1
|
Ng PR, Bush A, Vissani M, McIntyre CC, Richardson RM. Biophysical Principles and Computational Modeling of Deep Brain Stimulation. Neuromodulation 2024; 27:422-439. [PMID: 37204360 DOI: 10.1016/j.neurom.2023.04.471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 04/02/2023] [Accepted: 04/24/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) has revolutionized the treatment of neurological disorders, yet the mechanisms of DBS are still under investigation. Computational models are important in silico tools for elucidating these underlying principles and potentially for personalizing DBS therapy to individual patients. The basic principles underlying neurostimulation computational models, however, are not well known in the clinical neuromodulation community. OBJECTIVE In this study, we present a tutorial on the derivation of computational models of DBS and outline the biophysical contributions of electrodes, stimulation parameters, and tissue substrates to the effects of DBS. RESULTS Given that many aspects of DBS are difficult to characterize experimentally, computational models have played an important role in understanding how material, size, shape, and contact segmentation influence device biocompatibility, energy efficiency, the spatial spread of the electric field, and the specificity of neural activation. Neural activation is dictated by stimulation parameters including frequency, current vs voltage control, amplitude, pulse width, polarity configurations, and waveform. These parameters also affect the potential for tissue damage, energy efficiency, the spatial spread of the electric field, and the specificity of neural activation. Activation of the neural substrate also is influenced by the encapsulation layer surrounding the electrode, the conductivity of the surrounding tissue, and the size and orientation of white matter fibers. These properties modulate the effects of the electric field and determine the ultimate therapeutic response. CONCLUSION This article describes biophysical principles that are useful for understanding the mechanisms of neurostimulation.
Collapse
Affiliation(s)
| | - Alan Bush
- Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Matteo Vissani
- Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Cameron C McIntyre
- Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Robert Mark Richardson
- Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
2
|
Martinez-Nunez AE, Sarmento FP, Chandra V, Hess CW, Hilliard JD, Okun MS, Wong JK. Management of essential tremor deep brain stimulation-induced side effects. Front Hum Neurosci 2024; 18:1353150. [PMID: 38454907 PMCID: PMC10918853 DOI: 10.3389/fnhum.2024.1353150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/01/2024] [Indexed: 03/09/2024] Open
Abstract
Deep brain stimulation (DBS) is an effective surgical therapy for carefully selected patients with medication refractory essential tremor (ET). The most popular anatomical targets for ET DBS are the ventral intermedius nucleus (VIM) of the thalamus, the caudal zona incerta (cZI) and the posterior subthalamic area (PSA). Despite extensive knowledge in DBS programming for tremor suppression, it is not uncommon to experience stimulation induced side effects related to DBS therapy. Dysarthria, dysphagia, ataxia, and gait impairment are common stimulation induced side effects from modulation of brain tissue that surround the target of interest. In this review, we explore current evidence about the etiology of stimulation induced side effects in ET DBS and provide several evidence-based strategies to troubleshoot, reprogram and retain tremor suppression.
Collapse
Affiliation(s)
- Alfonso Enrique Martinez-Nunez
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Filipe P. Sarmento
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
| | - Vyshak Chandra
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Christopher William Hess
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Justin David Hilliard
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Michael S. Okun
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Joshua K. Wong
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
| |
Collapse
|
3
|
Smeets S, Boogers A, Van Bogaert T, Peeters J, McLaughlin M, Nuttin B, Theys T, Vandenberghe W, De Vloo P. Deep brain stimulation with short versus conventional pulse width in Parkinson's disease and essential tremor: A systematic review and meta-analysis. Brain Stimul 2024; 17:71-82. [PMID: 38160999 DOI: 10.1016/j.brs.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 12/04/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND To maximize clinical benefit and minimize stimulation-induced side effects, optimising deep brain stimulation (DBS) parameters is paramount. Recent literature suggests a potential benefit of short pulse width DBS (spDBS; ≤40 μs) over conventional pulse width DBS (cDBS; ≥60 μs) in movement disorders. OBJECTIVE To compare therapeutic window (TW), therapeutic and side effects and energy consumption of spDBS and cDBS in movement disorders. METHODS We systematically searched Medline, Embase, Cochrane Library and Web of Science. Appropriate paired analyses were performed. RESULTS Nine Parkinson's disease (PD) (143 patients), 4 essential tremor (ET) (26 patients) and no dystonia studies were included in the meta-analysis. TW defined as therapeutic amplitude range was larger with spDBS vs. cDBS in PD (standardized mean difference (SMD) = -1.04, p < 0.001) and ET (SMD = -0.71, p < 0.001), but the TW in terms of charge per pulse (CPP) did not differ. In PD, no differences were found in therapeutic and side effects (MDS-UPDRS-III, speech and gait, dyskinesia, non-motor symptoms and quality of life). In ET, Fahn-Tolosa-Marin Tremor Rating Scale was lower with spDBS vs. cDBS (SMD = 0.36, p < 0.001). A qualitative analysis suggested fewer stimulation-induced side effects with spDBS. CPP was lower with spDBS vs. cDBS in PD (SMD = 0.79, p < 0.001) and ET (MD = 46.46 nC, p < 0.001), but real-world data on battery longevity are lacking. CONCLUSION Although spDBS enlarges the TW as a wider amplitude range in both PD and ET, it does not alter TW defined by CPP. The therapeutic efficacy of spDBS is not different from cDBS in PD, but spDBS apparently induces more tremor reduction in ET.
Collapse
Affiliation(s)
- Sara Smeets
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Alexandra Boogers
- Department of Neurology, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada
| | - Tine Van Bogaert
- Experimental Oto-rhino-laryngology, Department of Neurosciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jana Peeters
- Experimental Oto-rhino-laryngology, Department of Neurosciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Myles McLaughlin
- Experimental Oto-rhino-laryngology, Department of Neurosciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Bart Nuttin
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Laboratory for Experimental Functional Neurosurgery, Research Group of Experimental Neurosurgery and Neuroanatomy, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Tom Theys
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Laboratory for Experimental Functional Neurosurgery, Research Group of Experimental Neurosurgery and Neuroanatomy, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Wim Vandenberghe
- Department of Neurology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Laboratory for Parkinson Research, Research Group Experimental Neurology, Department of Neurosciences, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Philippe De Vloo
- Department of Neurosurgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium; Laboratory for Experimental Functional Neurosurgery, Research Group of Experimental Neurosurgery and Neuroanatomy, KU Leuven, Herestraat 49, 3000, Leuven, Belgium
| |
Collapse
|
4
|
Hidding U, Lezius S, Schaper M, Buhmann C, Gerloff C, Pötter-Nerger M, Hamel W, Moll CKE, Choe CU. Combined Short-Pulse and Directional Deep Brain Stimulation of the Thalamic Ventral Intermediate Area for Essential Tremor. Neuromodulation 2023; 26:1680-1688. [PMID: 36369082 DOI: 10.1016/j.neurom.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 08/30/2022] [Accepted: 09/20/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Novel deep brain stimulation (DBS) systems allow directional and short-pulse stimulation to potentially improve symptoms and reduce side effects. The aim of this study was to investigate the effect of short-pulse and directional stimulation, in addition to a combination of both, in the ventral intermediate thalamus (VIM)/posterior subthalamic area (PSA) on tremor and stimulation-induced side effects in patients with essential tremor. MATERIALS AND METHODS We recruited 11 patients with essential tremor and VIM/PSA-DBS. Tremor severity (Fahn-Tolosa-Marin), ataxia (International Cooperative Ataxia Rating Scale), and paresthesia (visual analog scale) were assessed with conventional omnidirectional and directional stimulation with pulse width of 60 μs and 30 μs. RESULTS All stimulation conditions reduced tremor. The best directional stimulation with 60 μs reduced more tremor than did most other stimulation settings. The best directional stimulation, regardless of pulse width, effectively reduced stimulation-induced ataxia compared with the conventional stimulation (ring 60 μs) or worst directional stimulation with 60 μs. All new stimulation modes reduced occurrence of paresthesia, but only the best directional stimulation with 30 μs attenuated paresthesia compared with the conventional stimulation (ring 60 μs) or worst directional stimulation with 60 μs. The best directional stimulation with 30 μs reduced tremor, ataxia, and paresthesia compared with conventional stimulation in most patients. Correlation analyses indicated that more anterior stimulation sites are associated with stronger ataxia reduction with directional 30 μs than with conventional 60 μs stimulation. CONCLUSION Directional and short-pulse stimulation, and a combination of both, revealed beneficial effects on stimulation-induced adverse effects.
Collapse
Affiliation(s)
- Ute Hidding
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Susanne Lezius
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miriam Schaper
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K E Moll
- Department of Neurophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chi-Un Choe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
5
|
Boogers A, Peeters J, Van Bogaert T, De Vloo P, Vandenberghe W, Nuttin B, Mc Laughlin M. Interphase Gaps in Symmetric Biphasic Pulses Reduce the Therapeutic Window in Ventral Intermediate Nucleus of the Thalamus-Deep Brain Stimulation for Essential Tremor. Neuromodulation 2023; 26:1699-1704. [PMID: 36404213 DOI: 10.1016/j.neurom.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/23/2022] [Accepted: 09/13/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Symmetric biphasic pulses enlarge the therapeutic window in thalamic deep brain stimulation in patients with essential tremor. Adding an interphase gap to these symmetric biphasic pulses may further affect the therapeutic window. MATERIALS AND METHODS Nine patients (16 hemispheres) were included in this study. Biphasic pulses (anodic phase first) with interphase gaps of 0, 10, 20, 50, and 100 μs were tested, in random order. The outcome parameters were the therapeutic threshold (TT) and side-effect threshold (SET), and thus also the therapeutic window (TW). RESULTS Increasing interphase gaps lowered both SET and TT (linear mixed-effects model; p < 0.001 and p < 0.001). Because SET decreased predominantly, increasing interphase gaps resulted in smaller TWs (linear mixed-effects model; p < 0.001). DISCUSSION AND CONCLUSIONS Introducing an interphase gap in a symmetric biphasic pulse may lead to less selectivity in fiber or neuronal activation. Our findings show that, in the context of anode-first biphasic pulses, the use of zero-interphase gaps results in the largest TW. CLINICAL TRIAL REGISTRATION The Clinicaltrials.gov registration number for the study is NCT05177900.
Collapse
Affiliation(s)
- Alexandra Boogers
- Exp ORL, Department of Neurosciences, the Leuven Brain Institute, KU Leuven, Leuven, Belgium; Department of Neurology, UZ Leuven, Leuven, Belgium.
| | - Jana Peeters
- Exp ORL, Department of Neurosciences, the Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Tine Van Bogaert
- Exp ORL, Department of Neurosciences, the Leuven Brain Institute, KU Leuven, Leuven, Belgium
| | - Philippe De Vloo
- Department of Neurosurgery, UZ Leuven, Leuven, Belgium; Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Wim Vandenberghe
- Department of Neurology, UZ Leuven, Leuven, Belgium; Laboratory for Parkinson Research, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Bart Nuttin
- Department of Neurosurgery, UZ Leuven, Leuven, Belgium; Experimental Neurosurgery and Neuroanatomy, Department of Neurosciences, KU Leuven, Leuven, Belgium
| | - Myles Mc Laughlin
- Exp ORL, Department of Neurosciences, the Leuven Brain Institute, KU Leuven, Leuven, Belgium.
| |
Collapse
|
6
|
Gilbert Z, Mason X, Sebastian R, Tang AM, Martin Del Campo-Vera R, Chen KH, Leonor A, Shao A, Tabarsi E, Chung R, Sundaram S, Kammen A, Cavaleri J, Gogia AS, Heck C, Nune G, Liu CY, Kellis SS, Lee B. A review of neurophysiological effects and efficiency of waveform parameters in deep brain stimulation. Clin Neurophysiol 2023; 152:93-111. [PMID: 37208270 DOI: 10.1016/j.clinph.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 02/09/2023] [Accepted: 04/15/2023] [Indexed: 05/21/2023]
Abstract
Neurostimulation has diverse clinical applications and potential as a treatment for medically refractory movement disorders, epilepsy, and other neurological disorders. However, the parameters used to program electrodes-polarity, pulse width, amplitude, and frequency-and how they are adjusted have remained largely untouched since the 1970 s. This review summarizes the state-of-the-art in Deep Brain Stimulation (DBS) and highlights the need for further research to uncover the physiological mechanisms of neurostimulation. We focus on studies that reveal the potential for clinicians to use waveform parameters to selectively stimulate neural tissue for therapeutic benefit, while avoiding activating tissue associated with adverse effects. DBS uses cathodic monophasic rectangular pulses with passive recharging in clinical practice to treat neurological conditions such as Parkinson's Disease. However, research has shown that stimulation efficiency can be improved, and side effects reduced, through modulating parameters and adding novel waveform properties. These developments can prolong implantable pulse generator lifespan, reducing costs and surgery-associated risks. Waveform parameters can stimulate neurons based on axon orientation and intrinsic structural properties, providing clinicians with more precise targeting of neural pathways. These findings could expand the spectrum of diseases treatable with neuromodulation and improve patient outcomes.
Collapse
Affiliation(s)
- Zachary Gilbert
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States.
| | - Xenos Mason
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Rinu Sebastian
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Austin M Tang
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Roberto Martin Del Campo-Vera
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Kuang-Hsuan Chen
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Andrea Leonor
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Arthur Shao
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Emiliano Tabarsi
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Ryan Chung
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Shivani Sundaram
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Alexandra Kammen
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Jonathan Cavaleri
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Angad S Gogia
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States
| | - Christi Heck
- Department of Neurology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - George Nune
- Department of Neurology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Charles Y Liu
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; Department of Neurology, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Spencer S Kellis
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| | - Brian Lee
- Department of Neurological Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, United States; USC Neurorestoration Center, Keck School of Medicine of USC, Los Angeles, CA, United States
| |
Collapse
|
7
|
Rueb J, Goldman HB, Vasavada S, Moore C, Rackley R, Gill BC. Effect of pulse width variations on sacral neuromodulation for overactive bladder symptoms: A prospective randomized crossover feasibility study. Neurourol Urodyn 2023; 42:770-777. [PMID: 36840886 DOI: 10.1002/nau.25161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 01/24/2023] [Accepted: 02/11/2023] [Indexed: 02/26/2023]
Abstract
INTRODUCTION/BACKGROUND The pulse width (PW) parameter in sacral neuromodulation (SNM) is understudied, with no evidence-based guidance available on optimal PW for urinary indications. The aim of this prospective, randomized, single-blinded, 3 × 3 cross over design study was to estimate the effect of two PW settings (60 µs, 420 µs) compared to the industry standard (210 µs) on SNM efficacy, quality of life, and device parameters in patients who were stable and satisfied with their SNM treatment. METHODS/MATERIALS Eligible patients were previously implanted and had urge incontinence or urgency-frequency with satisfaction on SNM at time of enrollment. Patients completed a 3-day voiding diary, validated questionnaires, and device interrogations with sensory threshold assessment at baseline and after a 4-week period on each of the three PW settings, to which they were randomized. Eighteen participants completed the study, as called for by power analysis. RESULTS Eighteen patients were enrolled in the study. Mean age was 68 years and implant duration at the time of participation was 4.4 years. While PW variations did not produce significant differences in overall objective outcomes, device parameters, including sensory threshold amplitude and battery life differed significantly. Shortened PW necessitated higher amplitude while conserving battery life. Stimulus sensation location, quality, and intensity did not differ between PW. Standard PW was chosen by 11 patients after the study, 5 chose extended, and 2 chose shortened. Those who chose alternative PW achieved significant reductions in urinary frequency from enrollment -2.23 voids/day (p = 0.015). Upon sub-analysis, patients reporting "much better" or "very much better" on extended PW achieved significant reductions in urinary frequency and nocturia at 5.6 and 0.4, compared to 8.5 and 2.16 at baseline (p = 0.005, p = <0.001). Whereas those reporting "much better" or "very much better" on shortened PW achieved significant reductions in urinary frequency at 5.15 compared to 7.35 (p = 0.026). There were no adverse events or complications. CONCLUSIONS Overall SNM effectiveness was unchanged with alternative PW; however, 39% of patients preferred alternative to standard PW and achieved significant improvements in urinary symptoms with such. Shorter PW can also provide savings in estimated battery life without sacrificing therapeutic efficacy.
Collapse
Affiliation(s)
- Jessica Rueb
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Howard B Goldman
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sandip Vasavada
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Courtenay Moore
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Raymond Rackley
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bradley C Gill
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
8
|
Sajonz BE, Frommer ML, Walz ID, Reisert M, Maurer C, Rijntjes M, Piroth T, Schröter N, Jenkner C, Reinacher PC, Brumberg J, Meyer PT, Blazhenets G, Coenen VA. Unravelling delayed therapy escape after thalamic deep brain stimulation for essential tremor? - Additional clinical and neuroimaging evidence. Neuroimage Clin 2022; 36:103150. [PMID: 35988341 PMCID: PMC9402391 DOI: 10.1016/j.nicl.2022.103150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/15/2022] [Accepted: 08/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Delayed therapy escape after thalamic deep brain stimulation (DBS) for essential tremor is a serious yet frequent condition. It is often difficult to detect this process at onset due to its gradual evolution. OBJECTIVE Here we aim to identify clinical and neuroimaging hallmarks of delayed therapy escape. METHODS We retrospectively studied operationalized and quantitative analyses of tremor and gait, as well as [18F]fluorodeoxyglucose (FDG) PET of 12 patients affected by therapy escape. All examinations were carried out with activated DBS (ON) and 72 h after deactivation (OFF72h); gait and tremor were also analyzed directly after deactivation (OFF0h). Changes of normalized glucose metabolism between stimulation conditions were assessed using within-subject analysis of variance and statistical parametric mapping. Additionally, a comparison to the [18F]FDG PET of an age-matched control group was performed. Exploratory correlation analyses were conducted with operationalized and parametric clinical data. RESULTS Of the immediately accessible parametric tremor data (i.e. ON or OFF0h) only the rebound (i.e. OFF0h) frequency of postural tremor showed possible correlations with signs of ataxia at ON. Regional glucose metabolism was significantly increased bilaterally in the thalamus and dentate nucleus in ON compared to OFF72h. No differences in regional glucose metabolism were found in patients in ON and OFF72h compared with the healthy controls. CONCLUSIONS Rebound frequency of postural tremor seems to be a good diagnostic marker for delayed therapy escape. Regional glucose metabolism suggests that this phenomenon may be associated with increased metabolic activity in the thalamus and dentate nucleus possibly due to antidromic stimulation effects. We see reasons to interpret the delayed therapy escape phenomenon as being related to long term and chronic DBS.
Collapse
Affiliation(s)
- Bastian E.A. Sajonz
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Corresponding author at: Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Breisacher Strasse 64 – 79106 Freiburg, i.Br., Germany.
| | - Marvin L. Frommer
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Isabelle D. Walz
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Department of Sport and Sport Science, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marco Reisert
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christoph Maurer
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Michel Rijntjes
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Tobias Piroth
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Nils Schröter
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Carolin Jenkner
- Clinical Trials Unit, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Peter C. Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Fraunhofer Institute for Laser Technology (ILT), Aachen, Germany
| | - Joachim Brumberg
- Department of Nuclear Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Philipp T. Meyer
- Department of Nuclear Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ganna Blazhenets
- Department of Nuclear Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Volker A. Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Center for Deep Brain Stimulation, University of Freiburg, Germany,Center for Basics in Neuromodulation (Neuromod Basics), Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| |
Collapse
|
9
|
Overnight unilateral withdrawal of thalamic deep brain stimulation to identify reversibility of gait disturbances. Exp Neurol 2022; 355:114135. [DOI: 10.1016/j.expneurol.2022.114135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/11/2022] [Accepted: 05/30/2022] [Indexed: 11/20/2022]
|
10
|
Hidding U, Schaper M, Gulberti A, Buhmann C, Gerloff C, Moll CKE, Hamel W, Choe CU, Pötter-Nerger M. Short pulse and directional thalamic deep brain stimulation have differential effects in parkinsonian and essential tremor. Sci Rep 2022; 12:7251. [PMID: 35508680 PMCID: PMC9068767 DOI: 10.1038/s41598-022-11291-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 04/05/2022] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to assess the effects of novel stimulation algorithms of deep brain stimulation (short pulse and directional stimulation) in the ventrointermediate thalamus and posterior subthalamic area (VIM/PSA-DBS) on tremor in Parkinson’s disease (PD) and to compare the effects with those in essential tremor (ET). We recruited six PD patients (70.8 ± 10.4 years) and seven ET patients (64.4 ± 9.9 years) with implanted VIM/PSA-DBS in a stable treatment condition (> 3 months postoperatively). Tremor severity and ataxia were assessed in four different stimulation conditions in a randomized order: DBS switched off (STIM OFF), omnidirectional stimulation with 60 µs (oDBS60), omnidirectional stimulation with 30 µs (oDBS30), directional stimulation at the best segment with 60 µs (dDBS60). In both patient groups, all three DBS stimulation modes reduced the total tremor score compared to STIM OFF, whereas stimulation-induced ataxia was reduced by oDBS30 and partially by dDBS60 compared to oDBS60. Tremor reduction was more pronounced in PD than in ET due to a limited DBS effect on intention and action-specific drawing tremor in ET. In PD and ET tremor, short pulse or directional VIM/PSA-DBS is an effective and well tolerated therapeutic option. Trial registration: The study was registered in the DRKS (ID DRKS00025329, 18.05.2021, German Clinical Trials Register, DRKS—Deutsches Register Klinischer Studien).
Collapse
Affiliation(s)
- Ute Hidding
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Miriam Schaper
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Alessandro Gulberti
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.,Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christian K E Moll
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, 20246, Hamburg, Germany
| | - Chi-Un Choe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| |
Collapse
|
11
|
Frey J, Cagle J, Johnson KA, Wong JK, Hilliard JD, Butson CR, Okun MS, de Hemptinne C. Past, Present, and Future of Deep Brain Stimulation: Hardware, Software, Imaging, Physiology and Novel Approaches. Front Neurol 2022; 13:825178. [PMID: 35356461 PMCID: PMC8959612 DOI: 10.3389/fneur.2022.825178] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
Deep brain stimulation (DBS) has advanced treatment options for a variety of neurologic and neuropsychiatric conditions. As the technology for DBS continues to progress, treatment efficacy will continue to improve and disease indications will expand. Hardware advances such as longer-lasting batteries will reduce the frequency of battery replacement and segmented leads will facilitate improvements in the effectiveness of stimulation and have the potential to minimize stimulation side effects. Targeting advances such as specialized imaging sequences and “connectomics” will facilitate improved accuracy for lead positioning and trajectory planning. Software advances such as closed-loop stimulation and remote programming will enable DBS to be a more personalized and accessible technology. The future of DBS continues to be promising and holds the potential to further improve quality of life. In this review we will address the past, present and future of DBS.
Collapse
Affiliation(s)
- Jessica Frey
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Jackson Cagle
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Kara A. Johnson
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Joshua K. Wong
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Justin D. Hilliard
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Christopher R. Butson
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Michael S. Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
| | - Coralie de Hemptinne
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
- *Correspondence: Coralie de Hemptinne
| |
Collapse
|
12
|
Boogers A, Peeters J, Van Bogaert T, Asamoah B, De Vloo P, Vandenberghe W, Nuttin B, Laughlin MM. Anodic and symmetric biphasic pulses enlarge the therapeutic window in deep brain stimulation for essential tremor. Brain Stimul 2022; 15:286-290. [DOI: 10.1016/j.brs.2022.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 11/16/2021] [Accepted: 01/19/2022] [Indexed: 11/30/2022] Open
|
13
|
Zitman FMP, Janssen A, van der Gaag NA, Hoffmann CFE, Zutt R, Contarino MF. The actual use of directional steering and shorter pulse width in selected patients undergoing deep brain stimulation. Parkinsonism Relat Disord 2021; 93:58-61. [PMID: 34800852 DOI: 10.1016/j.parkreldis.2021.11.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Directional deep brain stimulation (DBS) and pulse with <60μs increase side-effects threshold, enlarging the therapeutic window. However, new systems allowing these advanced features are more expensive and often available only for a limited number of patients in some centers. It is unknown how many and which DBS patients actually need the advanced features because of an insufficient improvement with standard parameters. METHODS We included in the analysis all patients with Parkinson's disease, dystonia and tremor who were selected to receive implantation of advanced DBS systems based on specific preoperative or intraoperative clinical features. RESULTS After a median follow-up of 15 months, 54.9% of the 51 patients implanted with directional leads were using the advanced features in one or both leads (n = 42 leads, 42%), meaning these leads were programmed either with directional stimulation (n = 9, 9%), a shorter pw (n = 20, 20%) or both (n = 13, 13%). This included 92% of patients implanted in the Vim, 44% of those implanted in the STN, and 40% of those implanted in the GPi. CONCLUSIONS DBS systems with advanced features may be particularly indicated for selected patients based on some clinical characteristics and the chosen target. This data may help clinicians allocate resources in a more informed way.
Collapse
Affiliation(s)
- Femke M P Zitman
- Department of Neurology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Alexander Janssen
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - Niels A van der Gaag
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands; Department of Neurosurgery, Leiden University Medical Center, Leiden, the Netherlands
| | - Carel F E Hoffmann
- Department of Neurosurgery, Haga Teaching Hospital, The Hague, the Netherlands
| | - Rodi Zutt
- Department of Neurology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Maria Fiorella Contarino
- Department of Neurology, Haga Teaching Hospital, The Hague, the Netherlands; Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands.
| |
Collapse
|
14
|
Bremm RP, Berthold C, Krüger R, Koch KP, Gonçalves J, Hertel F. Therapeutic maps for a sensor-based evaluation of deep brain stimulation programming. BIOMED ENG-BIOMED TE 2021; 66:603-611. [PMID: 34727584 DOI: 10.1515/bmt-2020-0210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 10/01/2021] [Indexed: 11/15/2022]
Abstract
Programming in deep brain stimulation (DBS) is a labour-intensive process for treating advanced motor symptoms. Specifically for patients with medication-refractory tremor in multiple sclerosis (MS). Wearable sensors are able to detect some manifestations of pathological signs, such as intention tremor in MS. However, methods are needed to visualise the response of tremor to DBS parameter changes in a clinical setting while patients perform the motor task finger-to-nose. To this end, we attended DBS programming sessions of a MS patient and intention tremor was effectively quantified by acceleration amplitude and frequency. A new method is introduced which results in the generation of therapeutic maps for a systematic review of the programming procedure in DBS. The maps visualise the combination of tremor acceleration power, clinical rating scores, total electrical energy delivered to the brain and possible side effects. Therapeutic maps have not yet been employed and could lead to a certain degree of standardisation for more objective decisions about DBS settings. The maps provide a base for future research on visualisation tools to assist physicians who frequently encounter patients for DBS therapy.
Collapse
Affiliation(s)
- Rene Peter Bremm
- National Department of Neurosurgery, Centre Hospitalier de Luxembourg, Luxembourg (City), Luxembourg
- Interventional Neuroscience, Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Christophe Berthold
- National Department of Neurosurgery, Centre Hospitalier de Luxembourg, Luxembourg (City), Luxembourg
| | - Rejko Krüger
- Translational Neuroscience, Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Klaus Peter Koch
- Department of Electrical Engineering, Trier University of Applied Sciences, Trier, Germany
| | - Jorge Gonçalves
- Systems Control, Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| | - Frank Hertel
- National Department of Neurosurgery, Centre Hospitalier de Luxembourg, Luxembourg (City), Luxembourg
- Interventional Neuroscience, Luxembourg Centre for Systems Biomedicine, University of Luxembourg, Esch-sur-Alzette, Luxembourg
| |
Collapse
|
15
|
Seger A, Gulberti A, Vettorazzi E, Braa H, Buhmann C, Gerloff C, Hamel W, Moll CKE, Pötter-Nerger M. Short Pulse and Conventional Deep Brain Stimulation Equally Improve the Parkinsonian Gait Disorder. JOURNAL OF PARKINSONS DISEASE 2021; 11:1455-1464. [PMID: 34057096 DOI: 10.3233/jpd-202492] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Gait disturbances and balance remain challenging issues in Parkinsonian patients (PD) with deep brain stimulation (DBS). Short pulse deep brain stimulation (spDBS) increases the therapeutic window in PD patients, yet the effect on gait and postural symptoms remains unknown. OBJECTIVE We assessed the efficacy of spDBS compared to conventional DBS (cDBS) within the subthalamic nucleus (STN) on Parkinsonian gait. METHODS The study was a single-centre, randomized, double-blind, clinical short-term trial. 20 PD patients were studied postoperatively in three different conditions (DBS stimulation switched off (off DBS), spDBS with 40μs pulse width, cDBS with 60μs pulse width) on regular medication. The primary endpoint was the relative difference of gait velocity at self-paced speed during quantitative gait analysis between stimulation conditions. Secondary endpoints were changes of further measures of quantitative gait analysis, Ziegler course, Berg balance scale, FOG questionnaire, MDS-UPDRS, PDQ-39, and HADS. Mixed-model analysis and post-hoc t-tests were performed. RESULTS Both spDBS and cDBS improved gait velocity at self-paced speed compared to off DBS, however, there was no significant difference between both stimulation modes. Still, 40% of the patients preferred spDBS over cDBS subjectively. Both stimulation modes were equally effective in improving secondary endpoints of gait, balance, motor and non-motor performances. CONCLUSION The use of spDBS and cDBS is equally effective in improving gait and balance in PD and might be beneficial in specified cohorts of PD patients.
Collapse
Affiliation(s)
- Aline Seger
- Department of Neurology, Hamburg, University Medical Center Hamburg-Eppendorf, Germany
| | - Alessandro Gulberti
- Department of Neurology, Hamburg, University Medical Center Hamburg-Eppendorf, Germany.,Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eik Vettorazzi
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hanna Braa
- Department of Neurology, Hamburg, University Medical Center Hamburg-Eppendorf, Germany
| | - Carsten Buhmann
- Department of Neurology, Hamburg, University Medical Center Hamburg-Eppendorf, Germany
| | - Christian Gerloff
- Department of Neurology, Hamburg, University Medical Center Hamburg-Eppendorf, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K E Moll
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Pötter-Nerger
- Department of Neurology, Hamburg, University Medical Center Hamburg-Eppendorf, Germany
| |
Collapse
|
16
|
Rueb J, Fascelli M, Goldman HB, Vasavada S, Rackley R, Moore C, Gill B. The role of pulse width manipulation compared to program changes alone for unsatisfactory sacral neuromodulation therapy: A retrospective matched-cohort analysis. Neurourol Urodyn 2020; 40:522-528. [PMID: 33305838 DOI: 10.1002/nau.24593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/27/2020] [Accepted: 11/20/2020] [Indexed: 01/20/2023]
Abstract
AIM Pulse width (PW) influences neuromodulation by its impact on nerve fiber recruitment. A paucity of data regarding the manipulation of PW in sacral neuromodulation (SNM) exists. This study describes the clinical features and outcomes of PW manipulation for unsatisfactory SNM therapy. METHODS A retrospective, single-institution review was performed of reprogrammed SNM patients between 2010 and 2019. Two cohorts were created: those with PW changes ± program changes and age-matched controls with program changes alone. Patients lacking follow-up and non-InterStim II models were excluded. RESULTS Out of 710 SNM interrogations, 147 (20.7%) had PW changes and 80 met inclusion criteria. Most PW changes were shortened (61/80, 76.3%). Clinical features did not differ between cohorts except by indication for reprogramming. The most common indication for PW change was painful stimulation (34/80, 43%), whereas in controls it was suboptimal efficacy (76/80, 95%). Clinical success was stratified by indication. There was a higher improvement in efficacy in the PW cohort (61%, 17/28 vs. 36%, 27/76, p = .02). PW manipulation successfully relieved painful stimulation in 50% (17/34 vs. 0/3, p = .23), which was more likely with a shortened compared to extended PW (14/15, 93.3% vs. 0/6, 0%, p < .01). PW resulted in improvement in localization of the stimulus in 94% (17/18 vs. 0/1, p = .10). The subsequent lead revision or explant was significantly higher in the PW cohort (43% vs. 25%, p = .03). CONCLUSION PW manipulation may aid the salvage of unsatisfactory SNM therapy. These findings represent an initial assessment of the role of PW in SNM, particularly regarding the efficacy and painful stimuli. The further prospective investigation is warranted.
Collapse
Affiliation(s)
- Jessica Rueb
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michele Fascelli
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Howard B Goldman
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sandip Vasavada
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Raymond Rackley
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Courtenay Moore
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bradley Gill
- Department of Urology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Lerner College of Medicine, Education Institute, Cleveland Clinic, Cleveland, Ohio, USA
| |
Collapse
|
17
|
Wirth T, Dayal V, de Roquemaurel A, Ferreira F, Vijiaratnam N, Akram H, Zrinzo L, Foltynie T, Limousin P. Endurance of Short Pulse Width Thalamic Stimulation Efficacy in Intention Tremor. Stereotact Funct Neurosurg 2020; 99:281-286. [PMID: 33227807 DOI: 10.1159/000511716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 09/18/2020] [Indexed: 11/19/2022]
Abstract
The benefit of short pulse width stimulation in patients suffering from essential tremor (ET) refractory to thalamic deep brain stimulation remains controversial. Here, we add to the minimal body of evidence available by reporting the effect of this type of stimulation in 3 patients with a persistent and severe intention tremor component despite iterative DBS setting adjustments. While a reduction in pulse width to 30 μs initially showed promise in these patients by improving tremor control and mitigating cerebellar side effects arguably by widening the therapeutic window, these benefits seemed to dissipate during early follow-up. Our experience supports the need for measuring longer-term outcomes when reporting the usefulness of this mode of stimulation in ET.
Collapse
Affiliation(s)
- Thomas Wirth
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom, .,Neurology Department, Strasbourg University Hospital, Strasbourg, France, .,INSERM-U964/CNRS-UMR7104/University of Strasbourg, Illkirch-Graffenstaden, Strasbourg, France,
| | - Viswas Dayal
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Alexis de Roquemaurel
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Francisca Ferreira
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Nirosen Vijiaratnam
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Harith Akram
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Ludvic Zrinzo
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Thomas Foltynie
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Patricia Limousin
- Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| |
Collapse
|
18
|
Wang KL, Ren Q, Chiu S, Patel B, Meng FG, Hu W, Shukla AW. Deep brain stimulation and other surgical modalities for the management of essential tremor. Expert Rev Med Devices 2020; 17:817-833. [PMID: 33081571 DOI: 10.1080/17434440.2020.1806709] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Surgical treatments are considered for essential tremor (ET) when patients do not respond to oral pharmacological therapies. These treatments mainly comprise radiofrequency (RF) thalamotomy, gamma knife radiosurgery (GKRS), deep brain stimulation (DBS), and focused ultrasound (FUS) procedures. AREAS COVERED We reviewed the strengths and weaknesses of each procedure and clinical outcomes for 7 RF studies (n = 85), 11 GKRS (n = 477), 33 DBS (n = 1061), and 13 FUS studies (n = 368). A formal comparison was not possible given the heterogeneity in studies. Improvements were about 42%-90% RF, 10%-79% GKRS, 45%-83% DBS, 42%-83% FUS at short-term follow-up (<12 months) and were about 54%-82% RF, 11%-84% GKRS, 18%-92% DBS, and 42%-80% FUS at long-term follow-up (>12 months). EXPERT OPINION We found DBS with inherent advantages of being an adjustable and reversible procedure as the most frequently employed surgical procedure for control of ET symptoms. FUS is a promising procedure but has limited applicability for unilateral control of symptoms. RF is invasive, and GKRS has unpredictable delayed effects. Each of these surgical modalities has advantages and limitations that need consideration when selecting a treatment for the ET patients.
Collapse
Affiliation(s)
- Kai-Liang Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University , Beijing, China.,Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Qianwei Ren
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Shannon Chiu
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Bhavana Patel
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Fan-Gang Meng
- Department of Functional Neurosurgery, Beijing Neurosurgical Institute, Capital Medical University , Beijing, China
| | - Wei Hu
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| | - Aparna Wagle Shukla
- Department of Neurology, University of Florida College of Medicine , Gainesville, FL, USA
| |
Collapse
|
19
|
Bruno S, Nikolov P, Hartmann CJ, Trenado C, Slotty PJ, Vesper J, Schnitzler A, Groiss SJ. Directional Deep Brain Stimulation of the Thalamic Ventral Intermediate Area for Essential Tremor Increases Therapeutic Window. Neuromodulation 2020; 24:343-352. [PMID: 32666569 DOI: 10.1111/ner.13234] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/16/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Deep brain stimulation (DBS) of the posterior subthalamic area (PSA) and the ventral intermediate thalamic nucleus (VIM) is a well-established therapy for essential tremor (ET), but it is frequently associated with side effects like dysarthria or gait ataxia. Directional DBS (dDBS) may be a way to activate fiber tracts more selectively. Is dDBS for ET superior to omnidirectional DBS (oDBS) regarding therapeutic window and clinically as effective as oDBS? MATERIALS AND METHODS Ten patients with ET treated with PSA/VIM-DBS were recruited. Therapeutic window served as primary outcome parameter; clinical efficacy, volume of neuronal activation, and total electrical energy delivered (TEED) served as secondary outcome parameters. Therapeutic window was calculated for all three dDBS directions and for oDBS by determining therapeutic thresholds and side effect thresholds. Clinical efficacy was assessed by comparing the effect of best dDBS and oDBS on tremor and ataxia rating scales, and accelerometry. Volume of neural activation and TEED were also calculated for both paradigms. RESULTS For best dDBS, therapeutic window was wider and therapeutic threshold was lower compared to oDBS. While side effect threshold did not differ, volume of neural activation was larger for dDBS. In terms of clinical efficacy, dDBS was as effective as oDBS. CONCLUSIONS dDBS for ET widens therapeutic window due to reduction of therapeutic threshold. Larger volume of neural activation for dDBS at side effect threshold supports the notion of persistent directionality even at higher intensities. dDBS may compensate for slightly misplaced leads and should be considered first line for PSA/VIM-DBS.
Collapse
Affiliation(s)
- Sabine Bruno
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Petyo Nikolov
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian J Hartmann
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Carlos Trenado
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Functional Neurosurgery and Stereotaxy, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefan J Groiss
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
20
|
Senemmar F, Hartmann CJ, Slotty PJ, Vesper J, Schnitzler A, Groiss SJ. Asleep Surgery May Improve the Therapeutic Window for Deep Brain Stimulation of the Subthalamic Nucleus. Neuromodulation 2020; 24:279-285. [PMID: 32662156 DOI: 10.1111/ner.13237] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The effect of anesthesia type in terms of asleep vs. awake deep brain stimulation (DBS) surgery on therapeutic window (TW) has not been investigated so far. The objective of the study was to investigate whether asleep DBS surgery of the subthalamic nucleus (STN) improves TW for both directional (dDBS) and omnidirectional (oDBS) stimulation in a large single-center population. MATERIALS AND METHODS A total of 104 consecutive patients with Parkinson's disease (PD) undergoing STN-DBS surgery (80 asleep and 24 awake) were compared regarding TW, therapeutic threshold, side effect threshold, improvement of Unified PD Rating Scale motor score (UPDRS-III) and degree of levodopa equivalent daily dose (LEDD) reduction. RESULTS Asleep DBS surgery led to significantly wider TW compared to awake surgery for both dDBS and oDBS. However, dDBS further increased TW compared to oDBS in the asleep group only and not in the awake group. Clinical efficacy in terms of UPDRS-III improvement and LEDD reduction did not differ between groups. CONCLUSIONS Our study provides first evidence for improvement of therapeutic window by asleep surgery compared to awake surgery, which can be strengthened further by dDBS. These results support the notion of preferring asleep over awake surgery but needs to be confirmed by prospective trials.
Collapse
Affiliation(s)
- Farhad Senemmar
- Department of Neurology & Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian J Hartmann
- Department of Neurology & Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Functional Neurosurgery and Stereotaxy, Neurosurgical Clinic, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Neurosurgical Clinic, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology & Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefan Jun Groiss
- Department of Neurology & Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
21
|
Sun X, Huang L, Pan Y, Zhang C, Wang T, Li H, Sun B, Ding J, Wu Y, Li D. Bilateral Posterior Subthalamic Area Deep Brain Stimulation for Essential Tremor: A Case Series. Front Hum Neurosci 2020; 14:16. [PMID: 32116604 PMCID: PMC7013085 DOI: 10.3389/fnhum.2020.00016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 01/16/2020] [Indexed: 11/16/2022] Open
Abstract
Background Deep brain stimulation (DBS) of the posterior subthalamic area (PSA) provides a potentially effective treatment for medication-refractory essential tremor (ET). Objective To study the clinical benefits and adverse-event profile of bilateral PSA-DBS for refractory ET. Methods Seven patients with refractory ET underwent bilateral PSA-DBS surgery under general anesthesia between September 2017 and May 2018. Clinical outcome assessments, using the Essential Tremor Rating Scale, were performed at 1-, 6-, and 12-month follow-up, except for the last assessment of one patient who was followed up to 9 months. Analysis was focused on changes in patients’ motor symptoms and quality of life following surgery as well as documenting the adverse-event profile associated with the surgical PSA-DBS treatment. Results After surgery, patients’ motor symptoms, including upper limb tremor and head tremor, were improved by 84.2% and their quality of life by 81.25% at 1-month follow-up. The clinical benefits to patients were maintained at 6-month and last follow-up. Adverse side effects included dysarthria (n = 4), balance disorder (n = 2), and paresthesia of the right limb (n = 1). No habituation effects were observed throughout the follow-up. Conclusion Bilateral PSA-DBS seems to offer an effective and safe alternative treatment for medically intractable ET, warranting further research into its clinical utility, adverse-event profile, and comparative effectiveness.
Collapse
Affiliation(s)
- Xiaoyu Sun
- Department of Functional Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Luke Huang
- Department of Neurology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yixin Pan
- Department of Functional Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chencheng Zhang
- Department of Functional Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Tao Wang
- Department of Functional Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hongxia Li
- Department of Neurology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bomin Sun
- Department of Functional Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jianqing Ding
- Department of Neurology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yiwen Wu
- Department of Neurology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Dianyou Li
- Department of Functional Neurosurgery, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| |
Collapse
|
22
|
Wu A, Halpern C. Essential Tremor: Deep Brain Stimulation. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
23
|
Essential tremor: New advances. Clin Park Relat Disord 2019; 3:100031. [PMID: 34316617 PMCID: PMC8298793 DOI: 10.1016/j.prdoa.2019.100031] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 11/30/2019] [Accepted: 12/18/2019] [Indexed: 01/15/2023] Open
Abstract
Background Essential Tremor (ET) is one of the most common movement disorders but many controversies still exist in regards to its definition and pathophysiology. In view of the recent published criteria by the Tremor Task Force of the International Parkinson's and Movement Disorders Society (IPMDS), we intended to analyze if this has changed our view of ET and if new developments have arisen since. Methods A Medline search for English-written articles was done on June 15, 2019 using the keyword "Essential Tremor". Publications from November 2017 (publication date of the new tremor classification) were taken into account. Reviews, letters and original studies relevant to the subject were selected and reviewed according to the following themes: clinical characteristics, epidemiology, genetics, pathology, biomarkers and treatment. Results Out of 132 publications the most relevant articles were selected and reviewed (total of 65 articles). The great majority of these studies focused on surgical treatments (new targets, new technologies) while relatively few articles addressed epidemiology, pathology and pathophysiology. Conclusions The use of the new classification is not commonly used still, excepting more recent studies on therapeutics. This is in keeping with diverse opinions and criticisms reported by the IPMDS task force members themselves. One important change has been validating ET as a heterogeneous condition and defining the ET-plus category. We propose a further sub-group classification derived from the new definition of ET-plus.
Collapse
|
24
|
Dayal V, Grover T, Tripoliti E, Milabo C, Salazar M, Candelario‐McKeown J, Athauda D, Zrinzo L, Akram H, Hariz M, Limousin P, Foltynie T. Short Versus Conventional Pulse‐Width Deep Brain Stimulation in Parkinson's Disease: A Randomized Crossover Comparison. Mov Disord 2019; 35:101-108. [DOI: 10.1002/mds.27863] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 06/17/2019] [Accepted: 08/23/2019] [Indexed: 11/05/2022] Open
Affiliation(s)
- Viswas Dayal
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Timothy Grover
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Elina Tripoliti
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Catherine Milabo
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Maricel Salazar
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Joseph Candelario‐McKeown
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Dilan Athauda
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Ludvic Zrinzo
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Harith Akram
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Marwan Hariz
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
- Department of Clinical Neuroscience Umeå University Umeå Sweden
| | - Patricia Limousin
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Thomas Foltynie
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
- Unit of Functional Neurosurgery, National Hospital for Neurology and Neurosurgery London United Kingdom
| |
Collapse
|
25
|
Kroneberg D, Ewert S, Meyer AC, Kühn AA. Shorter pulse width reduces gait disturbances following deep brain stimulation for essential tremor. J Neurol Neurosurg Psychiatry 2019; 90:1046-1050. [PMID: 30765417 PMCID: PMC6820151 DOI: 10.1136/jnnp-2018-319427] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/12/2018] [Accepted: 01/04/2019] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Gait disturbances are frequent side effects occurring during chronic thalamic deep brain stimulation (DBS) in patients with essential tremor (ET). Adapting stimulation settings to shorter pulse widths has been shown to reduce side effects of subthalamic DBS. Here, we assess how a reduction of pulse width changes gait performance of affected patients. METHODS Sensor-based gait assessment was performed to record spatiotemporal gait parameters in 10 healthy subjects (HS) and 7 patients with ET with gait disturbances following thalamic DBS. Patients were tested during standard DBS, after 72 hours of stimulation withdrawal and at least 30 days after adjusting DBS settings to a shorter pulse width of 40 µs (DBS40PW). RESULTS Patients with ET on standard DBS showed significantly higher variability of several spatiotemporal gait parameters compared with HS. Variability of stride length and range of motion of the shanks significantly decreased OFF DBS as compared with standard DBS. This improvement was maintained over 30 days with DBS40PW while providing effective tremor suppression in six out of seven patients. CONCLUSION Shorter pulse widths may reduce gait disturbances in patients with ET that are induced by DBS while preserving a level of tremor suppression equal to standard stimulation settings.
Collapse
Affiliation(s)
- Daniel Kroneberg
- Charité - Universitätsmedizin Berlin, Department of Neurology, Movement Disorder and Neuromodulation Unit, Berlin, Germany
| | - Siobhan Ewert
- Charité - Universitätsmedizin Berlin, Department of Neurology, Movement Disorder and Neuromodulation Unit, Berlin, Germany
| | - Anne-Christiane Meyer
- Charité - Universitätsmedizin Berlin, Department of Neurology, Movement Disorder and Neuromodulation Unit, Berlin, Germany
| | - Andrea A Kühn
- Charité - Universitätsmedizin Berlin, Department of Neurology, Movement Disorder and Neuromodulation Unit, Berlin, Germany .,Charité - Universitätsmedizin Berlin, NeuroCure Cluster of Excellence, Berlin, Germany
| |
Collapse
|
26
|
Koeglsperger T, Palleis C, Hell F, Mehrkens JH, Bötzel K. Deep Brain Stimulation Programming for Movement Disorders: Current Concepts and Evidence-Based Strategies. Front Neurol 2019; 10:410. [PMID: 31231293 PMCID: PMC6558426 DOI: 10.3389/fneur.2019.00410] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 04/04/2019] [Indexed: 11/16/2022] Open
Abstract
Deep brain stimulation (DBS) has become the treatment of choice for advanced stages of Parkinson's disease, medically intractable essential tremor, and complicated segmental and generalized dystonia. In addition to accurate electrode placement in the target area, effective programming of DBS devices is considered the most important factor for the individual outcome after DBS. Programming of the implanted pulse generator (IPG) is the only modifiable factor once DBS leads have been implanted and it becomes even more relevant in cases in which the electrodes are located at the border of the intended target structure and when side effects become challenging. At present, adjusting stimulation parameters depends to a large extent on personal experience. Based on a comprehensive literature search, we here summarize previous studies that examined the significance of distinct stimulation strategies for ameliorating disease signs and symptoms. We assess the effect of adjusting the stimulus amplitude (A), frequency (f), and pulse width (pw) on clinical symptoms and examine more recent techniques for modulating neuronal elements by electrical stimulation, such as interleaving (Medtronic®) or directional current steering (Boston Scientific®, Abbott®). We thus provide an evidence-based strategy for achieving the best clinical effect with different disorders and avoiding adverse effects in DBS of the subthalamic nucleus (STN), the ventro-intermedius nucleus (VIM), and the globus pallidus internus (GPi).
Collapse
Affiliation(s)
- Thomas Koeglsperger
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Carla Palleis
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Department of Translational Neurodegeneration, German Center for Neurodegenerative Diseases (DZNE), Munich, Germany
| | - Franz Hell
- Department of Neurology, Ludwig Maximilians University, Munich, Germany.,Graduate School of Systemic Neurosciences, Ludwig-Maximilians-Universität München, Martinsried, Germany
| | - Jan H Mehrkens
- Department of Neurosurgery, Ludwig Maximilians University, Munich, Germany
| | - Kai Bötzel
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
| |
Collapse
|
27
|
Sidiropoulos C. Reader response: DBS of the PSA and the VIM in essential tremor: A randomized, double-blind, crossover trial. Neurology 2019; 92:975. [PMID: 31085730 DOI: 10.1212/wnl.0000000000007522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
28
|
Hidding U, Schaper M, Moll CKE, Gulberti A, Köppen J, Buhmann C, Gerloff C, Pötter-Nerger M, Hamel W, Choe CU. Mapping stimulation-induced beneficial and adverse effects in the subthalamic area of essential tremor patients. Parkinsonism Relat Disord 2019; 64:150-155. [PMID: 30981663 DOI: 10.1016/j.parkreldis.2019.03.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 12/19/2018] [Accepted: 03/30/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Stimulation of the subthalamic area (STA) is an effective treatment in essential tremor patients, but limited by stimulation induced adverse effects. The aim of this study was to determine the spatial distribution of stimulus related tremor suppression, ataxia induction and paresthesia of the upper limb in the subthalamic area (STA) of essential tremor patients. METHODS We recruited eight patients with essential tremor in a stable postoperative condition (>3 months after surgery). Stimulation-induced effects were assessed with suprathreshold stimulation. Tremor severity was assessed with the Fahn-Tolosa-Marin tremor rating scale (TRS) and cerebellar impairment was evaluated using the international cooperative ataxia rating scale (ICARS). Patients rated paresthesia intensity with a visual analog scale. Linear regression analysis was performed to associate stereotactic coordinates with tremor, ataxia and paresthesia. RESULTS Suprathreshold stimulation significantly decreased tremor and elicited ataxia and paresthesia in all patients (P < 0.001). Tremor rating scale (TRS) total score was positively correlated with y-coordinates (r = 0.44, P < 0.05), i.e. anterior stimulation sites were more effective to suppress tremor. Concerning adverse effects, ataxia induction was positively correlated with z-coordinates almost reaching statistical significance (r = 0.50, P = 0.07), i.e. inferior stimulation sites elicit stronger ataxia. Furthermore, paresthesia was positively correlated with y-coordinates (r = 0.66; P < 0.01) and to a lesser degree with x-coordinates (r = 0.32; P = 0.08), i.e. posterior and lateral stimulation sites within the STA caused more paresthesia. CONCLUSION Antero-dorso-medial stimulation site in the STA were associated with less tremor and adverse effects in our small single-center cohort of ET patients with thalamic DBS.
Collapse
Affiliation(s)
- Ute Hidding
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Miriam Schaper
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K E Moll
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandro Gulberti
- Department of Neurophysiology and Pathophysiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Köppen
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Carsten Buhmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Pötter-Nerger
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Chi-Un Choe
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| |
Collapse
|
29
|
Hartmann CJ, Fliegen S, Groiss SJ, Wojtecki L, Schnitzler A. An update on best practice of deep brain stimulation in Parkinson's disease. Ther Adv Neurol Disord 2019; 12:1756286419838096. [PMID: 30944587 PMCID: PMC6440024 DOI: 10.1177/1756286419838096] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 02/01/2019] [Indexed: 11/16/2022] Open
Abstract
During the last 30 years, deep brain stimulation (DBS) has evolved into the clinical standard of care as a highly effective treatment for advanced Parkinson’s disease. Careful patient selection, an individualized anatomical target localization and meticulous evaluation of stimulation parameters for chronic DBS are crucial requirements to achieve optimal results. Current hardware-related advances allow for a more focused, individualized stimulation and hence may help to achieve optimal clinical results. However, current advances also increase the degrees of freedom for DBS programming and therefore challenge the skills of healthcare providers. This review gives an overview of the clinical effects of DBS, the criteria for patient, target, and device selection, and finally, offers strategies for a structured programming approach.
Collapse
Affiliation(s)
- Christian J Hartmann
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Sabine Fliegen
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefan J Groiss
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Lars Wojtecki
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology/Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|
30
|
Neumann WJ, Turner RS, Blankertz B, Mitchell T, Kühn AA, Richardson RM. Toward Electrophysiology-Based Intelligent Adaptive Deep Brain Stimulation for Movement Disorders. Neurotherapeutics 2019; 16:105-118. [PMID: 30607748 PMCID: PMC6361070 DOI: 10.1007/s13311-018-00705-0] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Deep brain stimulation (DBS) represents one of the major clinical breakthroughs in the age of translational neuroscience. In 1987, Benabid and colleagues demonstrated that high-frequency stimulation can mimic the effects of ablative neurosurgery in Parkinson's disease (PD), while offering two key advantages to previous procedures: adjustability and reversibility. Deep brain stimulation is now an established therapeutic approach that robustly alleviates symptoms in patients with movement disorders, such as Parkinson's disease, essential tremor, and dystonia, who present with inadequate or adverse responses to medication. Currently, stimulation electrodes are implanted in specific target regions of the basal ganglia-thalamic circuit and stimulation pulses are delivered chronically. To achieve optimal therapeutic effect, stimulation frequency, amplitude, and pulse width must be adjusted on a patient-specific basis by a movement disorders specialist. The finding that pathological neural activity can be sampled directly from the target region using the DBS electrode has inspired a novel DBS paradigm: closed-loop adaptive DBS (aDBS). The goal of this strategy is to identify pathological and physiologically normal patterns of neuronal activity that can be used to adapt stimulation parameters to the concurrent therapeutic demand. This review will give detailed insight into potential biomarkers and discuss next-generation strategies, implementing advances in artificial intelligence, to further elevate the therapeutic potential of DBS by capitalizing on its modifiable nature. Development of intelligent aDBS, with an ability to deliver highly personalized treatment regimens and to create symptom-specific therapeutic strategies in real-time, could allow for significant further improvements in the quality of life for movement disorders patients with DBS that ultimately could outperform traditional drug treatment.
Collapse
Affiliation(s)
- Wolf-Julian Neumann
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, Campus Charite Mitte, Chariteplatz 1, 10117, Berlin, Germany.
| | - Robert S Turner
- Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Benjamin Blankertz
- Department of Computer Science, Technische Universität Berlin, Berlin, Germany
| | - Tom Mitchell
- Machine Learning Department, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Andrea A Kühn
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, Campus Charite Mitte, Chariteplatz 1, 10117, Berlin, Germany
- Berlin School of Mind and Brain, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Neurocure, Centre of Excellence, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - R Mark Richardson
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|