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1.
Nat Biomed Eng ; 4(2): 223-231, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-32051578

RESUMO

The use of nanophotonics to rapidly and precisely reconfigure light beams for the optical stimulation of neurons in vivo has remained elusive. Here we report the design and fabrication of an implantable silicon-based probe that can switch and route multiple optical beams to stimulate identified sets of neurons across cortical layers and simultaneously record the produced spike patterns. Each switch in the device consists of a silicon nitride waveguide structure that can be rapidly (<20 µs) reconfigured by electrically tuning the phase of light. By using an eight-beam probe, we show in anaesthetized mice that small groups of single neurons can be independently stimulated to produce multineuron spike patterns at sub-millisecond precision. We also show that a probe integrating co-fabricated electrical recording sites can simultaneously optically stimulate and electrically measure deep-brain neural activity. The technology is scalable, and it allows for beam focusing and steering and for structured illumination via beam shaping. The high-bandwidth optical-stimulation capacity of the device might facilitate the probing of the spatiotemporal neural codes underlying behaviour.


Assuntos
Estimulação Encefálica Profunda/instrumentação , Estimulação Encefálica Profunda/métodos , Hipocampo/fisiologia , Nanotecnologia , Neurônios/fisiologia , Córtex Visual/fisiologia , Potenciais de Ação , Animais , Desenho de Equipamento , Feminino , Camundongos Transgênicos , Processamento de Sinais Assistido por Computador , Silício
2.
Neuron ; 105(4): 604-620, 2020 02 19.
Artigo em Inglês | MEDLINE | ID: mdl-32078796

RESUMO

Stroke is one of the leading causes of long-term disability. Advanced technological solutions ("neurotechnologies") exploiting robotic systems and electrodes that stimulate the nervous system can increase the efficacy of stroke rehabilitation. Recent studies on these approaches have shown promising results. However, a paradigm shift in the development of new approaches must be made to significantly improve the clinical outcomes of neurotechnologies compared with those of traditional therapies. An "evolutionary" change can occur only by understanding in great detail the basic mechanisms of natural stroke recovery and technology-assisted neurorehabilitation. In this review, we first describe the results achieved by existing neurotechnologies and highlight their current limitations. In parallel, we summarize the data available on the mechanisms of recovery from electrophysiological, behavioral, and anatomical studies in humans and rodent models. Finally, we propose new approaches for the effective use of neurotechnologies in stroke survivors, as well as in people with other neurological disorders.


Assuntos
Estimulação Encefálica Profunda/métodos , Destreza Motora/fisiologia , Plasticidade Neuronal/fisiologia , Recuperação de Função Fisiológica/fisiologia , Córtex Sensório-Motor/fisiologia , Reabilitação do Acidente Vascular Cerebral/métodos , Estimulação Encefálica Profunda/instrumentação , Humanos , Doenças do Sistema Nervoso/diagnóstico por imagem , Doenças do Sistema Nervoso/fisiopatologia , Doenças do Sistema Nervoso/reabilitação , Reabilitação Neurológica/instrumentação , Reabilitação Neurológica/métodos , Córtex Sensório-Motor/diagnóstico por imagem , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/fisiopatologia , Acidente Vascular Cerebral/terapia , Reabilitação do Acidente Vascular Cerebral/instrumentação
3.
PLoS One ; 14(8): e0220043, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31390346

RESUMO

Patients with deep brain stimulation (DBS) implants can significantly benefit from magnetic resonance imaging (MRI), however access to MRI is restricted in these patients because of safety concerns due to RF heating of the leads. Recently we introduced a patient-adjustable reconfigurable transmit coil for low-SAR imaging of DBS at 1.5T. A previous simulation study demonstrated a substantial reduction in the local SAR around single DBS leads in 9 unilateral lead models. This work reports the first experimental results of temperature measurement at the tips of bilateral DBS leads with realistic trajectories extracted from postoperative CT images of 10 patients (20 leads in total). A total of 200 measurements were performed to record temperature rise at the tips of the leads during 2 minutes of scanning with the coil rotated to cover all accessible rotation angles. In all patients, we were able to find an optimum coil rotation angle and reduced the heating of both left and right leads to a level below the heating produced by the body coil. An average heat reduction of 65% was achieved for bilateral leads. When considering each lead alone, an average heat reduction of 80% was achieved. Our results suggest that reconfigurable coil technology introduces a promising approach for imaging of patients with DBS implants.


Assuntos
Estimulação Encefálica Profunda/efeitos adversos , Estimulação Encefálica Profunda/instrumentação , Temperatura Alta , Imagem por Ressonância Magnética/instrumentação , Próteses e Implantes , Ondas de Rádio , Rotação
4.
Nat Commun ; 10(1): 3591, 2019 08 09.
Artigo em Inglês | MEDLINE | ID: mdl-31399570

RESUMO

Practice improves perception and enhances neural representations of trained visual stimuli, a phenomenon known as visual perceptual learning (VPL). While attention to task-relevant stimuli plays an important role in such learning, Pavlovian stimulus-reinforcer associations are sufficient to drive VPL, even subconsciously. It has been proposed that reinforcement facilitates perceptual learning through the activation of neuromodulatory centers, but this has not been directly confirmed in primates. Here, we paired task-irrelevant visual stimuli with microstimulation of a dopaminergic center, the ventral tegmental area (VTA), in macaques. Pairing VTA microstimulation with a task-irrelevant visual stimulus increased fMRI activity and improved classification of fMRI activity patterns selectively for the microstimulation-paired stimulus. Moreover, pairing VTA microstimulation with a task-irrelevant visual stimulus improved the subject's capacity to discriminate that stimulus. This is the first causal demonstration of the role of neuromodulatory centers in VPL in primates.


Assuntos
Condicionamento Clássico/fisiologia , Macaca mulatta/fisiologia , Área Tegmentar Ventral/fisiologia , Percepção Visual/fisiologia , Animais , Estimulação Encefálica Profunda/instrumentação , Estimulação Encefálica Profunda/métodos , Neuroestimuladores Implantáveis , Imagem por Ressonância Magnética , Masculino , Microeletrodos , Estimulação Luminosa/instrumentação , Estimulação Luminosa/métodos , Área Tegmentar Ventral/diagnóstico por imagem
5.
J Clin Neurosci ; 68: 13-19, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31375306

RESUMO

Implantable neurostimulation devices provide a direct therapeutic link to the nervous system and can be considered brain-computer interfaces (BCI). Under this definition, BCI are not simply science fiction, they are part of existing neurosurgical practice. Clinical BCI are standard of care for historically difficult to treat neurological disorders. These systems target the central and peripheral nervous system and include Vagus Nerve Stimulation, Responsive Neurostimulation, and Deep Brain Stimulation. Recent advances in clinical BCI have focused on creating "closed-loop" systems. These systems rely on biomarker feedback and promise individualized therapy with optimal stimulation delivery and minimal side effects. Success of clinical BCI has paralleled research efforts to create BCI that restore upper extremity motor and sensory function to patients. Efforts to develop closed loop motor/sensory BCI is linked to the successes of today's clinical BCI.


Assuntos
Interfaces Cérebro-Computador/tendências , Estimulação Encefálica Profunda/tendências , Doenças do Sistema Nervoso/terapia , Estimulação do Nervo Vago/tendências , Estimulação Encefálica Profunda/instrumentação , Estimulação Encefálica Profunda/métodos , Humanos , Estimulação do Nervo Vago/instrumentação , Estimulação do Nervo Vago/métodos
6.
Stereotact Funct Neurosurg ; 97(3): 153-159, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31430753

RESUMO

BACKGROUND: 7.0-T T2-weighted MRI offers excellent visibility of the subthalamic nucleus (STN), which is used as a target for deep brain stimulation (DBS) in Parkinson's disease (PD). A comparison of 7.0-T MRI to microelectrode recordings (MER) for STN border identification has not been performed. OBJECTIVE: To compare representation of STN borders on 7.0-T T2 MRI with the borders identified during MER in patients undergoing DBS for PD and to evaluate whether STN identification on 7.0-T T2 MRI leads to alterations in stereotactic target planning. DESIGN/METHODS: STN border identification was done using volumetric 7.0-T T2 MRI acquisitions. This was compared to the STN borders identified by MER. STN target planning was independently performed by 3 DBS surgeons on T2 imaging using 1.5-, 3.0-, and 7.0-T MRI. RESULTS: A total of 102 microelectrode tracks were evaluated in 19 patients. Identification of the dorsal STN border was well feasible on 7-T T2, whereas the ventral STN was un-distinguishable from the substantia nigra. The dorsal STN border on MRI was located more dorsal than MER in 73% of trajectories. The average distance from MRI to MER border was 0.9 mm (range -4.4 to +3.5 mm). STN target planning showed high correspondence between the 3 field strengths. CONCLUSION: 7.0-T T2 MRI offers the possibility of easy identification of the dorsal border of the STN. However, higher field strength MRI does not change the planning of the target. Compared to MER, the dorsal border on MRI was located more dorsal in the majority of cases, situating MER activity within STN representation.


Assuntos
Estimulação Encefálica Profunda/instrumentação , Estimulação Encefálica Profunda/métodos , Imagem por Ressonância Magnética/instrumentação , Imagem por Ressonância Magnética/métodos , Doença de Parkinson/diagnóstico por imagem , Núcleo Subtalâmico/diagnóstico por imagem , Idoso , Feminino , Humanos , Imageamento Tridimensional/instrumentação , Imageamento Tridimensional/métodos , Masculino , Microeletrodos , Pessoa de Meia-Idade , Doença de Parkinson/cirurgia , Doença de Parkinson/terapia , Núcleo Subtalâmico/cirurgia
7.
BMC Surg ; 19(1): 92, 2019 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-31307448

RESUMO

BACKGROUND: The accuracy of deep brain stimulation (DBS) depends on precise electrode positioning, which has been pursued for ideal treatment outcomes. As a critical component of DBS, the fixation performance of lead anchoring devices has been widely studied. Possible reasons for lead shift were analyzed in the current study and we further provided effective solutions to reduce potential manual errors. METHODS: Seventy-nine patients who received DBS implantations at the Ruijin Hospital from April to November 2017 were retrospectively reviewed. Intraoperative lead shifts were measured by C-arm fluoroscopy. Lead adjustment counts were recorded and compared among three lead fixation devices: Stimloc™ (Medtronic, Minneapolis, MN, USA), TouchLoc (SceneRay, Suzhou, China), and the traditional lead anchoring device. RESULTS: Mean (± SD) distances of lead shifts were 0.29 ± 2.42 mm in Stimloc devices, 0.43 ± 0.55 mm in TouchLoc devices, and 1.52 ± 1.05 mm in traditional devices (p < 0.0001). Average numbers of adjustments in this series were 0.3 ± 0.5 in Stimloc devices, 0.3 ± 1.3 in TouchLoc devices, and 1.1 ± 1.0 in traditional devices (p = 0.0001). Pairwise comparisons among the three devices (TouchLoc vs. Stimloc: p = 0.273; TouchLoc vs. Traditional: p = 0.0001; Stimloc vs. traditional: p < 0.0001) suggested significant differences, which were mainly attributed to the traditional devices. CONCLUSIONS: Three lead anchoring devices have been compared for their performance in the accuracy of lead fixation, in which the newly designed lead fixation devices have presented its advantages to the traditional one. In addition to the application of the Stimloc and TouchLoc devices, verification by C-arm fluoroscopy should be performed to provide an intuitive view of the depth deviation of electrode position during DBS electrode implantation.


Assuntos
Estimulação Encefálica Profunda/instrumentação , Eletrodos Implantados , Transtornos dos Movimentos/terapia , Adolescente , Adulto , Idoso , China , Feminino , Fluoroscopia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
8.
World Neurosurg ; 130: e786-e793, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31295615

RESUMO

BACKGROUND: Interleaving stimulation (ILS) is a stimulation strategy that can help the physician manage more challenging cases of patients with deep brain stimulation (DBS) for Parkinson disease (PD). It consists of altering 2 different programs on the electrode with the same frequency. OBJECTIVES: Our objective was to overview our patients' experience with ILS and explore clinical scenarios in which ILS should be considered when programming DBS in patients with PD. METHODS: We retrospectively reviewed medical charts from 120 patients with PD treated with DBS between 2011 and 2018. RESULTS: Eighteen patients received ILS. One was excluded because of the medical chart was incomplete. The remaining 17 patients had subthalamic nucleus DBS (n = 14) and globus pallidus internus DBS (n = 3). Eight patients (47%) received ILS to improve rigidity and bradykinesia, 4 to improve dyskinesias, 4 because of refractory tremor, and 1 for gait management. Until the end of data collection, 13 of 17 patients (70%) were still on ILS, with a mean duration time of 28.8 months (range, 2-44 months). Four patients reported no benefit from ILS and had their program changed. CONCLUSIONS: Overall, ILS is useful 1) to use 2 contacts that optimally improve 2 specific symptoms but have different therapeutic windows; 2) to avoid side effects related to current spreading to nearby areas; 3) to increase frequency in a small region; or 4) to stimulate a larger target area.


Assuntos
Estimulação Encefálica Profunda/instrumentação , Estimulação Encefálica Profunda/métodos , Neuroestimuladores Implantáveis , Doença de Parkinson/diagnóstico por imagem , Doença de Parkinson/terapia , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento
9.
Stereotact Funct Neurosurg ; 97(2): 101-105, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31280257

RESUMO

BACKGROUND/AIMS: Internal pulse generator (IPG) replacement is considered a relatively minor surgery but exposes the deep brain stimulation system to the risk of infectious and mechanical adverse events. We retrospectively reviewed complications associated with IPG replacement surgery in our center and reviewed the most relevant publications on the issue. METHODS: A retrospective analysis of all the IPG replacements performed in our center from January 2003 until March 2018 was performed. A logistic regression model was used to analyze the risk factors associated with IPG infections at our center. RESULTS: A total of 171 IPG replacements in 93 patients were analyzed. The overall rate of replacement complications was 8.8%, whereas the rate of infection was 5.8%. IPG removal was required in 8 out of 10 infected cases. An increased risk of infection was found in patients with subcutaneous thoracic placement of the IPG (OR 5.3, p = 0.016). The most commonly isolated germ was Staphylococcus coagulase negative (60%). We found a non-significant trend towards increased risk of infection in patients with more than 3 replacements (p = 0.07). CONCLUSIONS: Infection is the most frequent complication related to IPG replacement. Staphylococcus coagulase negative is the most commonly isolated bacteria causing the infection. According to our results, the subcutaneous thoracic placement represents a greater risk of infection compared to subcutaneous abdominal placement.


Assuntos
Estimulação Encefálica Profunda/efeitos adversos , Estimulação Encefálica Profunda/instrumentação , Eletrodos Implantados/efeitos adversos , Neuroestimuladores Implantáveis/efeitos adversos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/etiologia , Adulto , Idoso , Estimulação Encefálica Profunda/métodos , Tremor Essencial/diagnóstico , Tremor Essencial/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/diagnóstico , Doença de Parkinson/cirurgia , Estudos Retrospectivos , Fatores de Risco
10.
Handb Clin Neurol ; 160: 345-355, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31277859

RESUMO

Electrophysiologic mapping remains an integral component of deep brain stimulation (DBS) surgical procedures, particularly in movement disorder cases where functional maps are used to guide DBS lead placement in patients with Parkinson's disease, dystonia, or tremor. Overall, the goal of the surgical procedure is to implant the distal end of a chronic, multicontact depth electrode into a specific brain region for the purpose of delivering therapeutic electrical stimulation. Regions that are currently targeted for patients with movement disorders include the subthalamic nucleus, the ventral intermediate nucleus of the thalamus, and the globus pallidus. Multiple imaging modalities are used initially to derive a stereotactic plan and guide the initial microelectrode trajectory. Changes in neuronal firing rate and pattern, both spontaneous and in response to somatosensory stimulation, are used to establish the location of the tip of the microelectrode(s), while acute stimulation can be used to estimate the proximity of neighboring brain regions. In this chapter, we will provide an overview of the microelectrode recording process as it is commonly applied to refine image-based targeting of lead placement for DBS surgery.


Assuntos
Mapeamento Encefálico/métodos , Estimulação Encefálica Profunda/métodos , Transtornos dos Movimentos/fisiopatologia , Transtornos dos Movimentos/terapia , Mapeamento Encefálico/instrumentação , Estimulação Encefálica Profunda/instrumentação , Globo Pálido/fisiologia , Humanos , Microeletrodos , Transtornos dos Movimentos/diagnóstico , Núcleo Subtalâmico/fisiologia
11.
Dermatol Surg ; 45(10): 1228-1236, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31318829

RESUMO

BACKGROUND: In dermatologic and procedural surgery settings, there are commonly encountered devices in patients. Safe surgical planning requires familiarity with these devices. OBJECTIVE: To review the current implanted devices in patients and recommendations for surgical planning around these devices. METHODS AND MATERIALS: A comprehensive review using PubMed and published device recommendations was performed, searching for those most relevant to dermatologic surgery. RESULTS: Devices such as pacemakers and implantable cardiac defibrillators, deep brain stimulators, cochlear implants, and various nerve stimulators are potential devices that may be encountered in patients and specific recommendations exist for each of these devices. CONCLUSION: Dermatologic surgeons' knowledge of implanted devices in patients is paramout to safe surgical procedures.


Assuntos
Procedimentos Cirúrgicos Dermatológicos/métodos , Planejamento de Assistência ao Paciente , Neoplasias Cutâneas/cirurgia , Implantes Cocleares/efeitos adversos , Estimulação Encefálica Profunda/instrumentação , Desfibriladores Implantáveis/efeitos adversos , Humanos , Neuroestimuladores Implantáveis/efeitos adversos , Marca-Passo Artificial/efeitos adversos , Estimulação do Nervo Vago/instrumentação
12.
Stereotact Funct Neurosurg ; 97(2): 113-119, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31288242

RESUMO

BACKGROUND/AIMS: Nonrechargeable deep brain stimulation implantable pulse generators (IPGs) for movement disorders require surgical replacement every few years due to battery depletion. Rechargeable IPGs reduce frequency of replacement surgeries and inherent risks of complications but require frequent recharging. Here, we evaluate patient experience with rechargeable IPGs and define predictive characteristics for higher satisfaction. METHODS: We contacted all patients implanted with rechargeable IPGs at a single center in a survey-based study. We analyzed patient satisfaction with respect to age, diagnosis, target, charging duration, and body mass index. We tabulated hardware-related adverse events. RESULTS: Dystonia patients had significantly higher satisfaction than Parkinson's disease patients in recharging, display, programmer, and training domains. Common positive responses were "fewer surgeries" and "small size." Common negative responses were "difficulty finding the right position to recharge" and "need to recharge every day." Hardware-related adverse events occurred in 21 of 59 participants. CONCLUSION: Patient experience with rechargeable IPGs was largely positive; however, frustrations with recharging and adverse events were common. Dystonia diagnosis was most predictive of high satisfaction across multiple categories, potentially related to expected long disease duration with need for numerous IPG replacements.


Assuntos
Estimulação Encefálica Profunda/psicologia , Fontes de Energia Elétrica , Eletrodos Implantados/psicologia , Neuroestimuladores Implantáveis/psicologia , Transtornos dos Movimentos/psicologia , Transtornos dos Movimentos/terapia , Adulto , Idoso , Estimulação Encefálica Profunda/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Satisfação do Paciente , Inquéritos e Questionários , Fatores de Tempo
13.
Stereotact Funct Neurosurg ; 97(2): 83-93, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31085935

RESUMO

BACKGROUND: Frameless stereotactic surgery utilizing fiducial-based (FB) registration is an established tool in the armamentarium of deep brain stimulation (DBS) surgeons. Fiducial-less (FL) registration via intraoperative CT, such as the O-arm, has been routinely used in spine surgery, but its accuracy for DBS surgery has not been studied in a clinical setting. OBJECTIVE: We undertook a study to analyze the accuracy of the FL technique in DBS surgery and compare it to the FB method. METHODS: In this prospective cohort study, 97 patients underwent DBS surgery using the NexFrame and the O-arm registration stereotactic system. Patients underwent FB (n = 50) registration from 2015 to 2016 and FL (n = 47) O-arm registration from 2016 to 2017. RESULTS: The radial errors (RE) and vector/euclidean errors of FB and FL registration were not significantly different. There was no difference in additional passes between methods, but there was an increase in the number of RE ≥2.5 mm in the FL method. CONCLUSION: Although there was no statistically significant difference in RE or the need for additional passes, the increased number of errors ≥2.5 mm with the FL method (17 vs. 4% in FB) indicates the need for further study. We concluded that O-arm images of the implants should be utilized to assess and correct for this error.


Assuntos
Estimulação Encefálica Profunda/normas , Marcadores Fiduciais/normas , Técnicas Estereotáxicas/normas , Cirurgia Assistida por Computador/normas , Adulto , Idoso , Estudos de Coortes , Estimulação Encefálica Profunda/instrumentação , Estimulação Encefálica Profunda/métodos , Feminino , Humanos , Imageamento Tridimensional/métodos , Imageamento Tridimensional/normas , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/diagnóstico por imagem , Doenças do Sistema Nervoso/cirurgia , Estudos Prospectivos , Técnicas Estereotáxicas/instrumentação , Cirurgia Assistida por Computador/instrumentação , Cirurgia Assistida por Computador/métodos , Tomografia Computadorizada por Raios X/métodos , Tomografia Computadorizada por Raios X/normas
14.
Neurotherapeutics ; 16(2): 369-380, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-31062294

RESUMO

Implantable neural stimulators represent an advanced treatment adjunct to medication for pharmacoresistant epilepsy and alternative for patients that are not good candidates for resective surgery. Three treatment modalities are currently FDA-approved: vagus nerve stimulation, responsive neurostimulation, and deep brain stimulation. These devices were originally trialed in very similar patient populations with focal epilepsy, but head-to-head comparison trials have not been performed. As such, device selection may be challenging due to large overlaps in clinical indications and efficacy. Here we will review the data reported in the original pivotal clinical trials as well as long-term experience with these technologies. We will highlight differences in their features and mechanisms of action which may help optimize device selection on a case-by-case basis.


Assuntos
Estimulação Encefálica Profunda/instrumentação , Epilepsia/terapia , Neuroestimuladores Implantáveis , Estimulação do Nervo Vago/instrumentação , Humanos
15.
World Neurosurg ; 128: e683-e687, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31059853

RESUMO

BACKGROUND: The decision to replace deep brain stimulation (DBS) generators in end-stage Parkinson disease (PD) is based on the patients' clinical status and the risks of this surgery. The infection rates of initial DBS implantation surgery and generator replacement surgery are well established. But the risks of DBS generator replacement for the severely disabled end-stage PD patient have not been described. METHODS: A retrospective analysis of all DBS procedures (n = 446) for PD spanning 20 years in a single institution was performed. The focus was on generator replacement procedure performed in end-stage PD. Infections related to DBS surgery were evaluated. RESULTS: Perioperative infections (<90 days) after generator replacements occurred in 0.6% of 172 cases and 2.5% of 232 primary lead implantation. Delayed infections (>90 days) occurred in 2.7% of all cases. Generator replacement was performed in 11 end-stage PD patients. None of these patients developed perioperative or delayed infections, and none were readmitted for medical or surgical complications. CONCLUSIONS: DBS generator replacement surgery is low risk, even in patients who have end-stage PD.


Assuntos
Estimulação Encefálica Profunda/instrumentação , Remoção de Dispositivo/métodos , Fontes de Energia Elétrica , Doença de Parkinson/reabilitação , Implantação de Prótese/métodos , Idoso , Feminino , Humanos , Neuroestimuladores Implantáveis , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Índice de Gravidade de Doença , Infecção da Ferida Cirúrgica/epidemiologia
16.
Arq Neuropsiquiatr ; 77(3): 174-178, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30970130

RESUMO

BACKGROUND: Transcranial direct current stimulation (tDCS) has been investigated in movement disorders, making it a therapeutic alternative in clinical settings. However, there is still no consensus on the most appropriate treatment protocols in most cases, and the presence of deep brain stimulation (DBS) electrodes has been regarded as a contraindication to the procedure. We recently studied the effects of cerebellar tDCS on a female patient already undergoing subthalamic nucleus deep brain stimulation (STN-DBS) for generalized dystonia. She also presented with chronic pain and depression. With STN-DBS, there was improvement of dystonia, and botulinum toxin significantly reduced pain. However, depressive symptoms were worse after STN-DBS surgery. METHODS: Neuromodulation with 2 mA anodal cerebellar tDCS was initiated, targeting both hemispheres in each daily 30 minute session: 15 minutes of left cerebellar stimulation followed by 15 minutes of right cerebellar stimulation. The DBS electrodes were in place and functional, but the current was turned off during tDCS. RESULTS: Although our goal was to improve dystonic movements, after 10 tDCS sessions there was also improvement in mood with normalization of Beck Depression Inventory scores. There were no complications in spite of the implanted STN-DBS leads. CONCLUSION: Our results indicate that tDCS is safe in patients with DBS electrodes and may be an effective add-on neuromodulatory tool in the treatment of potential DBS partial efficacy in patients with movement disorders.


Assuntos
Estimulação Encefálica Profunda/instrumentação , Estimulação Encefálica Profunda/métodos , Distúrbios Distônicos/terapia , Eletrodos Implantados , Estimulação Transcraniana por Corrente Contínua/instrumentação , Estimulação Transcraniana por Corrente Contínua/métodos , Dor Crônica/terapia , Transtorno Depressivo/terapia , Feminino , Humanos , Testes de Estado Mental e Demência , Reprodutibilidade dos Testes , Fatores de Tempo , Resultado do Tratamento
17.
World Neurosurg ; 127: e65-e68, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30974267

RESUMO

OBJECTIVE: Generators implanted for deep brain stimulation must be replaced after several years. If a Kinetra generator is replaced by the Activa-PC, an adaptor will be required to attach it to the original extension cables. On the basis of our clinical impression that the battery life of the Active-PC generator was shorter when an adaptor was used, we performed this retrospective study. METHODS: We determined the battery lifetimes of deep brain stimulation generators that had been implanted in our department. The inclusion criterion was the initial implantation of a Kinetra generator that was later replaced by an Activa-PC with adaptor, which itself was subsequently also replaced. These patients were compared with an Activa-PC control group without an adaptor but identical with regard to number of battery exchanges, disease, and target. RESULTS: There were 28 patients in the study group and 14 in the control group. Battery lifetime of the Activa-PC with adaptor (32.4 ± 7.7 months) was significantly shorter than that of the Kinetra (53.5 ± 15.7 months, P = 0.000006). The battery life of Activa-PC without an adaptor (35.3 ± 8.2 months) did not differ significantly from that of the Activa-PC with an adaptor (P = 0.333). CONCLUSIONS: The battery lifetime in a replacement Activa-PC is shorter than that in the original Kinetra generator. Adaptors have no significant effect on battery life. Patients should be informed that the battery in their new generator must be checked more frequently than before.


Assuntos
Estimulação Encefálica Profunda/instrumentação , Idoso , Idoso de 80 Anos ou mais , Fontes de Energia Elétrica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/terapia , Estudos Retrospectivos , Fatores de Tempo
18.
Neuromodulation ; 22(4): 451-455, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30951239

RESUMO

OBJECTIVES: To compare the therapeutic window (TW) of cathodic monopolar, bipolar, anodic monopolar, and a novel "semi-bipolar" stimulation in ten Parkinson's disease patients who underwent deep brain stimulation of the subthalamic nucleus. MATERIALS AND METHODS: Patients were assessed in the "OFF" L-dopa condition. Each upper limb was tested separately for therapeutic threshold, TW and side-effect threshold (SET). Battery consumption index (BCI) also was documented. RESULTS: Compared to cathodic stimulation, therapeutic threshold was significantly higher for anodic, bipolar, and semi-bipolar stimulation (3.8 ± 1.6 vs. 4.9 ± 2.1, 5.0 ± 1.9, and 5.2 ± 1.9 mA, p = 0.0006, 0.0002, and 0.008, respectively). SET was significantly higher for bipolar stimulation (10.9 ± 2.5 mA) vs. cathodic (6.8 ± 2.2 mA, p < 0.0001) and anodic stimulation (9.2 ± 2.6 mA, p = 0.005). The SET of anodic and semi-bipolar stimulation was significantly higher vs. cathodic stimulation (p < 0.0001). TW of cathodic stimulation (2.5 ± 1.5 mA) was significantly narrower vs. bipolar (5.4 ± 2.0 mA, p < 0.0001), semi-bipolar (4.6 ± 2.6 mA, p = 0.001) and anodic stimulation (4.3 ± 2.3 mA, p < 0.0001). Bipolar (p = 0.005) and semi-bipolar (p = 0.0005) stimulation had a significantly wider TW vs. anodic stimulation. BCI of cathodic stimulation (5.9 ± 1.3) was significantly lower compared to bipolar (13.7 ± 6.8, p < 0.0001), semi-bipolar (11.0 ± 4.3, p = 0.0005), and anodic stimulation (8.1 ± 3.0, p < 0.0001). Anodic BCI was significantly lower than bipolar (p = 0.005) and semi-bipolar (p = 0.0002) stimulation while semi-bipolar BCI was lower than bipolar stimulation (p = 0.0005). CONCLUSIONS: While awaiting further studies, our findings suggest that cathodic stimulation should be preferred in light of its reduced battery consumption, possibly followed by semi-bipolar in case of stimulation-induced side-effects.


Assuntos
Estimulação Encefálica Profunda/tendências , Eletrodos Implantados/tendências , Doença de Parkinson/terapia , Idoso , Estimulação Encefálica Profunda/instrumentação , Estimulação Encefálica Profunda/normas , Eletrodos/normas , Eletrodos/tendências , Eletrodos Implantados/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Doença de Parkinson/diagnóstico
19.
World Neurosurg ; 128: e87-e97, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30986582

RESUMO

INTRODUCTION: Implant-related infections carry a high morbidity. Infectious rates for neuromodulation implants range from 1% to 9% for deep brain stimulation (DBS), 0% to 10% for spinal cord stimulation (SCS) systems, and 3% to 15% for intrathecal (IT) pump systems. Meanwhile, studies of care bundles report infection rate reduction to 1.0% for SCS and 0.3% for cardiac implants. Herein, we evaluate the effectiveness of an infection prevention bundle (IPB) in minimizing infections after surgeries for neuromodulation implants. METHODS: An IPB focused on preoperative checklists, screening questionnaires, methicillin-resistant and methicillin-sensitive Staphylococcus aureus decolonization, weight-based antibiotic prophylaxis, strict draping and surgical techniques, and wound care education was implemented in our functional neurosurgery division in April 2015. We retrospectively reviewed all surgeries for implantation or replacement of SCS, DBS, and IT pump system components from March 2013 to October 2017. The patients were divided into pre-IPB and post-IPB groups. All procedures were performed by a single surgeon. Each surgical site was considered a unique surgical case. Infection rates were calculated for pre-IPB and post-IPB groups. RESULTS: A total of 688 patients underwent 1161 unique surgical procedures (222 DBS electrodes, 419 IPG, 203 SCS, 317 IT pumps) during the study period. There were 546 pre-IPB and 615 post-IPB surgical procedures. The pre-IPB infection rates were 0%, 1.3%, and 8.7% for SCS, DBS, and IT pumps, respectively. The post-IPB infection rates were 0%, 0.3%, and 1.8% for SCS, DBS, and IT pumps, respectively. CONCLUSIONS: Implementation of a standardized IPB approach reduced the number of infections for all neuromodulation implants studied. This approach can be adopted within any specialty to potentially decrease the incidence of implant-related infections.


Assuntos
Procedimentos Neurocirúrgicos/métodos , Pacotes de Assistência ao Paciente , Implantação de Prótese/métodos , Infecções Relacionadas à Prótese/prevenção & controle , Infecção da Ferida Cirúrgica/prevenção & controle , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Portador Sadio/diagnóstico por imagem , Estimulação Encefálica Profunda/instrumentação , Feminino , Humanos , Bombas de Infusão Implantáveis , Infusão Espinal , Masculino , Pessoa de Meia-Idade , Assistência Perioperatória , Estudos Retrospectivos , Estimulação da Medula Espinal/instrumentação , Infecções Estafilocócicas/tratamento farmacológico , Campos Cirúrgicos
20.
Neuromodulation ; 22(4): 441-450, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31012530

RESUMO

OBJECTIVES: Deep brain stimulation (DBS) and stereo-electroencephalography (SEEG) electrode implantation are the most important and frequent manipulations in nonhuman primates (NHP) neuromodulation research. However, traditional methods tend to be arduous and inaccurate. MATERIALS AND METHODS: Twelve adult male rhesus monkeys were selected for the study, with six subthalamic nucleus (STN) DBS, six anterior nucleus of the thalamus (ANT) DBS and six hippocampus-SEEG (Hippo-SEEG) electrodes implantation. Mean Euclidean errors of entrance and the target were calculated by postoperative image fusion, and the correlation between entrance and target error, as well as the differences among the various manipulations, were analyzed. The accuracy of target was further confirmed by gross anatomy examination. Moreover, the time consumption was recorded. RESULTS: The mean (±SD) Euclidean errors of the target point and entry point of the three manipulations were STN-DBS: 1.05 ± 0.54 mm and 0.52 ± 0.17 mm; ANT-DBS: 1.12 ± 0.74 mm and 0.58 ± 0.24 mm; and Hippo-SEEG: 2.68 ± 1.03 mm and 1.47 ± 0.63 mm. Significant differences were observed in both target and entry point errors between the DBS and Hippo-SEEG groups, with superior accuracy in the DBS group. The entrance errors had a significantly positive correlation with the target errors in the STN-DBS and Hippo-SEEG groups. Moreover, the time consumption in robotic surgery was much shorter than that in the traditional method, without any severe complications. CONCLUSION: The application of robot-assisted lead implantation in NHP neuromodulation research is feasible, accurate, safe, and efficient, and can prospectively be beneficial to neurological studies.


Assuntos
Estimulação Encefálica Profunda/métodos , Eletrodos Implantados , Eletroencefalografia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Animais , Estimulação Encefálica Profunda/instrumentação , Estimulação Encefálica Profunda/normas , Eletrodos Implantados/normas , Eletroencefalografia/instrumentação , Eletroencefalografia/normas , Estudos de Viabilidade , Macaca mulatta , Masculino , Estudos Prospectivos , Procedimentos Cirúrgicos Robóticos/instrumentação , Procedimentos Cirúrgicos Robóticos/normas
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