Application of Remote Deep Brain Stimulation Programming for Parkinson's Disease Patients.

BACKGROUND: Deep brain stimulation (DBS) is an important treatment for patients with advanced Parkinson's disease (PD). Patients after DBS implantation need specialized programming to get optimal outcomes. However, access to timely and economical postoperative programming for many patients living in remote areas is limited. Teleprogramming, which refers to deliver real-time remote programming through Internet, can help to address this gap. OBJECTIVE: We aimed to evaluate the clinical application of remote programming for PD patients with DBS. METHODS: We retrospectively studied 90 patients with PD who received remote DBS programming after implantation at Yuquan Hospital (Beijing, China) between March 2016 and June 2018. Patients' medical records were reviewed in an electronic database. A self-designed questionnaire was performed on all patients by phone. RESULTS: Over a mean follow-up period of 27.0 months, 90 patients underwent a total of 386 remote programming visits, of which the average frequency within 6 months after DBS was 2.27 times/person. The average distance between the patients' residences and Yuquan Hospital was 1243.8 ± 746.5 km. The questionnaire survey showed that each remote programming visit saved ≥2000¥ for 76.7% of the patients and ≥12 hours for 90.0% of the patients, compared with the on-site programming visit. The acceptability of the remote programming platform was highly rated. Transient side effects related to programming were reported and were relieved after adjustments of parameters. CONCLUSIONS: Remote programming may offer a feasible and acceptable approach to timely and economic management in patients with PD after DBS implantation.

Learning fine-grained estimation of physiological states from coarse-grained labels by distribution restoration.

Due to its importance in clinical science, the estimation of physiological states (e.g., the severity of pathological tremor) has aroused growing interest in machine learning community. While the physiological state is a continuous variable, its continuity is lost when the physiological state is quantized into a few discrete classes during recording and labeling. The discreteness introduces misalignment between the true value and its label, meaning that these labels are unfortunately imprecise and coarse-grained. Most previous work did not consider the inaccuracy and directly utilized the coarse labels to train the machine learning algorithms, whose predictions are also coarse-grained. In this work, we propose to learn a precise, fine-grained estimation of physiological states using these coarse-grained ground truths. Established on mathematical rigorous proof, we utilize imprecise labels to restore the probabilistic distribution of precise labels in an approximate order-preserving fashion, then the deep neural network learns from this distribution and offers fine-grained estimation. We demonstrate the effectiveness of our approach in assessing the pathological tremor in Parkinson's Disease and estimating the systolic blood pressure from bioelectrical signals.

An Intraoperative Multibranch Abnormal Muscle Response Monitoring Method During Microvascular Decompression for Hemifacial Spasm.

BACKGROUND: Intraoperative abnormal muscle response (AMR) is widely used as an indicator during microvascular decompression surgery for hemifacial spasm. Usually only 1 muscle is recorded, and not all patients show a response, leaving the surgery somewhat blinded. We propose an improved method to record from multiple muscles innervated by multiple branches of the facial nerve to increase the positive AMR detection rate. METHODS: Retrospective analysis was performed of 1604 patients with hemifacial spasm undergoing microvascular decompression at a single center. All patients were monitored for AMR by stimulating the zygomatic branch of the facial nerve. Only mentalis was recorded in 158 cases (single-branch AMR). Orbicularis oris, frontalis, and mentalis were simultaneously monitored in 148 cases (3-branch AMR), and platysma was further added in the remaining 1298 cases (4-branch AMR). Positive AMR detection rates were compared across the groups. RESULTS: Total positive AMR detection rates significantly increased as more muscles were included in monitoring and were 74.1% for single-branch AMR, 86.5% for 3-branch AMR, and 98.4% for 4-branch AMR. Detection rates from single muscles were not significantly different across the groups. For all available cases, rates were 73.5% from mentalis, 47.2% from frontalis, 64.1% from orbicularis oris, and 40.8% from platysma. CONCLUSIONS: This new multibranch AMR monitoring method can effectively increase the positive detection rate to as high as 98.4%. It is expected to better assist surgery.

Vision-Based Method for Automatic Quantification of Parkinsonian Bradykinesia.

Non-volitional discontinuation of motion, namely bradykinesia, is a common motor symptom among patients with Parkinson's disease (PD). Evaluating bradykinesia severity is an important part of clinical examinations on PD patients in both diagnosis and monitoring phases. However, subjective evaluations from different clinicians often show low consistency. The research works that explore objective quantification of bradykinesia are mostly based on highly-integrated sensors. Although these sensor-based methods demonstrate applaudable performance, it is unrealistic to promote them for wide use because the special devices they require are far from popularized in daily lives. In this paper, we take advantage of computer vision and machine learning technologies, proposing a vision-based method to automatically and objectively quantify bradykinesia severity. Three bradykinesia-related items are investigated in our study: finger tapping, hand clasping and hand pro/supination. In our method, human pose estimation technology is utilized to extract kinematic characteristics and supervised-learning-based classifiers are employed to generate score ratings. Clinical experiment on 60 patients shows that the scoring accuracy of our method over 360 examination videos is 89.7%, which is competitive with other related works. The devices our method requires are only a camera for instrumentation and a laptop for data processing. Therefore, our method can produce reliable assessment results on Parkinsonian bradykinesia with minimal device requirement, showing great potential of realizing long-term remote monitoring on patients' condition.

Long-Term Effect of Modified Incision to Prevent Related Complications in Deep Brain Stimulation.

BACKGROUND: Skin complications are a frequent type of complication of deep brain stimulation (DBS) neurosurgical procedure and are always observed in the postauricular area, scalp area, and implantable pulse generator pocket. Modifications to the surgical techniques for DBS have been proposed as therapeutic options. To prevent skin complications, we modified the surgical incisions. METHODS: At our center, we retrospectively analyzed the complications associated with traditional surgical incisions and then adjusted the double C-shaped incision and changed the postauricular incision from vertical to horizontal in patients undergoing DBS for movement disorders. RESULTS: Skin complications were observed in 4 patients among 30 patients who underwent traditional surgical incisions. In 102 consecutive patients who underwent operations with modified surgical incisions, we did not encounter any skin complications such as skin infection or erosion related to our modified incision. A single patient experienced pain and was cured after a week of local antiinflammatory treatment. CONCLUSION: By trying to avoid placing hardware directly under the suture line, our modified surgical incision successfully reduces the incidence of skin complications.

Trigeminal somatosensory-evoked potential: A neurophysiological tool to monitor the extent of lesion of ganglion radiofrequency thermocoagulation in idiopathic trigeminal neuralgia: A case-control study.

To reflect the extent of thermolesion of ganglion by testing the change of trigeminal somatosensory-evoked potential (TSEP) before and after ganglion radiofrequency thermocoagulation surgery (GRT), and evaluate long-term clinic effect by follow-up visiting of 1 year.Patients with idiopathic trigeminal neuralgia (TN) in the second division were enrolled between October 2014 and October 2015. They were treated with computed tomography-guided GRT and a follow-up visiting of 1 year. Bilateral TSEP measurements were performed 1 day before and 2 days after the GRT surgery. The latency and peak-to-peak amplitude of W2 and W3 were recorded.Immediate postprocedure pain relief (grades I-III) was 100% and 92.5% 1 year later. Facial numbness rate of grades III and IV was 70%, 40%, and 12.5%, respectively, at immediate, 2 days, and 1 year after GRT. No sever complications happened. The latency of W2 and W3 of patients who had no pain no numbness after 1 year of GRT was 1.74 ±â€Š0.24 and 3.84 ±â€Š0.66 ms, respectively, of TN side, and 1.71 ±â€Š0.39 and 3.63 ±â€Š0.85 ms of the healthy side before GRT. The amplitude of W2 and W3 was 1.13 ±â€Š0.50 and 1.99 ±â€Š1.09 uv, respectively, of TN side and 1.24 ±â€Š0.40 and 1.89 ±â€Š0.81 uv of the healthy side before GRT. There was no statistical difference of the latency and amplitude between 2 sides of W2 and W3 before surgery (P > 0.05). The latency of W2 and W3 delayed and the amplitude reduced especially in TN side after surgery comparing before (P < 0.001). And, comparisons of the latency and amplitude of W2 and W3 between TN side and the healthy side after surgery showed the latency of W2 and W3 delayed (W2: P = 0.02; W3: P = 0.01) and the amplitude of W2 reduced (P = 0.003), but the amplitude of W3 had no statistical difference (P = 0.22). The mean delayed latency and 95% confident interval of W2 and W3 were 0.22 ±â€Š0.35 (0.1-0.34) ms and 0.35 ±â€Š0.64 (0.14-0.57) ms, respectively. The mean decreased amplitude and 95% confident interval of W2 and W3 were 22 ±â€Š24 (14-30)% and 23 ±â€Š32 (12-34)%, respectively.GRT can make the latency delay and the amplitude decrease of TSEP. And the latency and amplitude of W2 and W3 can be considered reliable and safe reference for monitoring the extent of thermolesion.

An optimized abnormal muscle response recording method for intraoperative monitoring of hemifacial spasm and its long-term prognostic value.

BACKGROUND: Intraoperative electrophysiological monitoring is used to determine whether decompression is sufficient during microvascular decompression (MVD) for hemifacial spasm (HFS). However, the real offending vessel is sometimes neglected by the neurosurgeons. Here, we reported our experience in using optimized abnormal muscle response (AMR) monitoring and continuous intraoperative monitoring for MVD. METHODS: This study included 2161 HFS patients who underwent MVD using traditional (1023 patients) and optimized (1138 patients) methods. Modified AMR monitoring was adopted in our study, with the zygomatic branch of the facial nerve stimulated and the temporal branch, buccal branch, marginal mandibular branch and cervical branch of the facial nerve detected for AMR. These cases were analyzed retrospectively with emphasis on the postoperative outcomes and intraoperative findings. The therapeutic effect was evaluated at day 1, month 3 and year 1 after operation. RESULTS: The relief rate at day 1, month 3 and year 1 after operation for patients who employed optimized AMR recording method was 95.1%, 97.4% and 99.3%, comparing with 92.2%, 95.0% and 97.8% in traditional method. There was significant difference in achieved immediate remission and recovery rate during 12-month follow-up between the two groups (P < 0.05). The modified intraoperative monitoring showed the sensitivity of AMR disappearance to judge the relief at day 1, month 3 and year 1 after HFS operation was 95.7%, 96.3% and 97.3%, respectively; the specificity was 44.6%, 43.3% and 50.0%, respectively; the accuracy was 93.1%, 94.9% and 97.4%, respectively. CONCLUSIONS: Our findings demonstrated that the optimized method could improve the positive detection rate of AMR and accuracy of decompression effect prediction. The evaluation for the decompression effect by optimized intraoperative monitoring can increase the immediate remission rate and reduce the delayed recovery rate.

Application of electrophysiological methods and magnetic resonance tomographic angiography in the differentiation between hemifacial spasm and Meige syndrome.

Bilateral hemifacial spasm and Meige syndrome can be easily confused due to their similar clinical manifestation. Here, we aimed to investigate the application of electrophysiological methods and magnetic resonance tomographic angiography (MRTA) in the differentiation between hemifacial spasm and Meige syndrome. 10 patients with bilateral hemifacial spasm and 9 patients with Meige syndrome received electrophysiological monitoring of nerves. There were two males and eight females with bilateral hemifacial spasm, aged 16-58 years with a course of 5-54 months. For the patients with Meige syndrome, there were three males and six females, aged 51-68 years with a course of 12-36 months. All patients received conventional MRTA of the brain blood vessels before decompression. We found that all patients with Meige syndrome showed synchronous contraction of bilateral orbicularis oculi muscles and (or) burst discharge from orbicularis oris muscles in surface electromyography (sEMG). However, those with hemifacial spasm presented with bilaterally asynchronous burst discharge. Electromyography for patients with Meige syndrome did not record abnormal muscle response (AMR), but recorded AMR for those with bilateral hemifacial spasm. The offending vessels were compressed in patients with hemifacial spasm in MRTA, while MRTA results were generally negative for those with Meige syndrome. Combining sEMG and AMR detection in EMG and MRTA, bilateral hemifacial spasm can be differentiated from Meige syndrome with a reduction of misdiagnosis rate.

Assessment of surface electromyographic clinical analysis of selective femoral neurotomy on cerebral palsy with stiff knee.

This study aimed to explore the role of surface electromyography (sEMG) on the changes of myoelectric activities of quadriceps femoris and the assessment of its clinical effect before and after selective femoral neurotomy on spastic cerebral palsy with stiff knee. Selective femoral neurotomy was carried out in 15 patients on 26 sides. The electromyography of quadriceps femoris was recorded before and after the operation. Passive and voluntary movements were performed during recording. The root mean square (RMS) and integrated electromyography (iEMG) was calculated by time domain analysis. Meanwhile, the range of the patients' knee joint motion (ROM) was measured by a joint goniometer. The RMS and iEMG of the quadriceps femoris during passive movement was significantly decreased post-operation when compared to those pre-operation (both P<0.05, n=26). Meanwhile, the RMS and iEMG of the quadriceps femoris during voluntary movement post-operation was significantly reduced than those pre-operation (both P<0.05, n=26). Additionally, total excursion on the sagittal plane and the peak knee flexion in the swing phase were significantly raised post-operation than those pre-operation (both P<0.05, n=26). The spasms in the quadriceps femoris in spastic cerebral palsy patients with stiff knee was clearly improved, and the ROM of the knee was significantly enhanced after the selective femoral neurotomy. Importantly, surface EMG can objectively evaluate the clinical therapeutic effect of spastic cerebral palsy stiff knee as a noninvasive detection method.

Neuronal firing in the ventrolateral thalamus of patients with Parkinson's disease differs from that with essential tremor.

BACKGROUND: Although thalamotomy could dramatically improve both parkinsonian resting tremor and essential tremor (ET), the mechanisms are obviously different. This study aimed to investigate the neuronal activities in the ventrolateral thalamus of Parkinson's disease (PD) and ET. METHODS: Thirty-six patients (PD: 20, ET: 16) were studied. Microelectrode recordings in the ventral oral posterior (Vop) and the ventral intermediate nucleus (Vim) of thalamus was performed on these patients who underwent thalamotomy. Electromyography (EMG) was recorded simultaneously on the contralateral limbs to surgery. Single unit analysis and the interspike intervals (ISIs) were measured for each neuronal type. ISI histogram and auto-correlograms were constructed to estimate the pattern of neuronal firing. Mann-Whitney test and Kruskal-Wallis (K-W) test were used to compare the mean spontaneous firing rate (MSFR) of neurons of PD and ET patients. RESULTS: Three hundred and twenty-three neurons were obtained from 20 PD trajectories, including 151 (46.7%) tremor related neuronal activity, 74 neurons (22.9%) with tonic firing, and 98 (30.4%) neurons with irregular discharge. One hundred and eighty-seven neurons were identified from 16 ET trajectories including 46 (24.6%) tremor-related neuronal activity, 77 (41.2%) neurons with tonic firing, and 64 neurons (34.2%) with irregular discharge. The analysis of MSFR of neurons with tonic firing was 26.7 (3.4 - 68.3) Hz (n = 74) and that of neurons with irregular discharge (n = 98) was 13.9 (3.0 - 58.1) Hz in PD; whereas MSFR of neurons with tonic firing (n = 77) was 48.8 (19.0 - 135.5) Hz and that of neurons with irregular discharge (n = 64) was 26.3 (8.7 - 84.7) Hz in ET. There were significant differences in the MSFR of two types of neuron for PD and ET (K-W test, both P < 0.05). Significant differences in the MSFR of neuron were also obtained from Vop and Vim of PD and ET (16.3 Hz vs. 34.8 Hz, 28.0 Hz vs. 49.9 Hz) (K-W test, both P < 0.05), respectively. CONCLUSION: In consistent with recent findings, the decreased MSFR of neurons observed in the Vop is likely to be involved in PD whereas the increased MSFR of neurons seen in the Vim may be a cause of ET.

[Neuronal activity of ventrolateral thalamus in patients with essential tremor].

OBJECTIVE: To investigate the neuronal activity in the ventrolateral thalamus in relation to essential tremor (ET). METHODS: Microelectrode recording in the ventral oral posterior (Vop) and ventral intermediate nucleus (Vim) of thalamus was performed on 10 patients with ET and 10 patients with Parkinson's disease (PD) who underwent thalamotomy for tremor during operation. Electromyography (EMG) was carried out on the contralateral limbs simultaneously. Single unit analysis was performed to measure the interspike interval (ISI) and histogram was constructed to evaluate the pattern of neuronal activity. Student t-test was employed to compare the mean spontaneous firing rate (MSFR) and ISI of neuronal firing in Vop/Vim between the ET patients and PD patients. and correlation test. RESULTS: Two hundred and sixty-six neurons were identified from 20 trajectories, 38.0% being neurons with tremor-related neuronal activity Tremor cells, 31.9% of neurons related to tonic firing, and 30.1% of neurons related to irregular discharge. 131 of these thalamic neurons, were obtained from 10 ET patients. 38 of these 131 neurons (29.0%) were related to tremor-related neuronal activity, 54 (41.2%) neurons were related to tonic firing with a mean spontaneous firing rate (MSFR) of (55+/-21) Hz, and 39 neurons (29.8%) were related to irregular discharge with a MSFR of (32+/-17) Hz. In the meantime, 135 neurons were obtained from 10 PD patients. Of these 135 neurons 63 (46.7%) were related to tremor, 31 neurons (23.0%) related to tonic firing with a MSFR of (39+/-15) Hz, and 41 (30.3%) were related to irregular discharge with a MSFR of (21+/-8) Hz. The MSFR levels of pooled neurons in Vop/Vim with tonic firing and irregular discharge of the ET patients were significantly higher than those of the PD patents (t=2.74 and 2.99, both P<0.05). And the MSFR levels in Vop and Vim of the ET patients were significantly higher than those of the PD patients (both P<0.05). CONCLUSION: Vim receives the projection from cerebellum. The increase of neuronal firing frequency observed in Vim suggests that the pathophysiology of ET may be correlated with excessive activity of cerebellum.