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1.
Stereotact Funct Neurosurg ; : 1-4, 2022 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-35576905

RESUMO

BACKGROUND: The US Food and Drug Administration (FDA) has granted deep brain stimulation (DBS) approval under the humanitarian device exemption (HDE) pathway for both dystonia and obsessive-compulsive disorder (OCD). However, recent reports from the community of functional neurosurgeons suggest that insurance authorization remains a disproportionate barrier to OCD DBS implantation despite both conditions having similar support from the FDA. This cross-sectional study of health insurance policies quantifies the current payer landscape for these two interventions. OBJECTIVES: The aim of this study was to quantify the current payer policy coverage of DBS under HDE status for OCD as compared to DBS for dystonia for eligible patients in the US insurance market. METHODS: A commercial health insurance policy database was queried for documentation on DBS for dystonia and OCD. Results were individually analyzed for payer policy coverage statements on DBS for either dystonia or OCD and categorized as unique or nonunique policies. Unique policy positions were then coded for the geographic region, whether coverage was offered, and guidelines cited as evidence and justification. RESULTS: From the 80 policies in the database, there were 34 unique policies addressing DBS for either dystonia or OCD representing coverage of all 50 states. Of the 34 unique policies, 3 (9%) covered DBS for OCD, while 32 (94%) covered dystonia. Only 2 policies covered neither intervention. CONCLUSIONS: In spite of similar levels of support from the FDA, DBS for OCD has less support from insurance companies on a national level. This study begins to quantify the disparity noted by functional neurosurgeons in recent literature.

2.
Neuromodulation ; 25(2): 222-231, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-35125141

RESUMO

OBJECTIVES: Neuromodulatory devices are increasingly used by neurosurgeons to manage a variety of chronic conditions. Given their potential benefits, it is imperative to create clear ethical guidelines for the use of these devices. We present a tiered ethical framework for neurosurgeon recommendations for the use of neuromodulatory devices. MATERIALS AND METHODS: We conducted a literature review to identify factors neurosurgeons should consider when choosing to offer a neuromodulatory device to a patient. RESULTS: Neurosurgeons must weigh reductions in debilitating symptoms, improved functionality, and preserved quality of life against risks for intraoperative complications and adverse events due to stimulation or the device itself. Neurosurgeons must also evaluate whether patients and families will maintain responsibility for the management of neuromodulatory devices. Consideration of these factors should occur on an axis of resource allocation, ranging from provision of neuromodulatory devices to those with greatest potential benefit in resource-limited settings to provision of neuromodulatory devices to all patients with indications in contexts without resource limitations. Neurosurgeons must also take action to promote device effectiveness throughout the duration of care. CONCLUSIONS: Weighing risks and benefits of providing neuromodulatory devices and assessing ability to remain responsible for the devices on the level of the individual patient indicate which patients are most likely to achieve benefit from these devices. Consideration of these factors on an axis of resource allocation will allow for optimal provision of neuromodulatory devices to patients in settings of varied resources. Neurosurgeons play a primary role in promoting the effectiveness of these devices.


Assuntos
Qualidade de Vida , Estimulação Elétrica Nervosa Transcutânea , Humanos
3.
Neurosurgery ; 90(2): 155-160, 2022 02 01.
Artigo em Inglês | MEDLINE | ID: mdl-34995216

RESUMO

Magnetic resonance image-guided laser interstitial thermal therapy (MRgLITT) is a novel tool in the neurosurgical armamentarium for the management of drug-resistant epilepsy. Given the recent introduction of this technology, the American Society for Stereotactic and Functional Neurosurgery (ASSFN), which acts as the joint section representing the field of stereotactic and functional neurosurgery on behalf of the Congress of Neurological Surgeons and the American Association of Neurological Surgeons, provides here the expert consensus opinion on evidence-based best practices for the use and implementation of this treatment modality. Indications for treatment are outlined, consisting of failure to respond to, or intolerance of, at least 2 appropriately chosen medications at appropriate doses for disabling, localization-related epilepsy in the setting of well-defined epileptogenic foci, or critical pathways of seizure propagation accessible by MRgLITT. Applications of MRgLITT in mesial temporal lobe epilepsy and hypothalamic hamartoma, along with its contraindications in the treatment of epilepsy, are discussed based on current evidence. To put this position statement in perspective, we detail the evidence and authority on which this ASSFN position statement is based.


Assuntos
Epilepsia Resistente a Medicamentos , Epilepsia , Terapia a Laser , Neurocirurgia , Epilepsia Resistente a Medicamentos/cirurgia , Epilepsia/cirurgia , Humanos , Lasers , Imageamento por Ressonância Magnética , Resultado do Tratamento , Estados Unidos
4.
PLoS Biol ; 20(1): e3001509, 2022 01.
Artigo em Inglês | MEDLINE | ID: mdl-34986157

RESUMO

Studies of neuronal oscillations have contributed substantial insight into the mechanisms of visual, auditory, and somatosensory perception. However, progress in such research in the human olfactory system has lagged behind. As a result, the electrophysiological properties of the human olfactory system are poorly understood, and, in particular, whether stimulus-driven high-frequency oscillations play a role in odor processing is unknown. Here, we used direct intracranial recordings from human piriform cortex during an odor identification task to show that 3 key oscillatory rhythms are an integral part of the human olfactory cortical response to smell: Odor induces theta, beta, and gamma rhythms in human piriform cortex. We further show that these rhythms have distinct relationships with perceptual behavior. Odor-elicited gamma oscillations occur only during trials in which the odor is accurately perceived, and features of gamma oscillations predict odor identification accuracy, suggesting that they are critical for odor identity perception in humans. We also found that the amplitude of high-frequency oscillations is organized by the phase of low-frequency signals shortly following sniff onset, only when odor is present. Our findings reinforce previous work on theta oscillations, suggest that gamma oscillations in human piriform cortex are important for perception of odor identity, and constitute a robust identification of the characteristic electrophysiological response to smell in the human brain. Future work will determine whether the distinct oscillations we identified reflect distinct perceptual features of odor stimuli.


Assuntos
Ondas Encefálicas/fisiologia , Eletrocorticografia/métodos , Percepção Olfatória/fisiologia , Córtex Piriforme/fisiologia , Sinais (Psicologia) , Epilepsia , Humanos , Odorantes , Olfato
5.
Epilepsy Behav ; 127: 108524, 2022 02.
Artigo em Inglês | MEDLINE | ID: mdl-34998267

RESUMO

Surgical resection and neuromodulation are well-established treatments for those with medically refractory epilepsy. These treatments entail important ethical considerations beyond those which extend to the treatment of epilepsy generally. In this paper, the authors explore these unique considerations through a framework that relates foundational principles of bioethics to features of resective epilepsy surgery and neuromodulation. The authors conducted a literature review to identify ethical considerations for a variety of epilepsy surgery procedures and to examine how foundational principles in bioethics may inform treatment decisions. Healthcare providers should be cognizant of how an increased prevalence of somatic and psychiatric comorbidities, the dynamic nature of symptom burden over time, the individual and systemic barriers to treatment, and variable sociocultural contexts constitute important ethical considerations regarding the use of surgery or neuromodulation for the treatment of epilepsy. Moreover, careful attention should be paid to how resective epilepsy surgery and neuromodulation relate to notions of patient autonomy, safety and privacy, and the shared responsibility for device management and maintenance. A three-tiered approach-(1) gathering information and assessing the risks and benefits of different treatment options, (2) clear communication with patient or proxy with awareness of patient values and barriers to treatment, and (3) long-term decision maintenance through continued identification of gaps in understanding and provision of information-allows for optimal treatment of the individual person with epilepsy while minimizing disparities in epilepsy care.


Assuntos
Estimulação Encefálica Profunda , Epilepsia Resistente a Medicamentos , Epilepsia , Estimulação do Nervo Vago , Estimulação Encefálica Profunda/métodos , Epilepsia Resistente a Medicamentos/cirurgia , Epilepsia/cirurgia , Humanos , Procedimentos Neurocirúrgicos/métodos
6.
Annu Int Conf IEEE Eng Med Biol Soc ; 2021: 4978-4981, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34892325

RESUMO

Radiofrequency (RF) heating of tissue during magnetic resonance imaging (MRI) is a known safety risk in the presence of active implantable medical devices (AIMDs). As a result, access to MRI is limited for patients with these implants including those with deep brain stimulation (DBS) systems. Numerous factors contribute to excessive RF tissue heating at the DBS lead-tip, most notable being the trajectory of the lead. Phantom studies have demonstrated that looping the extracranial portion of the DBS lead at the surgical burr hole reduces the heating at the lead-tip; however, clinical implementation of this technique is challenging due to surgical constraints. As such, the intended looped trajectory is usually different from what is implanted in patients. To date, no data is available to quantify the extent by which surgical trajectory modification reduces RF heating of DBS leads compared to the typical surgical approach. In this work, we measured RF heating of a commercial DBS system during 3 T MRI, where the trajectory of the lead and extension cable mimicked lead trajectories constructed from postoperative CT images of 13 patients undergoing modified DBS surgery and 2 patients with unmodified trajectories. Two manually created trajectories mimicking typical heating cases seen in the literature were also evaluated. We found that modified lead trajectories reduced the average heating by 3-folds compared to unmodified lead trajectories.Clinical Relevance- This study evaluates the performance of a surgical modification in the routing of DBS leads in reducing RF-induced heating during MRI at 3 T.


Assuntos
Estimulação Encefálica Profunda , Calefação , Humanos , Imageamento por Ressonância Magnética , Imagens de Fantasmas , Ondas de Rádio
7.
Proc Natl Acad Sci U S A ; 118(49)2021 12 07.
Artigo em Inglês | MEDLINE | ID: mdl-34853173

RESUMO

Tactile nerve fibers fall into a few classes that can be readily distinguished based on their spatiotemporal response properties. Because nerve fibers reflect local skin deformations, they individually carry ambiguous signals about object features. In contrast, cortical neurons exhibit heterogeneous response properties that reflect computations applied to convergent input from multiple classes of afferents, which confer to them a selectivity for behaviorally relevant features of objects. The conventional view is that these complex response properties arise within the cortex itself, implying that sensory signals are not processed to any significant extent in the two intervening structures-the cuneate nucleus (CN) and the thalamus. To test this hypothesis, we recorded the responses evoked in the CN to a battery of stimuli that have been extensively used to characterize tactile coding in both the periphery and cortex, including skin indentations, vibrations, random dot patterns, and scanned edges. We found that CN responses are more similar to their cortical counterparts than they are to their inputs: CN neurons receive input from multiple classes of nerve fibers, they have spatially complex receptive fields, and they exhibit selectivity for object features. Contrary to consensus, then, the CN plays a key role in processing tactile information.


Assuntos
Bulbo/fisiologia , Percepção/fisiologia , Percepção do Tato/fisiologia , Potenciais de Ação/fisiologia , Animais , Feminino , Macaca/fisiologia , Masculino , Mecanorreceptores/fisiologia , Bulbo/metabolismo , Fibras Nervosas/fisiologia , Neurônios/fisiologia , Pele/inervação , Tato/fisiologia , Vibração
8.
IEEE Trans Electromagn Compat ; 63(5): 1757-1766, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34898696

RESUMO

Interaction of an active electronic implant such as a deep brain stimulation (DBS) system and MRI RF fields can induce excessive tissue heating, limiting MRI accessibility. Efforts to quantify RF heating mostly rely on electromagnetic (EM) simulations to assess individualized specific absorption rate (SAR), but such simulations require extensive computational resources. Here, we investigate if a predictive model using machine learning (ML) can predict the local SAR in the tissue around tips of implanted leads from the distribution of the tangential component of the MRI incident electric field, Etan. A dataset of 260 unique patient-derived and artificial DBS lead trajectories was constructed, and the 1 g-averaged SAR, 1gSARmax, at the lead-tip during 1.5 T MRI was determined by EM simulations. Etan values along each lead's trajectory and the simulated SAR values were used to train and test the ML algorithm. The resulting predictions of the ML algorithm indicated that the distribution of Etan could effectively predict 1gSARmax at the DBS lead-tip (R = 0.82). Our results indicate that ML has the potential to provide a fast method for predicting MR-induced power absorption in the tissue around tips of implanted leads such as those in active electronic medical devices.

10.
Parkinsonism Relat Disord ; 92: 41-45, 2021 11.
Artigo em Inglês | MEDLINE | ID: mdl-34688029

RESUMO

BACKGROUND: The initial COVID-19 pandemic shutdown led to the canceling of elective surgeries throughout most of the USA and Canada. OBJECTIVE: This survey was carried out on behalf of the Parkinson Study Group (PSG) to understand the impact of the shutdown on deep brain stimulation (DBS) practices in North America. METHODS: A survey was distributed through RedCap® to the members of the PSG Functional Neurosurgical Working Group. Only one member from each site was asked to respond to the survey. Responses were collected from May 15 to June 6, 2020. RESULTS: Twenty-three sites participated; 19 (83%) sites were from the USA and 4 (17%) from Canada. Twenty-one sites were academic medical centers. COVID-19 associated DBS restrictions were in place from 4 to 16 weeks. One-third of sites halted preoperative evaluations, while two-thirds of the sites offered limited preoperative evaluations. Institutional policy was the main contributor for the reported practice changes, with 87% of the sites additionally reporting patient-driven surgical delays secondary to pandemic concerns. Pre-post DBS associated management changes affected preoperative assessments 96%; electrode placement 87%; new implantable pulse generator (IPG) placement 83%; IPG replacement 65%; immediate postoperative DBS programming 74%; and routine DBS programming 91%. CONCLUSION: The COVID-19 pandemic related shutdown resulted in DBS practice changes in almost all North American sites who responded to this large survey. Information learned could inform development of future contingency plans to reduce patient delays in care under similar circumstances.


Assuntos
COVID-19/prevenção & controle , Estimulação Encefálica Profunda/estatística & dados numéricos , Neuroestimuladores Implantáveis/estatística & dados numéricos , Transtornos dos Movimentos/terapia , Doença de Parkinson/terapia , Cuidados Pós-Operatórios/estatística & dados numéricos , Cuidados Pré-Operatórios/estatística & dados numéricos , Quarentena/estatística & dados numéricos , Telemedicina/estatística & dados numéricos , Centros Médicos Acadêmicos , Canadá , Pesquisas sobre Serviços de Saúde , Humanos , Neurologistas/estatística & dados numéricos , Neurocirurgiões/estatística & dados numéricos , Estados Unidos
12.
PLoS One ; 16(9): e0257077, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34492090

RESUMO

Ultra-high field MRI at 7 T can produce much better visualization of sub-cortical structures compared to lower field, which can greatly help target verification as well as overall treatment monitoring for patients with deep brain stimulation (DBS) implants. However, use of 7 T MRI for such patients is currently contra-indicated by guidelines from the device manufacturers due to the safety issues. The aim of this study was to provide an assessment of safety and image quality of ultra-high field magnetic resonance imaging at 7 T in patients with deep brain stimulation implants. We performed experiments with both lead-only and complete DBS systems implanted in anthropomorphic phantoms. RF heating was measured for 43 unique patient-derived device configurations. Magnetic force measurements were performed according to ASTM F2052 test method, and device integrity was assessed before and after experiments. Finally, we assessed electrode artifact in a cadaveric brain implanted with an isolated DBS lead. RF heating remained below 2°C, similar to a fever, with the 95% confidence interval between 0.38°C-0.52°C. Magnetic forces were well below forces imposed by gravity, and thus not a source of concern. No device malfunctioning was observed due to interference from MRI fields. Electrode artifact was most noticeable on MPRAGE and T2*GRE sequences, while it was minimized on T2-TSE images. Our work provides the safety assessment of ultra-high field MRI at 7 T in patients with DBS implants. Our results suggest that 7 T MRI may be performed safely in patients with DBS implants for specific implant models and MRI hardware.


Assuntos
Estimulação Encefálica Profunda , Aumento da Imagem , Imageamento por Ressonância Magnética , Artefatos , Humanos , Imagens de Fantasmas , Ondas de Rádio , Temperatura
13.
Curr Biol ; 31(20): 4499-4511.e8, 2021 10 25.
Artigo em Inglês | MEDLINE | ID: mdl-34450088

RESUMO

Encoding and retaining novel sequences of sensory stimuli in working memory is crucial for adaptive behavior. A fundamental challenge for the central nervous system is to maintain each sequence item in an active and discriminable state, while also preserving their temporal context. Nested neural oscillations have been postulated to disambiguate the "what" and "when" of sequences, but the mechanisms by which these multiple streams of information are coordinated in the human brain remain unclear. Drawing from foundational animal studies, we recorded local field potentials from the human piriform cortex and hippocampus during a working memory task in which subjects experienced sequences of three distinct odors. Our data revealed a unique organization of odor memories across multiple timescales of the theta rhythm. During encoding, odors elicited greater gamma at distinct theta phases in both regions, time stamping their positions in the sequence, whereby the robustness of this effect was predictive of temporal order memory. During maintenance, stimulus-driven patterns of theta-coupled gamma were spontaneously reinstated in piriform cortex, recapitulating the order of the initial sequence. Replay events were time compressed across contiguous theta cycles, coinciding with periods of enhanced piriform-hippocampal theta-phase synchrony, and their prevalence forecasted subsequent recall accuracy on a trial-by-trial basis. Our data provide a novel link between endogenous replay orchestrated by the theta rhythm and short-term retention of sequential memories in the human brain.


Assuntos
Memória de Curto Prazo , Córtex Piriforme , Animais , Hipocampo/fisiologia , Humanos , Memória de Curto Prazo/fisiologia , Córtex Piriforme/fisiologia , Olfato , Ritmo Teta/fisiologia
15.
World Neurosurg ; 151: 341-347, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34243667

RESUMO

Neurosurgery is considered to have one of the greatest risks of medical malpractice claims. However, medicolegal issues in neurosurgery are often disregarded and underrated worldwide. Medical errors in the neurosurgical field can be attributed to multiple factors, including highly morbid pathologies, the technical difficulty of neurosurgical procedures, and the involvement and interaction of a multidisciplinary team in the care of neurosurgical patients. Health care providers worldwide are at risk of lawsuits, sometimes even when no deviation from the standard of care had occurred in a given case. Often, governments use additional tactics to decrease the burden on compensators and extrajudicial institutions and to decrease the court's flow of irrational litigation. Continuous amendments to health care acts and newer reforms to address these issues have materialized worldwide. In the present narrative review, we have reviewed the global perspectives of medicolegal issues, with a focus on neurosurgical discipline.


Assuntos
Responsabilidade Legal/economia , Imperícia/economia , Imperícia/legislação & jurisprudência , Neurocirurgia/legislação & jurisprudência , Fatores Socioeconômicos , Humanos , Procedimentos Neurocirúrgicos/efeitos adversos
16.
World Neurosurg ; 151: 348-352, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34243668

RESUMO

Practicing neurosurgery in 2021 requires a detailed knowledge of the vocabulary and mechanisms for coding and reimbursement, which should include general knowledge at the global level and fluency at the provider level. It is specifically of interest for the neurosurgeon to understand conceptually the nuances of hospital reimbursement. That knowledge is especially germane as more neurosurgeons become hospital employees. Here we provide an overview of the mechanics of coding. We illustrate the formula to generate physician reimbursement through the current relative value unit structure. We also seek to explain hospital-level reimbursement through the diagnosis-related group structure. Finally, we expand about different and ancillary income streams available to neurosurgeons and provide a realistic assessment including the opportunities and challenges of those entities.


Assuntos
Neurocirurgia/economia , Procedimentos Neurocirúrgicos/economia , Mecanismo de Reembolso , Humanos , Classificação Internacional de Doenças
17.
World Neurosurg ; 151: 353-363, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34243669

RESUMO

No physician can successfully deliver high-value patient care in the modern-day health care system in isolation. Delivery of effective patient care requires integrated and collaborative systems that depend on dynamic professional relationships among members of the health care team. An overview of the socioeconomic implications of professional relationships within modern care delivery systems and potential employment models is presented.


Assuntos
Atenção à Saúde/economia , Neurocirurgia/organização & administração , Equipe de Assistência ao Paciente/economia , Equipe de Assistência ao Paciente/organização & administração , Fatores Socioeconômicos , Atenção à Saúde/métodos , Humanos , Neurocirurgia/economia , Neurocirurgia/métodos
18.
World Neurosurg ; 151: 364-369, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34243670

RESUMO

Credentialing and certification are essential processes during hiring to ensure that the physician is competent and possesses the qualifications and skill sets claimed. Peer review ensures the continuing evolution of these skills to meet a standard of care. We have provided an overview and discussion of these processes in the United States. Credentialing is the process by which a physician is determined to be competent and able to practice, used to ensure that medical staff meets specific standards, and to grant operative privileges at an institution. Certification is a standardized affirmation of a physician's competence on a nationwide basis. Although not legally required to practice in the United States, many institutions emphasize certification for full privileges on an ongoing basis at a hospital. In the United States, peer review of adverse events is a mandatory prerequisite for accreditation. The initial lack of standardization led to the development of the Health Care Quality Improvement Act, which protects those involved in the peer review process from litigation, and the National Provider Databank, which was established as a national database to track misconduct. A focus on quality improvement in the peer review process can lead to improved performance and patient outcomes. A thorough understanding of the processes of credentialing, certification, and peer review in the United States will benefit neurosurgeons by allowing them to know what institutions are looking for as well and their rights and responsibilities in any given situation. It could also be useful to compare these policies and practices in the United States to those in other countries.


Assuntos
Certificação/métodos , Competência Clínica/normas , Credenciamento/normas , Neurocirurgia/normas , Revisão dos Cuidados de Saúde por Pares/métodos , Certificação/normas , Humanos , Neurocirurgiões , Revisão dos Cuidados de Saúde por Pares/normas , Estados Unidos
19.
World Neurosurg ; 151: 370-374, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34243671

RESUMO

Medical malpractice litigation is something that every neurosurgeon encounters in his or her career and causes significant strife to amateur physicians attempting to navigate the medicolegal process. Neurosurgery in particular is one of the highest risk specialties for litigation. This calls to order the importance of a clear understanding of the medicolegal proceedings that may follow after a complaint has been filed. This report describes the steps to be taken by the physician in the instance that litigation is expected or considered a possibility. We describe the elements that comprise a medical malpractice claim, details of the lawsuit process including hospital peer review and expert witness selection, and how to communicate appropriately with the patients and their families in an empathetic way. It is imperative to gain an appropriate understanding of the entirety of the malpractice claim process to ease the anxiety of litigation for the physician and decrease the amount of avoidable complications.


Assuntos
Imperícia/legislação & jurisprudência , Neurocirurgia/legislação & jurisprudência , Humanos
20.
Neuromodulation ; 2021 Jun 17.
Artigo em Inglês | MEDLINE | ID: mdl-34139037

RESUMO

BACKGROUND AND OBJECTIVES: Bilateral subthalamic nucleus deep brain stimulation (STN DBS) in Parkinson's disease (PD) can have detrimental effects on eye movement inhibitory control. To investigate this detrimental effect of bilateral STN DBS, we examined the effects of manipulating STN DBS amplitude on inhibitory control during the antisaccade task. The prosaccade error rate during the antisaccade task, that is, directional errors, was indicative of impaired inhibitory control. We hypothesized that as stimulation amplitude increased, the prosaccade error rate would increase. MATERIALS AND METHODS: Ten participants with bilateral STN DBS completed the antisaccade task on six different stimulation amplitudes (including zero amplitude) after a 12-hour overnight withdrawal from antiparkinsonian medication. RESULTS: We found that the prosaccade error rate increased as stimulation amplitude increased (p < 0.01). Additionally, prosaccade error rate increased as the modeled volume of tissue activated (VTA) and STN overlap decreased, but this relationship depended on stimulation amplitude (p = 0.04). CONCLUSIONS: Our findings suggest that higher stimulation amplitude settings can be modulatory for inhibitory control. Some individual variability in the effect of stimulation amplitude can be explained by active contact location and VTA-STN overlap. Higher stimulation amplitudes are more deleterious if the active contacts fall outside of the STN resulting in a smaller VTA-STN overlap. This is clinically significant as it can inform clinical optimization of STN DBS parameters. Further studies are needed to determine stimulation amplitude effects on other aspects of cognition and whether inhibitory control deficits on the antisaccade task result in a meaningful impact on the quality of life.

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