encefálicas/fisiología , Estimulación Encefálica Profunda , Distonía/fisiopatología , Distonía/terapia , Trastornos Distónicos/fisiopatología , Trastornos Distónicos/terapia , Globo Pálido , Anciano , Anciano de 80 o más Años , Estimulación Encefálica Profunda/métodos , Estimulación Encefálica Profunda/normas , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
INTRODUCTION: Subthalamic nucleus deep brain stimulation (STN DBS) improves cardinal motor symptoms of Parkinson's disease (PD) but can worsen verbal fluency (VF). An optimal site of stimulation for overall motor improvement has been previously identified using an atlas-independent, fully individualized, field-modeling approach. This study examines if cardinal motor components (bradykinesia, tremor, and rigidity) share this identified optimal improvement site and if there is co-localization with a site that worsens VF. METHODS: An atlas-independent, field-modeling approach was used to identify sites of maximal STN DBS effect on overall and cardinal motor symptoms and VF in 60 patients. Anatomic coordinates were referenced to the STN midpoint. Symptom severity was assessed with the MDS-UPDRS part III and established VF scales. RESULTS: Sites for improved bradykinesia and rigidity co-localized with each other and the overall part III site (0.09 mm lateral, 0.93 mm posterior, 1.75 mm dorsal). The optimal site for tremor was posterior to this site (0.10 mm lateral, 1.40 mm posterior, 1.93 mm dorsal). Semantic and phonemic VF sites were indistinguishable and co-localized medial to the motor sites (0.32 mm medial, 1.18 mm posterior, 1.74 mm dorsal). CONCLUSION: This study identifies statistically distinct, maximally effective stimulation sites for tremor improvement, VF worsening, and overall and other cardinal motor improvements in STN DBS. Current electrode sizes and voltage settings stimulate all of these sites simultaneously. However, future targeted lead placement and focused directional stimulation may avoid VF worsening while maintaining motor improvements in STN DBS.
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Disfunción Cognitiva/fisiopatología , Estimulación Encefálica Profunda , Hipocinesia/fisiopatología , Enfermedad de Parkinson/fisiopatología , Núcleo Subtalámico , Temblor/fisiopatología , Anciano , Disfunción Cognitiva/etiología , Disfunción Cognitiva/rehabilitación , Estimulación Encefálica Profunda/efectos adversos , Estimulación Encefálica Profunda/métodos , Estimulación Encefálica Profunda/normas , Femenino , Humanos , Hipocinesia/etiología , Hipocinesia/rehabilitación , Masculino , Persona de Mediana Edad , Enfermedad de Parkinson/complicaciones , Enfermedad de Parkinson/rehabilitación , Temblor/etiología , Temblor/rehabilitaciónRESUMEN
INTRODUCTION: Subthalamic nucleus deep brain stimulation (STN DBS) for Parkinson disease (PD) normalizes neuronal hypersynchrony in the beta frequency range (13-30 Hz). The spatial correspondence of maximal beta power to the site of optimal stimulation along the DBS lead trajectory has been debated. METHODS: We determined the trajectory locations of the active contact, maximal beta power, and the dorsal border of the STN (DB-STN) in DBS patients. Beta power profiles were measured during intraoperative microelectrode recording (MER). Active contact locations were assigned during blinded, postoperative DBS programming. The DB-STN was identified both electrophysiologically during MER and anatomically on MRI. After grouping DBS trajectories into quadrants relative to the anatomic STN midpoint, we examined regional variations in the relative trajectory locations of the three entities. RESULTS: STN DBS significantly improved motor performance for all 13 DBS patients, with active contacts at the DB-STN. Along trajectories passing posterior-medial to the STN midpoint, maximal beta power co-localized with active contacts at the DB-STN (difference Δ = 0.4 ± 1.6 mm, p = 0.57). By contrast, in posterior-lateral trajectories, maximal beta arose within the STN, ventral to active contacts (Δ = 1.9 ± 1.3 mm, p = 0.002). For trajectories anterior to the STN midpoint, maximal beta power co-localized with the DB-STN, while active contacts were ventral to peak beta power (p = 0.05). CONCLUSION: Our findings indicate that co-localization of optimal stimulation and beta power varies by anatomical region in STN DBS for Parkinson disease.
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Ritmo beta/fisiología , Neuroestimuladores Implantables , Evaluación de Procesos y Resultados en Atención de Salud/normas , Enfermedad de Parkinson/fisiopatología , Enfermedad de Parkinson/terapia , Núcleo Subtalámico , Anciano , Estimulación Encefálica Profunda/métodos , Estimulación Encefálica Profunda/normas , Femenino , Humanos , Monitorización Neurofisiológica Intraoperatoria , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Núcleo Subtalámico/anatomía & histología , Núcleo Subtalámico/diagnóstico por imagen , Núcleo Subtalámico/fisiologíaRESUMEN
Background: The centromedian (CM) region of the thalamus is a common target for deep brain stimulation (DBS) treatment for Tourette Syndrome (TS). However, there are currently no standard microelectrode recording or macrostimulation methods to differentiate CM thalamus from other nearby structures and nuclei. Case Report: Here we present a case of failed conventional stereotactic targeting in TS DBS. Postoperative local field potential recordings (LFPs) showed features including beta power desynchronization during voluntary movement and thalamo-cortical phase amplitude coupling at rest. These findings suggested that the DBS lead was suboptimally placed in the ventral intermediate (VIM) nucleus of the thalamus rather than the intended CM region. Due to a lack of clinical improvement in tic severity scales three months following the initial surgery, the patient underwent lead revision surgery. Slight repositioning of the DBS leads resulted in a remarkably different clinical outcome. Afterwards, LFPs revealed less beta desynchronization and disappearance of the thalamo-cortical phase amplitude coupling. Follow-up clinical visits documented improvement of the patient's global tic scores. Discussion: This case provides preliminary evidence that combining physiology with atlas based targeting may possibly enhance outcomes in some cases of Tourette DBS. A larger prospective study will be required to confirm these findings. Highlight: This report demonstrates a case of failed centromedian nucleus region deep brain stimulation (DBS). We observed suboptimal tic improvement several months following DBS surgery and subsequent lead revision improved the outcome. The neurophysiology provided an important clue suggesting the possibility of suboptimally placed DBS leads. Repeat LFPs during lead revision revealed less beta desynchronization and disappearance of the thalamo-cortical phase amplitude coupling. There was improvement in tic outcome following slight repositioning during bilateral DBS lead revision. This case provides preliminary evidence supporting the use of physiology to augment the atlas based targeting of Tourette DBS cases.
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Estimulación Encefálica Profunda , Núcleos Talámicos Intralaminares , Síndrome de Tourette/terapia , Adulto , Atlas como Asunto , Mapeo Encefálico , Estimulación Encefálica Profunda/normas , Humanos , Núcleos Talámicos Intralaminares/cirugía , Masculino , ReoperaciónRESUMEN
Impulsivity is a frequent non-motor symptom in Parkinson disease (PD). It comprises psycho-behavioral alterations that negatively impact quality of life. Dopaminergic treatments underpin many impulsive controls disorders however, side effects, such as increased impulsivity, are described also after neurosurgical procedure of deep brain stimulation (DBS). We investigated the effect of deep brain stimulation on psycho-behavioral alterations and quality of life (QoL) in PD patients, analyzing, also, the role of dopaminergic therapies.Twenty idiopathic PD patients with and 20 idiopathic PD patients without DBS were included in the study. All patient underwent to neuropsychological assessment for a screening of executive functions, impulsivity, anxiety and depressive symptoms and QoL.Differences were found between DBS and no DBS groups and in term of dopaminergic therapies. The comparison between 2 groups showed a greater motor and attentional impulsivity in DBS patients. Moreover, this impulsivity worse QoL and interpersonal relationships. The combination of Levodopa and dopamine agonists exerted a great impact on impulsivity behavior.The emergence of postoperative impulsivity seems to be a neurostimulator phenomenon related to the computational role of the subthalamic nucleus in modulation of behavior.
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Estimulación Encefálica Profunda/normas , Dopaminérgicos/uso terapéutico , Enfermedad de Parkinson/terapia , Núcleo Subtalámico/fisiopatología , Anciano , Estimulación Encefálica Profunda/instrumentación , Estimulación Encefálica Profunda/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pruebas Neuropsicológicas , Calidad de Vida/psicología , Estadísticas no Paramétricas , Núcleo Subtalámico/fisiologíaRESUMEN
BACKGROUND: The microTargetingTM MicrotableTM Platform is a novel stereotactic system that can be more rapidly fabricated than currently available 3D-printed alternatives. We present the first case series of patients who underwent deep brain stimulation (DBS) surgery guided by this platform and demonstrate its in vivo accuracy. METHODS: Ten patients underwent DBS at a single institution by the senior author and 15 leads were placed. The mean age was 69.1 years; four were female. The ventralis intermedius nucleus was targeted for patients with essential tremor and the subthalamic nucleus was targeted for patients with Parkinson's disease. RESULTS: Nine DBS leads in 6 patients were appropriately imaged to enable measurement of accuracy. The mean Euclidean electrode placement error (EPE) was 0.97 ± 0.37 mm, and the mean radial error was 0.80 ± 0.41 mm (n = 9). In the subset of CT scans performed greater than 1 month postoperatively (n = 3), the mean Euclidean EPE was 0.75 ± 0.17 mm and the mean radial error was 0.69 ± 0.17 mm. There were no surgical complications. CONCLUSION: The MicrotableTM platform is capable of submillimetric accuracy in patients undergoing stereotactic surgery. It has achieved clinical efficacy in our patients without surgical complications and has demonstrated the potential for superior accuracy compared to both traditional stereotactic frames and other common frameless systems.
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Estimulación Encefálica Profunda/normas , Electrodos Implantados/normas , Temblor Esencial/cirugía , Enfermedad de Parkinson/cirugía , Técnicas Estereotáxicas/normas , Anciano , Estimulación Encefálica Profunda/instrumentación , Estimulación Encefálica Profunda/métodos , Temblor Esencial/diagnóstico por imagen , Femenino , Humanos , Imagenología Tridimensional/métodos , Imagenología Tridimensional/normas , Masculino , Persona de Mediana Edad , Enfermedad de Parkinson/diagnóstico por imagen , Estudios Retrospectivos , Núcleo Subtalámico/diagnóstico por imagen , Núcleo Subtalámico/cirugía , Tomografía Computarizada por Rayos X/métodos , Tomografía Computarizada por Rayos X/normas , Resultado del Tratamiento , Núcleos Talámicos Ventrales/diagnóstico por imagen , Núcleos Talámicos Ventrales/cirugíaRESUMEN
Most medical centers are postponing elective procedures and deferring non-urgent clinic visits to conserve hospital resources and prevent spread of COVID-19. The pandemic crisis presents some unique challenges for patients currently being treated with deep brain stimulation (DBS). Movement disorder (Parkinson's disease, essential tremor, dystonia), neuropsychiatric disorder (obsessive compulsive disorder, Tourette syndrome, depression), and epilepsy patients can develop varying degrees of symptom worsening from interruption of therapy due to neurostimulator battery reaching end of life, device malfunction or infection. Urgent intervention to maintain or restore stimulation may be required for patients with Parkinson's disease who can develop a rare but potentially life-threatening complication known as DBS-withdrawal syndrome. Similarly, patients with generalized dystonia can develop status dystonicus, patients with obsessive compulsive disorder can become suicidal, and epilepsy patients can experience potentially life-threatening worsening of seizures as a result of therapy cessation. DBS system infection can require urgent, and rarely emergent surgery. Elective interventions including new implantations and initial programming should be postponed. For patients with existing DBS systems, the battery status and electrical integrity interrogation can now be performed using patient programmers, and employed through telemedicine visits or by phone consultations. The decision for replacement of the implantable pulse generator to prevent interruption of DBS therapy should be made on a case-by-case basis taking into consideration battery status and a patient's tolerance to potential therapy disruption. Scheduling of the procedures, however, depends heavily on the hospital system regulations and on triage procedures with respect to safety and resource utilization during the health crisis.
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Betacoronavirus , Infecciones por Coronavirus/terapia , Estimulación Encefálica Profunda/normas , Pandemias/prevención & control , Enfermedad de Parkinson/terapia , Neumonía Viral/terapia , Guías de Práctica Clínica como Asunto/normas , COVID-19 , Infecciones por Coronavirus/epidemiología , Estimulación Encefálica Profunda/métodos , Manejo de la Enfermedad , Contaminación de Equipos/prevención & control , Humanos , Neuroestimuladores Implantables/normas , Enfermedad de Parkinson/epidemiología , Neumonía Viral/epidemiología , SARS-CoV-2RESUMEN
BACKGROUND: Achieving deep brain stimulation (DBS) dose equivalence is challenging, especially with pulse width tuning and directional contacts. Further, the precise effects of pulse width tuning are unknown, and recent reports of the effects of pulse width tuning on neural selectivity are at odds with classic biophysical studies. METHODS: We created multicompartment neuron models for two axon diameters and used finite element modeling to determine extracellular influence from standard and segmented electrodes. We analyzed axon activation profiles and calculated volumes of tissue activated. RESULTS: We find that long pulse widths focus the stimulation effect on small, nearby fibers, suppressing distant white matter tract activation (responsible for some DBS side effects) and improving battery utilization when equivalent activation is maintained for small axons. Directional leads enable similar benefits to a greater degree. Reexamining previous reports of short pulse stimulation reducing side effects, we explore a possible alternate explanation: non-dose equivalent stimulation may have resulted in reduced spread of neural activation. Finally, using internal capsule avoidance as an example in the context of subthalamic stimulation, we present a patient-specific model to show how long pulse widths could help increase the biophysical therapeutic window. DISCUSSION: We find agreement with classic studies and predict that long pulse widths may focus the stimulation effect on small, nearby fibers and improve power consumption. While future pre-clinical and clinical work is necessary regarding pulse width tuning, it is clear that future studies must ensure dose equivalence, noting that energy- and charge-equivalent amplitudes do not result in equivalent spread of neural activation when changing pulse width.
Asunto(s)
Estimulación Encefálica Profunda/métodos , Modelos Neurológicos , Axones/fisiología , Estimulación Encefálica Profunda/instrumentación , Estimulación Encefálica Profunda/normas , Electrodos/normas , Humanos , Modelación Específica para el PacienteRESUMEN
INTRODUCTION: Optimal placement of Deep Brain Stimulation (DBS) lead is critical to ensure an adequate therapeutic benefit and minimize stimulation-induced side effects. METHODS: We reviewed data from 2004 to 2018 of all cases of essential tremor treated with thalamic DBS at the University of Cincinnati. All procedures were performed with the patient awake. Change in parallel trajectory was classified as major repositioning, whereas a change in depth of electrode classified as minor repositioning. The following data were compared between groups (no vs. minor vs. major repositioning): age at surgery, sex, AC-PC length, third ventricle width, cerebral atrophy, small vessel disease burden, and intraoperative tremor control. Univariate and multivariate analyses were conducted to identify factors associated with intraoperative repositioning. RESULTS: Of the 127 encounters with essential tremor, 71 required repositioning (33 major and 38 minor). Comparing procedures with major, minor, and no repositioning, mean number of changes per procedure (4 vs. 1.2 vs 0; p < 0.001) and AC-PC length (26 vs. 27 vs. 27.2 mm; p = 0.021) differed between the three groups. Older age at surgery (OR 1.04, p = 0.042), left side (OR 2.56, p = 0.04) and decrease in AC-PC length (OR 1.33, p = 0.026) were associated with greater odds of any (minor or major) repositioning. A decrease in AC-PC length was associated with greater odds of major repositioning (OR 1.37, p = 0.009). CONCLUSION: Intraoperative functional testing may be critical to ensure the accuracy of thalamic DBS targeting based on neuroimaging data, particularly in patients with reduced AC-PC length.