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Lefaucheur JP, Moro E, Shirota Y, Ugawa Y, Grippe T, Chen R, Benninger DH, Jabbari B, Attaripour S, Hallett M, Paulus W. Clinical neurophysiology in the treatment of movement disorders: IFCN handbook chapter. Clin Neurophysiol 2024; 164:57-99. [PMID: 38852434 DOI: 10.1016/j.clinph.2024.05.007] [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: 10/17/2023] [Revised: 03/02/2024] [Accepted: 05/15/2024] [Indexed: 06/11/2024]
Abstract
In this review, different aspects of the use of clinical neurophysiology techniques for the treatment of movement disorders are addressed. First of all, these techniques can be used to guide neuromodulation techniques or to perform therapeutic neuromodulation as such. Neuromodulation includes invasive techniques based on the surgical implantation of electrodes and a pulse generator, such as deep brain stimulation (DBS) or spinal cord stimulation (SCS) on the one hand, and non-invasive techniques aimed at modulating or even lesioning neural structures by transcranial application. Movement disorders are one of the main areas of indication for the various neuromodulation techniques. This review focuses on the following techniques: DBS, repetitive transcranial magnetic stimulation (rTMS), low-intensity transcranial electrical stimulation, including transcranial direct current stimulation (tDCS) and transcranial alternating current stimulation (tACS), and focused ultrasound (FUS), including high-intensity magnetic resonance-guided FUS (MRgFUS), and pulsed mode low-intensity transcranial FUS stimulation (TUS). The main clinical conditions in which neuromodulation has proven its efficacy are Parkinson's disease, dystonia, and essential tremor, mainly using DBS or MRgFUS. There is also some evidence for Tourette syndrome (DBS), Huntington's disease (DBS), cerebellar ataxia (tDCS), and axial signs (SCS) and depression (rTMS) in PD. The development of non-invasive transcranial neuromodulation techniques is limited by the short-term clinical impact of these techniques, especially rTMS, in the context of very chronic diseases. However, at-home use (tDCS) or current advances in the design of closed-loop stimulation (tACS) may open new perspectives for the application of these techniques in patients, favored by their easier use and lower rate of adverse effects compared to invasive or lesioning methods. Finally, this review summarizes the evidence for keeping the use of electromyography to optimize the identification of muscles to be treated with botulinum toxin injection, which is indicated and widely performed for the treatment of various movement disorders.
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Affiliation(s)
- Jean-Pascal Lefaucheur
- Clinical Neurophysiology Unit, Henri Mondor University Hospital, AP-HP, Créteil, France; EA 4391, ENT Team, Paris-Est Créteil University, Créteil, France.
| | - Elena Moro
- Grenoble Alpes University, Division of Neurology, CHU of Grenoble, Grenoble Institute of Neuroscience, Grenoble, France
| | - Yuichiro Shirota
- Department of Neurology, Division of Neuroscience, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshikazu Ugawa
- Department of Human Neurophysiology, School of Medicine, Fukushima Medical University, Fukushima, Japan
| | - Talyta Grippe
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Neuroscience Graduate Program, Federal University of Minas Gerais, Belo Horizonte, Brazil; Krembil Brain Institute, Toronto, Ontario, Canada
| | - Robert Chen
- Division of Neurology, University of Toronto, Toronto, Ontario, Canada; Krembil Brain Institute, Toronto, Ontario, Canada
| | - David H Benninger
- Service of Neurology, Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Bahman Jabbari
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Sanaz Attaripour
- Department of Neurology, University of California, Irvine, CA, USA
| | - Mark Hallett
- Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Walter Paulus
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
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Vogel D, Nordin T, Feiler S, Wårdell K, Coste J, Lemaire JJ, Hemm S. Probabilistic stimulation mapping from intra-operative thalamic deep brain stimulation data in essential tremor. J Neural Eng 2024; 21:036017. [PMID: 38701768 DOI: 10.1088/1741-2552/ad4742] [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: 11/17/2023] [Accepted: 05/03/2024] [Indexed: 05/05/2024]
Abstract
Deep brain stimulation (DBS) is a therapy for Parkinson's disease (PD) and essential tremor (ET). The mechanism of action of DBS is still incompletely understood. Retrospective group analysis of intra-operative data recorded from ET patients implanted in the ventral intermediate nucleus of the thalamus (Vim) is rare. Intra-operative stimulation tests generate rich data and their use in group analysis has not yet been explored.Objective.To implement, evaluate, and apply a group analysis workflow to generate probabilistic stimulation maps (PSMs) using intra-operative stimulation data from ET patients implanted in Vim.Approach.A group-specific anatomical template was constructed based on the magnetic resonance imaging scans of 6 ET patients and 13 PD patients. Intra-operative test data (total:n= 1821) from the 6 ET patients was analyzed: patient-specific electric field simulations together with tremor assessments obtained by a wrist-based acceleration sensor were transferred to this template. Occurrence and weighted mean maps were generated. Voxels associated with symptomatic response were identified through a linear mixed model approach to form a PSM. Improvements predicted by the PSM were compared to those clinically assessed. Finally, the PSM clusters were compared to those obtained in a multicenter study using data from chronic stimulation effects in ET.Main results.Regions responsible for improvement identified on the PSM were in the posterior sub-thalamic area (PSA) and at the border between the Vim and ventro-oral nucleus of the thalamus (VO). The comparison with literature revealed a center-to-center distance of less than 5 mm and an overlap score (Dice) of 0.4 between the significant clusters. Our workflow and intra-operative test data from 6 ET-Vim patients identified effective stimulation areas in PSA and around Vim and VO, affirming existing medical literature.Significance.This study supports the potential of probabilistic analysis of intra-operative stimulation test data to reveal DBS's action mechanisms and to assist surgical planning.
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Affiliation(s)
- Dorian Vogel
- Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland, Hofackerstrasse 30, Muttenz, Switzerland
| | - Teresa Nordin
- Department of Biomedical Engineering, Linköping University, Campus US, Linköping, Sweden
| | - Stefanie Feiler
- Dynamics and statistics of complex systems, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland, Hofackerstrasse 30, Muttenz, Switzerland
| | - Karin Wårdell
- Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland, Hofackerstrasse 30, Muttenz, Switzerland
- Department of Biomedical Engineering, Linköping University, Campus US, Linköping, Sweden
| | - Jérôme Coste
- Université Clermont Auvergne, CNRS, SIGMA Clermont, Institut Pascal, Clermont-Ferrand, France
- Service de Neurochirurgie, Hôpital Gabriel-Montpied, Centre Hospitalier Universitaire de Clermont-Ferrand, 58 rue Montalembert, Clermont-Ferrand, France
| | - Jean-Jacques Lemaire
- Université Clermont Auvergne, CNRS, SIGMA Clermont, Institut Pascal, Clermont-Ferrand, France
- Service de Neurochirurgie, Hôpital Gabriel-Montpied, Centre Hospitalier Universitaire de Clermont-Ferrand, 58 rue Montalembert, Clermont-Ferrand, France
| | - Simone Hemm
- Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland, Hofackerstrasse 30, Muttenz, Switzerland
- Department of Biomedical Engineering, Linköping University, Campus US, Linköping, Sweden
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Patrick EE, Fleeting CR, Patel DR, Casauay JT, Patel A, Shepherd H, Wong JK. Modeling the volume of tissue activated in deep brain stimulation and its clinical influence: a review. Front Hum Neurosci 2024; 18:1333183. [PMID: 38660012 PMCID: PMC11039793 DOI: 10.3389/fnhum.2024.1333183] [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: 11/04/2023] [Accepted: 03/26/2024] [Indexed: 04/26/2024] Open
Abstract
Deep brain stimulation (DBS) is a neuromodulatory therapy that has been FDA approved for the treatment of various disorders, including but not limited to, movement disorders (e.g., Parkinson's disease and essential tremor), epilepsy, and obsessive-compulsive disorder. Computational methods for estimating the volume of tissue activated (VTA), coupled with brain imaging techniques, form the basis of models that are being generated from retrospective clinical studies for predicting DBS patient outcomes. For instance, VTA models are used to generate target-and network-based probabilistic stimulation maps that play a crucial role in predicting DBS treatment outcomes. This review defines the methods for calculation of tissue activation (or modulation) including ones that use heuristic and clinically derived estimates and more computationally involved ones that rely on finite-element methods and biophysical axon models. We define model parameters and provide a comparison of commercial, open-source, and academic simulation platforms available for integrated neuroimaging and neural activation prediction. In addition, we review clinical studies that use these modeling methods as a function of disease. By describing the tissue-activation modeling methods and highlighting their application in clinical studies, we provide the neural engineering and clinical neuromodulation communities with perspectives that may influence the adoption of modeling methods for future DBS studies.
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Affiliation(s)
- Erin E. Patrick
- Department of Electrical and Computer Engineering, University of Florida, Gainesville, FL, United States
| | - Chance R. Fleeting
- College of Medicine, University of Florida, Gainesville, FL, United States
| | - Drashti R. Patel
- College of Medicine, University of Florida, Gainesville, FL, United States
| | - Jed T. Casauay
- College of Medicine, University of Florida, Gainesville, FL, United States
| | - Aashay Patel
- College of Medicine, University of Florida, Gainesville, FL, United States
| | - Hunter Shepherd
- College of Medicine, University of Florida, Gainesville, FL, United States
| | - Joshua K. Wong
- Department of Neurology, Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
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Steina A, Sure S, Butz M, Vesper J, Schnitzler A, Hirschmann J. Mapping Subcortico-Cortical Coupling-A Comparison of Thalamic and Subthalamic Oscillations. Mov Disord 2024; 39:684-693. [PMID: 38380765 DOI: 10.1002/mds.29730] [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: 06/27/2023] [Revised: 11/29/2023] [Accepted: 01/08/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND The ventral intermediate nucleus of the thalamus (VIM) is an effective target for deep brain stimulation in tremor patients. Despite its therapeutic importance, its oscillatory coupling to cortical areas has rarely been investigated in humans. OBJECTIVES The objective of this study was to identify the cortical areas coupled to the VIM in patients with essential tremor. METHODS We combined resting-state magnetoencephalography with local field potential recordings from the VIM of 19 essential tremor patients. Whole-brain maps of VIM-cortex coherence in several frequency bands were constructed using beamforming and compared with corresponding maps of subthalamic nucleus (STN) coherence based on data from 19 patients with Parkinson's disease. In addition, we computed spectral Granger causality. RESULTS The topographies of VIM-cortex and STN-cortex coherence were very similar overall but differed quantitatively. Both nuclei were coupled to the ipsilateral sensorimotor cortex in the high-beta band; to the sensorimotor cortex, brainstem, and cerebellum in the low-beta band; and to the temporal cortex, brainstem, and cerebellum in the alpha band. High-beta coherence to sensorimotor cortex was stronger for the STN (P = 0.014), whereas low-beta coherence to the brainstem was stronger for the VIM (P = 0.017). Although the STN was driven by cortical activity in the high-beta band, the VIM led the sensorimotor cortex in the alpha band. CONCLUSIONS Thalamo-cortical coupling is spatially and spectrally organized. The overall similar topographies of VIM-cortex and STN-cortex coherence suggest that functional connections are not necessarily unique to one subcortical structure but might reflect larger frequency-specific networks involving VIM and STN to a different degree. © 2024 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Alexandra Steina
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Sarah Sure
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Markus Butz
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Neurosurgical Clinic, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Alfons Schnitzler
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
| | - Jan Hirschmann
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University, Düsseldorf, Germany
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Neudorfer C, Kultas-Ilinsky K, Ilinsky I, Paschen S, Helmers AK, Cosgrove GR, Richardson RM, Horn A, Deuschl G. The role of the motor thalamus in deep brain stimulation for essential tremor. Neurotherapeutics 2024; 21:e00313. [PMID: 38195310 PMCID: PMC11103222 DOI: 10.1016/j.neurot.2023.e00313] [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: 10/09/2023] [Revised: 12/10/2023] [Accepted: 12/27/2023] [Indexed: 01/11/2024] Open
Abstract
The advent of next-generation technology has significantly advanced the implementation and delivery of Deep Brain Stimulation (DBS) for Essential Tremor (ET), yet controversies persist regarding optimal targets and networks responsible for tremor genesis and suppression. This review consolidates key insights from anatomy, neurology, electrophysiology, and radiology to summarize the current state-of-the-art in DBS for ET. We explore the role of the thalamus in motor function and describe how differences in parcellations and nomenclature have shaped our understanding of the neuroanatomical substrates associated with optimal outcomes. Subsequently, we discuss how seminal studies have propagated the ventral intermediate nucleus (Vim)-centric view of DBS effects and shaped the ongoing debate over thalamic DBS versus stimulation in the posterior subthalamic area (PSA) in ET. We then describe probabilistic- and network-mapping studies instrumental in identifying the local and network substrates subserving tremor control, which suggest that the PSA is the optimal DBS target for tremor suppression in ET. Taken together, DBS offers promising outcomes for ET, with the PSA emerging as a better target for suppression of tremor symptoms. While advanced imaging techniques have substantially improved the identification of anatomical targets within this region, uncertainties persist regarding the distinct anatomical substrates involved in optimal tremor control. Inconsistent subdivisions and nomenclature of motor areas and other subdivisions in the thalamus further obfuscate the interpretation of stimulation results. While loss of benefit and habituation to DBS remain challenging in some patients, refined DBS techniques and closed-loop paradigms may eventually overcome these limitations.
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Affiliation(s)
- Clemens Neudorfer
- Brain Modulation Lab, Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Center for Brain Circuit Therapeutics Department of Neurology Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA; Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
| | | | - Igor Ilinsky
- Department of Anatomy and Cell Biology, The University of Iowa, Iowa City, IA, USA
| | - Steffen Paschen
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
| | | | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - R Mark Richardson
- Brain Modulation Lab, Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, 02114, USA; Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andreas Horn
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Center for Brain Circuit Therapeutics Department of Neurology Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA; Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Günther Deuschl
- Department of Neurology, Christian-Albrechts-University, Kiel, Germany
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Gregg NM, Valencia GO, Huang H, Lundstrom BN, Van Gompel JJ, Miller KJ, Worrell GA, Hermes D. Thalamic stimulation induced changes in effective connectivity. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.03.24303480. [PMID: 38496621 PMCID: PMC10942513 DOI: 10.1101/2024.03.03.24303480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Deep brain stimulation (DBS) is a viable treatment for a variety of neurological conditions, however, the mechanisms through which DBS modulates large-scale brain networks are unresolved. Clinical effects of DBS are observed over multiple timescales. In some conditions, such as Parkinson's disease and essential tremor, clinical improvement is observed within seconds. In many other conditions, such as epilepsy, central pain, dystonia, neuropsychiatric conditions or Tourette syndrome, the DBS related effects are believed to require neuroplasticity or reorganization and often take hours to months to observe. To optimize DBS parameters, it is therefore essential to develop electrophysiological biomarkers that characterize whether DBS settings are successfully engaging and modulating the network involved in the disease of interest. In this study, 10 individuals with drug resistant epilepsy undergoing intracranial stereotactic EEG including a thalamus electrode underwent a trial of repetitive thalamic stimulation. We evaluated thalamocortical effective connectivity using single pulse electrical stimulation, both at baseline and following a 145 Hz stimulation treatment trial. We found that when high frequency stimulation was delivered for >1.5 hours, the evoked potentials measured from remote regions were significantly reduced in amplitude and the degree of modulation was proportional to the strength of baseline connectivity. When stimulation was delivered for shorter time periods, results were more variable. These findings suggest that changes in effective connectivity in the network targeted with DBS accumulate over hours of DBS. Stimulation evoked potentials provide an electrophysiological biomarker that allows for efficient data-driven characterization of neuromodulation effects, which could enable new objective approaches for individualized DBS optimization.
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Affiliation(s)
| | | | - Harvey Huang
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester MN
| | | | | | - Kai J. Miller
- Department of Neurosurgery, Mayo Clinic, Rochester MN
| | | | - Dora Hermes
- Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester MN
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Prasad S, Saini J, Bharath RD, Pal PK. Differential patterns of functional connectivity in tremor dominant Parkinson's disease and essential tremor plus. J Neural Transm (Vienna) 2024:10.1007/s00702-024-02761-7. [PMID: 38430265 DOI: 10.1007/s00702-024-02761-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/23/2024] [Indexed: 03/03/2024]
Abstract
Tremor dominant Parkinson's disease (TDPD) and essential tremor plus (ETP) syndrome are commonly encountered tremor dominant neurological disorders. Although the basal ganglia thalamocortical (BGTC) and cerebello thalamocortical (CTC) networks are implicated in tremorogenesis, the extent of functional connectivity alterations across disorders is uncertain. This study aims to evaluate functional connectivity of the BGTC and CTC in TDPD and ETP. Resting state functional MRI was acquired for 25 patients with TDPD, ETP and 22 healthy controls (HC). Following pre-processing and denoising, seed-to-voxel based connectivity was carried out at FDR < 0.05 using ROIs belonging to the BGTC and CTC. Fahn-Tolosa-Marin tremor rating scale (FTMRS) was correlated with the average connectivity values at FDR < 0.05. Compared to HC, TDPD showed decreased connectivity between cerebellum and pre, post central gyrus. While, ETP showed decreased connectivity between pallidum and occipital cortex, precuneus, cuneus compared to HC. In comparison to ETP, TDPD showed increased connectivity between precentral gyrus, pallidum, SNc with the default mode network (DMN), and decreased connectivity between cerebellum with superior, middle frontal gyrus was observed. Tremor severity positively correlated with connectivity between SNc and DMN in TDPD, and negatively correlated with pallidal connectivity in ETP. Pattern of BGTC, CTC involvement is differential i.e., higher connectivity of the BGTC nodes in TDPD, and higher connectivity of cerebellar nodes in ETP. The interesting observation of pallidal involvement in ETP suggests the role of BGTC in the pathogenesis of ETP, and indicated similarities in concepts of tremor genesis in TDPD and ETP.
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Affiliation(s)
- Shweta Prasad
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health & Neurosciences (NIMHANS), Hosur Road, Bengaluru, Karnataka, 560029, India
| | - Jitender Saini
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health & Neurosciences (NIMHANS), Hosur Road, Bengaluru, Karnataka, 560029, India
| | - Rose Dawn Bharath
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health & Neurosciences (NIMHANS), Hosur Road, Bengaluru, Karnataka, 560029, India
| | - Pramod Kumar Pal
- Department of Neurology, National Institute of Mental Health & Neurosciences (NIMHANS), Hosur Road, Bengaluru, Karnataka, 560029, India.
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Sajonz BEA, Frommer ML, Reisert M, Blazhenets G, Schröter N, Rau A, Prokop T, Reinacher PC, Rijntjes M, Urbach H, Meyer PT, Coenen VA. Disbalanced recruitment of crossed and uncrossed cerebello-thalamic pathways during deep brain stimulation is predictive of delayed therapy escape in essential tremor. Neuroimage Clin 2024; 41:103576. [PMID: 38367597 PMCID: PMC10944187 DOI: 10.1016/j.nicl.2024.103576] [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: 11/27/2023] [Revised: 01/23/2024] [Accepted: 02/07/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND Thalamic deep brain stimulation (DBS) is an efficacious treatment for drug-resistant essential tremor (ET) and the dentato-rubro-thalamic tract (DRT) constitutes an important target structure. However, up to 40% of patients habituate and lose treatment efficacy over time, frequently accompanied by a stimulation-induced cerebellar syndrome. The phenomenon termed delayed therapy escape (DTE) is insufficiently understood. Our previous work showed that DTE clinically is pronounced on the non-dominant side and suggested that differential involvement of crossed versus uncrossed DRT (DRTx/DRTu) might play a role in DTE development. METHODS We retrospectively enrolled right-handed patients under bilateral thalamic DBS >12 months for ET from a cross-sectional study. They were characterized with the Fahn-Tolosa-Marin Tremor Rating Scale (FTMTRS) and Scale for the Assessment and Rating of Ataxia (SARA) scores at different timepoints. Normative fiber tractographic evaluations of crossed and uncrossed cerebellothalamic pathways and volume of activated tissue (VAT) studies together with [18F]Fluorodeoxyglucose positron emission tomography were applied. RESULTS A total of 29 patients met the inclusion criteria. Favoring DRTu over DRTx in the non-dominant VAT was associated with DTE (R2 = 0.4463, p < 0.01) and ataxia (R2 = 0.2319, p < 0.01). Moreover, increasing VAT size on the right (non-dominant) side was associated at trend level with more asymmetric glucose metabolism shifting towards the right (dominant) dentate nucleus. CONCLUSION Our results suggest that a disbalanced recruitment of DRTu in the non-dominant VAT induces detrimental stimulation effects on the dominant cerebellar outflow (together with contralateral stimulation) leading to DTE and thus hampering the overall treatment efficacy.
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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.
| | - Marvin L Frommer
- Department of Stereotactic and Functional Neurosurgery, Medical Center - University of Freiburg, Faculty of Medicine, 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; Division of Medical Physics, Department of Diagnostic and Interventional Radiology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Ganna Blazhenets
- Department of Nuclear Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Nils Schröter
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Alexander Rau
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Thomas Prokop
- Department of Stereotactic and Functional Neurosurgery, 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
| | - Michel Rijntjes
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Horst Urbach
- Department of Neuroradiology, 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
| | - 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
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Yu CH, Lench DH, Cooper C, Rowland NC, Takacs I, Revuelta G. Deep brain stimulation for essential tremor versus essential tremor plus: should we target the same spot in the thalamus? Front Hum Neurosci 2023; 17:1271046. [PMID: 38021224 PMCID: PMC10644388 DOI: 10.3389/fnhum.2023.1271046] [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: 08/01/2023] [Accepted: 10/06/2023] [Indexed: 12/01/2023] Open
Abstract
Background Although ET is a phenomenologically heterogeneous condition, thalamic DBS appears to be equally effective across subtypes. We hypothesized stimulation sites optimized for individuals with essential tremor (ET) would differ from individuals with essential tremor plus syndrome (ET-plus). We examined group differences in optimal stimulation sites within the ventral thalamus and their overlap of with relevant white matter tracts. By capturing these differences, we sought to determine whether ET subtypes are associated with anatomically distinct neural pathways. Methods A retrospective chart review was conducted on ET patients undergoing VIM DBS at MUSC between 01/2012 and 02/2022. Clinical, demographic, neuroimaging, and DBS stimulation parameter data were collected. Clinical characteristics and pre-DBS videos were reviewed to classify ET and ET-plus cohorts. Patients in ET-plus cohorts were further divided into ET with dystonia, ET with ataxia, and ET with others. DBS leads were reconstructed using Lead-DBS and the volume of tissue activated (VTA) overlap was performed using normative connectomes. Tremor improvement was measured by reduction in a subscore of tremor rating scale (TRS) post-DBS lateralized to the more affected limb. Results Sixty-eight ET patients were enrolled after initial screening, of these 10 ET and 24 ET-plus patients were included in the final analyses. ET group had an earlier age at onset (p = 0.185) and underwent surgery at a younger age (p = 0.096). Both groups achieved effective tremor control. No significant differences were found in lead placement or VTA overlap within ventral thalamus. The VTA center of gravity (COG) in the ET-plus cohort was located dorsal to that of the ET cohort. No significant differences were found in VTA overlap with the dentato-rubral-thalamic (DRTT) tracts or the ansa lenticularis. Dystonia was more prevalent than ataxia in the ET-plus subgroups (n = 18 and n = 5, respectively). ET-plus with dystonia subgroup had a more medial COG compared to ET-plus with ataxia. Conclusion VIM DBS therapy is efficacious in patients with ET and ET-plus. There were no significant differences in optimal stimulation site or VTA overlap with white-matter tracts between ET, ET-plus and ET-plus subgroups.
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Affiliation(s)
- Cherry H. Yu
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
| | - Daniel H. Lench
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
| | - Christine Cooper
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States
| | - Nathan C. Rowland
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Istvan Takacs
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, United States
| | - Gonzalo Revuelta
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
- Ralph H. Johnson VA Medical Center, Charleston, SC, United States
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10
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Chua MMJ, Warren AEL, Cosgrove GR, Rolston JD. Publication Rates and Characteristics of Clinical Trials in Deep Brain and Responsive Neurostimulation. Stereotact Funct Neurosurg 2023; 101:287-300. [PMID: 37552969 DOI: 10.1159/000531161] [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: 03/29/2023] [Accepted: 05/15/2023] [Indexed: 08/10/2023]
Abstract
INTRODUCTION Prompt dissemination of clinical trial results is essential for ensuring the safety and efficacy of intracranial neurostimulation treatments, including deep brain stimulation (DBS) and responsive neurostimulation (RNS). However, the frequency and completeness of results publication, and reasons for reporting delays, are unknown. Moreover, the patient populations, targeted anatomical locations, and stimulation parameters should be clearly reported for both reproducibility and to identify lacunae in trial design. Here, we examine DBS and RNS trials from 1997 to 2022, chart their characteristics, and examine rates and predictors of results reporting. METHODS Trials were identified using ClinicalTrials.gov. Associated publications were identified using ClinicalTrials.gov and PubMed.gov. Pearson's χ2 tests were used to assess differences in trial characteristics between published and unpublished trials. RESULTS Across 449 trials, representing a cumulative cohort of 42,769 patient interventions, there were 37 therapeutic indications and 44 stimulation targets. The most common indication and target were Parkinson's disease (40.55%) and the subthalamic nucleus (35.88%), respectively. Only 0.89% of trials were in pediatric patients (11.58% were mixed pediatric and adult). Explored targets represented 75% of potential basal ganglia targets but only 29% of potential thalamic targets. Allowing a 1-year grace period after trial completion, 34/169 (20.12%) had results reported on ClinicalTrials.gov, and 107/169 (63.31%) were published. ∼80% of published trials included details about stimulation parameters used. Published and unpublished trials did not significantly differ by trial characteristics. CONCLUSION We highlight key knowledge and performance gaps in DBS and RNS trial research. Over one-third of trials remain unpublished >1 year after completion; pediatric trials are scarce; most of the thalamus remains unexplored; about one-in-five trials fail to report stimulation parameters; and movement disorders comprise the most studied indications.
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Affiliation(s)
- Melissa M J Chua
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aaron E L Warren
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John D Rolston
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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11
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Andrews L, Keller SS, Osman-Farah J, Macerollo A. A structural magnetic resonance imaging review of clinical motor outcomes from deep brain stimulation in movement disorders. Brain Commun 2023; 5:fcad171. [PMID: 37304793 PMCID: PMC10257440 DOI: 10.1093/braincomms/fcad171] [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: 11/13/2022] [Revised: 04/05/2023] [Accepted: 05/30/2023] [Indexed: 06/13/2023] Open
Abstract
Patients with movement disorders treated by deep brain stimulation do not always achieve successful therapeutic alleviation of motor symptoms, even in cases where surgery is without complications. Magnetic resonance imaging (MRI) offers methods to investigate structural brain-related factors that may be predictive of clinical motor outcomes. This review aimed to identify features which have been associated with variability in clinical post-operative motor outcomes in patients with Parkinson's disease, dystonia, and essential tremor from structural MRI modalities. We performed a literature search for articles published between 1 January 2000 and 1 April 2022 and identified 5197 articles. Following screening through our inclusion criteria, we identified 60 total studies (39 = Parkinson's disease, 11 = dystonia syndromes and 10 = essential tremor). The review captured a range of structural MRI methods and analysis techniques used to identify factors related to clinical post-operative motor outcomes from deep brain stimulation. Morphometric markers, including volume and cortical thickness were commonly identified in studies focused on patients with Parkinson's disease and dystonia syndromes. Reduced metrics in basal ganglia, sensorimotor and frontal regions showed frequent associations with reduced motor outcomes. Increased structural connectivity to subcortical nuclei, sensorimotor and frontal regions was also associated with greater motor outcomes. In patients with tremor, increased structural connectivity to the cerebellum and cortical motor regions showed high prevalence across studies for greater clinical motor outcomes. In addition, we highlight conceptual issues for studies assessing clinical response with structural MRI and discuss future approaches towards optimizing individualized therapeutic benefits. Although quantitative MRI markers are in their infancy for clinical purposes in movement disorder treatments, structural features obtained from MRI offer the powerful potential to identify candidates who are more likely to benefit from deep brain stimulation and provide insight into the complexity of disorder pathophysiology.
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Affiliation(s)
- Luke Andrews
- Correspondence to: Luke Andrews The BRAIN Lab, University of Liverpool Cancer Research Centre 200 London Rd, Liverpool L3 9TA, United Kingdom E-mail:
| | - Simon S Keller
- The Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L3 9TA, UK
| | - Jibril Osman-Farah
- Department of Neurology and Neurosurgery, The Walton Centre NHS Foundation Trust, Liverpool L97LJ, UK
| | - Antonella Macerollo
- Correspondence may also be sent to: Antonella Macerollo. The Walton Centre NHS Trust, Lower Lane Liverpool L9 7LJ, United Kingdom E-mail:
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12
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Holcomb JM, Chopra R, Feltrin FS, Elkurd M, El-Nazer R, McKenzie L, O’Suilleabhain P, Maldjian JA, Dauer W, Shah BR. Improving tremor response to focused ultrasound thalamotomy. Brain Commun 2023; 5:fcad165. [PMID: 37533544 PMCID: PMC10390385 DOI: 10.1093/braincomms/fcad165] [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: 11/03/2022] [Revised: 04/18/2023] [Accepted: 05/19/2023] [Indexed: 08/04/2023] Open
Abstract
MRI-guided high-intensity focused ultrasound thalamotomy is an incisionless therapy for essential tremor. To reduce adverse effects, the field has migrated to treating at 2 mm above the anterior commissure-posterior commissure plane. We perform MRI-guided high-intensity focused ultrasound with an advanced imaging targeting technique, four-tract tractography. Four-tract tractography uses diffusion tensor imaging to identify the critical white matter targets for tremor control, the decussating and non-decussating dentatorubrothalamic tracts, while the corticospinal tract and medial lemniscus are identified to be avoided. In some patients, four-tract tractography identified a risk of damaging the medial lemniscus or corticospinal tract if treated at 2 mm superior to the anterior commissure-posterior commissure plane. In these patients, we chose to target 1.2-1.5 mm superior to the anterior commissure-posterior commissure plane. In these patients, post-operative imaging revealed that the focused ultrasound lesion extended into the posterior subthalamic area. This study sought to determine if patients with focused ultrasound lesions that extend into the posterior subthalamic area have a differnce in tremor improvement than those without. Twenty essential tremor patients underwent MRI-guided high-intensity focused ultrasound and were retrospectively classified into two groups. Group 1 included patients with an extension of the thalamic-focused ultrasound lesion into the posterior subthalamic area. Group 2 included patients without extension of the thalamic-focused ultrasound lesion into the posterior subthalamic area. For each patient, the percent change in postural tremor, kinetic tremor and Archimedes spiral scores were calculated between baseline and a 3-month follow-up. Two-tailed Wilcoxon rank-sum tests were used to compare the improvement in tremor scores, the total number of sonications, thermal dose to achieve initial tremor response, and skull density ratio between groups. Group 1 had significantly greater postural, kinetic, and Archimedes spiral score percent improvement than Group 2 (P values: 5.41 × 10-5, 4.87 × 10-4, and 5.41 × 10-5, respectively). Group 1 also required significantly fewer total sonications to control the tremor and a significantly lower thermal dose to achieve tremor response (P values: 6.60 × 10-4 and 1.08 × 10-5, respectively). No significant group differences in skull density ratio were observed (P = 1.0). We do not advocate directly targeting the posterior subthalamic area with MRI-guided high-intensity focused ultrasound because the shape of the focused ultrasound lesion can result in a high risk of adverse effects. However, when focused ultrasound lesions naturally extend from the thalamus into the posterior subthalamic area, they provide greater tremor control than those that only involve the thalamus.
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Affiliation(s)
- James M Holcomb
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Rajiv Chopra
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Fabricio S Feltrin
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Mazen Elkurd
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Rasheda El-Nazer
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
| | - Lauren McKenzie
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | | | - Joseph A Maldjian
- Focused Ultrasound Lab and Program, Department of Radiology, UTSW Medical Center, Dallas, TX 75235, USA
| | - William Dauer
- Department of Neurology, UTSW Medical Center, Dallas, TX 75235, USA
- O’Donnell Brain Institute, UTSW Medical Center, Dallas, TX 75235, USA
| | - Bhavya R Shah
- Correspondence to: Bhavya R. Shah Department of Radiology, UTSW Medical Center, 1801 Inwood Rd Dallas, TX 75235, USA E-mail:
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13
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Kyle K, Maller J, Barnett Y, Jonker B, Barnett M, D’Souza A, Calamante F, Maamary J, Peters J, Wang C, Tisch S. Tremor suppression following treatment with MRgFUS: skull density ratio consistency and degree of posterior dentatorubrothalamic tract lesioning predicts long-term clinical outcomes in essential tremor. Front Neurol 2023; 14:1129430. [PMID: 37181561 PMCID: PMC10166854 DOI: 10.3389/fneur.2023.1129430] [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: 12/22/2022] [Accepted: 03/27/2023] [Indexed: 05/16/2023] Open
Abstract
Objectives Magnetic resonance-guided focussed ultrasound (MRgFUS) is an incisionless ablative procedure, widely used for treatment of Parkinsonian and Essential Tremor (ET). Enhanced understanding of the patient- and treatment-specific factors that influence sustained long-term tremor suppression could help clinicians achieve superior outcomes via improved patient screening and treatment strategy. Methods We retrospectively analysed data from 31 subjects with ET, treated with MRgFUS at a single centre. Tremor severity was assessed with parts A, B and C of the Clinical Rating Scale for Tremor (CRST) as well as the combined CRST. Tremor in the dominant and non-dominant hand was assessed with Hand Tremor Scores (HTS), derived from the CRST. Pre- and post-treatment imaging data were analysed to determine ablation volume overlap with automated thalamic segmentations, and the dentatorubrothalamic tract (DRTT) and compared with percentage change in CRST and HTS following treatment. Results Tremor symptoms were significantly reduced following treatment. Combined pre-treatment CRST (mean: 60.7 ± 17.3) and HTS (mean: 19.2 ± 5.7) improved by an average of 45.5 and 62.6%, respectively. Percentage change in CRST was found to be significantly negatively associated with age (β = -0.375, p = 0.015), and SDR standard deviation (SDRSD; β = -0.324, p = 0.006), and positively associated with ablation overlap with the posterior DRTT (β = 0.535, p < 0.001). Percentage HTS improvement in the dominant hand decreased significantly with older age (β = -0.576, p < 0.01). Conclusion Our results suggest that increased lesioning of the posterior region of the DRTT could result in greater improvements in combined CRST and non-dominant hand HTS, and that subjects with lower SDR standard deviation tended to experience greater improvement in combined CRST.
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Affiliation(s)
- Kain Kyle
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Sydney Neuroimaging Analysis Centre, Camperdown, NSW, Australia
| | | | - Yael Barnett
- Department of Medical Imaging, and Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Department of Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
| | - Benjamin Jonker
- Department of Neurosurgery, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- Royal Prince Alfred Institute of Academic Surgery, University of Sydney, Camperdown, NSW, Australia
| | - Michael Barnett
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Sydney Neuroimaging Analysis Centre, Camperdown, NSW, Australia
- Department of Neurology, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Arkiev D’Souza
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
| | - Fernando Calamante
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- School of Biomedical Engineering, The University of Sydney, Sydney, NSW, Australia
- Sydney Imaging, The University of Sydney, Sydney, NSW, Australia
| | - Joel Maamary
- Department of Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - James Peters
- Department of Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
| | - Chenyu Wang
- Brain and Mind Centre, The University of Sydney, Sydney, NSW, Australia
- Sydney Neuroimaging Analysis Centre, Camperdown, NSW, Australia
| | - Stephen Tisch
- Department of Neurology, St Vincent’s Hospital, Darlinghurst, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
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14
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Lateral cerebellothalamic tract activation underlies DBS therapy for Essential Tremor. Brain Stimul 2023; 16:445-455. [PMID: 36746367 DOI: 10.1016/j.brs.2023.02.002] [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: 02/07/2022] [Revised: 01/17/2023] [Accepted: 02/01/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND While deep brain stimulation (DBS) therapy can be effective at suppressing tremor in individuals with medication-refractory Essential Tremor, patient outcome variability remains a significant challenge across centers. Proximity of active electrodes to the cerebellothalamic tract (CTT) is likely important in suppressing tremor, but how tremor control and side effects relate to targeting parcellations within the CTT and other pathways in and around the ventral intermediate (VIM) nucleus of thalamus remain unclear. METHODS Using ultra-high field (7T) MRI, we developed high-dimensional, subject-specific pathway activation models for 23 directional DBS leads. Modeled pathway activations were compared with post-hoc analysis of clinician-optimized DBS settings, paresthesia thresholds, and dysarthria thresholds. Mixed-effect models were utilized to determine how the six parcellated regions of the CTT and how six other pathways in and around the VIM contributed to tremor suppression and induction of side effects. RESULTS The lateral portion of the CTT had the highest activation at clinical settings (p < 0.05) and a significant effect on tremor suppression (p < 0.001). Activation of the medial lemniscus and posterior-medial CTT was significantly associated with severity of paresthesias (p < 0.001). Activation of the anterior-medial CTT had a significant association with dysarthria (p < 0.05). CONCLUSIONS This study provides a detailed understanding of the fiber pathways responsible for therapy and side effects of DBS for Essential Tremor, and suggests a model-based programming approach will enable more selective activation of lateral fibers within the CTT.
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15
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Middlebrooks EH, Popple RA, Greco E, Okromelidze L, Walker HC, Lakhani DA, Anderson AR, Thomas EM, Deshpande HD, McCullough BA, Stover NP, Sung VW, Nicholas AP, Standaert DG, Yacoubian T, Dean MN, Roper JA, Grewal SS, Holland MT, Bentley JN, Guthrie BL, Bredel M. Connectomic Basis for Tremor Control in Stereotactic Radiosurgical Thalamotomy. AJNR Am J Neuroradiol 2023; 44:157-164. [PMID: 36702499 PMCID: PMC9891328 DOI: 10.3174/ajnr.a7778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND PURPOSE Given the increased use of stereotactic radiosurgical thalamotomy and other ablative therapies for tremor, new biomarkers are needed to improve outcomes. Using resting-state fMRI and MR tractography, we hypothesized that a "connectome fingerprint" can predict tremor outcomes and potentially serve as a targeting biomarker for stereotactic radiosurgical thalamotomy. MATERIALS AND METHODS We evaluated 27 patients who underwent unilateral stereotactic radiosurgical thalamotomy for essential tremor or tremor-predominant Parkinson disease. Percentage postoperative improvement in the contralateral limb Fahn-Tolosa-Marin Clinical Tremor Rating Scale (TRS) was the primary end point. Connectome-style resting-state fMRI and MR tractography were performed before stereotactic radiosurgery. Using the final lesion volume as a seed, "connectivity fingerprints" representing ideal connectivity maps were generated as whole-brain R-maps using a voxelwise nonparametric Spearman correlation. A leave-one-out cross-validation was performed using the generated R-maps. RESULTS The mean improvement in the contralateral tremor score was 55.1% (SD, 38.9%) at a mean follow-up of 10.0 (SD, 5.0) months. Structural connectivity correlated with contralateral TRS improvement (r = 0.52; P = .006) and explained 27.0% of the variance in outcome. Functional connectivity correlated with contralateral TRS improvement (r = 0.50; P = .008) and explained 25.0% of the variance in outcome. Nodes most correlated with tremor improvement corresponded to areas of known network dysfunction in tremor, including the cerebello-thalamo-cortical pathway and the primary and extrastriate visual cortices. CONCLUSIONS Stereotactic radiosurgical targets with a distinct connectivity profile predict improvement in tremor after treatment. Such connectomic fingerprints show promise for developing patient-specific biomarkers to guide therapy with stereotactic radiosurgical thalamotomy.
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Affiliation(s)
- E H Middlebrooks
- From the Departments of Radiology (E.H.M., E.G., L.O., D.A.L.)
- Neurosurgery (E.H.M., S.S.G.), Mayo Clinic, Jacksonville, Florida
| | - R A Popple
- Departments of Radiation Oncology (R.A.P., A.R.A., E.M.T., M.B.)
| | - E Greco
- From the Departments of Radiology (E.H.M., E.G., L.O., D.A.L.)
| | - L Okromelidze
- From the Departments of Radiology (E.H.M., E.G., L.O., D.A.L.)
| | - H C Walker
- Neurology (H.C.W., B.A.M., N.P.S., V.W.S., A.P.N., D.G.S., T.Y., M.N.D.)
| | - D A Lakhani
- From the Departments of Radiology (E.H.M., E.G., L.O., D.A.L.)
- Department of Radiology (D.A.L.), West Virginia University, Morgantown, West Virginia
| | - A R Anderson
- Departments of Radiation Oncology (R.A.P., A.R.A., E.M.T., M.B.)
| | - E M Thomas
- Departments of Radiation Oncology (R.A.P., A.R.A., E.M.T., M.B.)
- Department of Radiation Oncology (E.M.T.), Ohio State University, Columbus, Ohio
| | | | - B A McCullough
- Neurology (H.C.W., B.A.M., N.P.S., V.W.S., A.P.N., D.G.S., T.Y., M.N.D.)
| | - N P Stover
- Neurology (H.C.W., B.A.M., N.P.S., V.W.S., A.P.N., D.G.S., T.Y., M.N.D.)
| | - V W Sung
- Neurology (H.C.W., B.A.M., N.P.S., V.W.S., A.P.N., D.G.S., T.Y., M.N.D.)
| | - A P Nicholas
- Neurology (H.C.W., B.A.M., N.P.S., V.W.S., A.P.N., D.G.S., T.Y., M.N.D.)
| | - D G Standaert
- Neurology (H.C.W., B.A.M., N.P.S., V.W.S., A.P.N., D.G.S., T.Y., M.N.D.)
| | - T Yacoubian
- Neurology (H.C.W., B.A.M., N.P.S., V.W.S., A.P.N., D.G.S., T.Y., M.N.D.)
| | - M N Dean
- Neurology (H.C.W., B.A.M., N.P.S., V.W.S., A.P.N., D.G.S., T.Y., M.N.D.)
| | - J A Roper
- School of Kinesiology (J.A.R.), Auburn University, Auburn, Alabama
| | - S S Grewal
- Neurosurgery (E.H.M., S.S.G.), Mayo Clinic, Jacksonville, Florida
| | - M T Holland
- Neurosurgery (M.T.H., J.N.B., B.L.G.), University of Alabama at Birmingham, Birmingham, Alabama
| | - J N Bentley
- Neurosurgery (M.T.H., J.N.B., B.L.G.), University of Alabama at Birmingham, Birmingham, Alabama
| | - B L Guthrie
- Neurosurgery (M.T.H., J.N.B., B.L.G.), University of Alabama at Birmingham, Birmingham, Alabama
| | - M Bredel
- Departments of Radiation Oncology (R.A.P., A.R.A., E.M.T., M.B.)
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16
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Cerebellar deep brain stimulation for movement disorders. Neurobiol Dis 2022; 175:105899. [DOI: 10.1016/j.nbd.2022.105899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
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17
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Zheng Y, Wan KR. Letter to the Editor. Precision deep brain stimulation. J Neurosurg 2022; 138:1165-1166. [PMID: 36334290 DOI: 10.3171/2022.9.jns222170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Yilong Zheng
- Yong Loo Lin School of Medicine, National University of Singapore, National Neuroscience Institute, Singapore
| | - Kai Rui Wan
- Yong Loo Lin School of Medicine, National University of Singapore, National Neuroscience Institute, Singapore
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18
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Neudorfer C, Kroneberg D, Al-Fatly B, Goede LL, Kübler D, Faust K, van Rienen U, Tietze A, Picht T, Herrington TM, Middlebrooks EH, Kühn A, Schneider GH, Horn A. Reply to "Deep Brain Stimulation for Tremor: Direct Targeting of a Novel Imaging Biomarker". Ann Neurol 2022; 92:343-344. [PMID: 35608332 DOI: 10.1002/ana.26420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Clemens Neudorfer
- MGH Neurosurgery & Center for Neurotechnology and Neurorecovery (CNTR), MGH Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Center for Brain Circuit Therapeutics Department of Neurology Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.,Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel Kroneberg
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Bassam Al-Fatly
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lukas L Goede
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Dorothee Kübler
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Ursula van Rienen
- Institute of General Electrical Engineering, University of Rostock, Rostock, Germany.,Department Life, Light & Matter, University of Rostock, Rostock, Germany.,Department Ageing of Individuals and Society, University of Rostock, Rostock, Germany
| | - Anna Tietze
- Institute of Neuroradiology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Thomas Picht
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Todd M Herrington
- MGH Neurosurgery & Center for Neurotechnology and Neurorecovery (CNTR), MGH Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.,Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Erik H Middlebrooks
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Andrea Kühn
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Horn
- MGH Neurosurgery & Center for Neurotechnology and Neurorecovery (CNTR), MGH Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Center for Brain Circuit Therapeutics Department of Neurology Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.,Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité -Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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19
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Middlebrooks EH, Grewal SS. Brain Connectomics. Neuroimaging Clin N Am 2022; 32:543-552. [PMID: 35843661 DOI: 10.1016/j.nic.2022.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
A central tenet of modern neuroscience is the conceptualization of the brain as a collection of complex networks or circuits with a shift away from traditional "localizationist" theories. Connectomics seeks to unravel these brain networks and their role in the pathophysiology of neurologic diseases. This article discusses the science of connectomics with the examples of its potential role in clinical medicine and neuromodulation in multiple disorders, such as essential tremor, Parkinson's disease, obsessive-compulsive disorder, and epilepsy.
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Affiliation(s)
- Erik H Middlebrooks
- Department of Radiology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA; Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
| | - Sanjeet S Grewal
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA
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Middlebrooks EH, Tipton P, Okromelidze L, Greco E, Mendez JA, Uitti R, Grewal SS. Deep Brain Stimulation for Tremor: Direct Targeting of a Novel Imaging Biomarker. Ann Neurol 2022; 92:341-342. [PMID: 35596936 DOI: 10.1002/ana.26422] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/19/2022] [Accepted: 05/19/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Erik H Middlebrooks
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA.,Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Philip Tipton
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | | | - Elena Greco
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Julio A Mendez
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Ryan Uitti
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
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21
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Neudorfer C, Kroneberg D, Al-Fatly B, Goede L, Kübler D, Faust K, van Rienen U, Tietze A, Picht T, Herrington TM, Middlebrooks EH, Kühn A, Schneider GH, Horn A. Personalizing Deep Brain Stimulation Using Advanced Imaging Sequences. Ann Neurol 2022; 91:613-628. [PMID: 35165921 DOI: 10.1002/ana.26326] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 02/09/2022] [Accepted: 02/11/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE With a growing appreciation for interindividual anatomical variability and patient-specific brain connectivity, advanced imaging sequences offer the opportunity to directly visualize anatomical targets for deep brain stimulation (DBS). The lack of quantitative evidence demonstrating their clinical utility, however, has hindered their broad implementation in clinical practice. METHODS Using fast gray matter acquisition T1 inversion recovery (FGATIR) sequences, the present study identified a thalamic hypointensity that holds promise as a visual marker in DBS. To validate the clinical utility of the identified hypointensity, we retrospectively analyzed 65 patients (26 female, mean age = 69.1 ± 12.7 years) who underwent DBS in the treatment of essential tremor. We characterized its neuroanatomical substrates and evaluated the hypointensity's ability to predict clinical outcome using stimulation volume modeling and voxelwise mapping. Finally, we determined whether the hypointensity marker could predict symptom improvement on a patient-specific level. RESULTS Anatomical characterization suggested that the identified hypointensity constituted the terminal part of the dentatorubrothalamic tract. Overlap between DBS stimulation volumes and the hypointensity in standard space significantly correlated with tremor improvement (R2 = 0.16, p = 0.017) and distance to hotspots previously reported in the literature (R2 = 0.49, p = 7.9e-4). In contrast, the amount of variance explained by other anatomical atlas structures was reduced. When accounting for interindividual neuroanatomical variability, the predictive power of the hypointensity increased further (R2 = 0.37, p = 0.002). INTERPRETATION Our findings introduce and validate a novel imaging-based marker attainable from FGATIR sequences that has the potential to personalize and inform targeting and programming in DBS for essential tremor. ANN NEUROL 2022;91:613-628.
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Affiliation(s)
- Clemens Neudorfer
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany.,MGH Neurosurgery & Center for Neurotechnology and Neurorecovery (CNTR), MGH Neurology Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Center for Brain Circuit Therapeutics Department of Neurology Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Kroneberg
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany
| | - Bassam Al-Fatly
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany
| | - Lukas Goede
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany
| | - Dorothee Kübler
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany
| | - Katharina Faust
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany
| | - Ursula van Rienen
- Institute of General Electrical Engineering, University of Rostock, Rostock, Germany.,Department Life, Light, and Matter, University of Rostock, Rostock, Germany.,Department of Ageing of Individuals and Society, University of Rostock, Rostock, Germany
| | - Anna Tietze
- Institute of Neuroradiology, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany
| | - Thomas Picht
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany
| | - Todd M Herrington
- Department of Neurology, Massachusetts General Hospital, Boston, MA.,Department of Neurology, Harvard Medical School, Boston, MA
| | - Erik H Middlebrooks
- Department of Radiology, Mayo Clinic, Jacksonville, FL.,Department of Neurosurgery, Mayo Clinic, Jacksonville, FL
| | - Andrea Kühn
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany
| | - Andreas Horn
- Movement Disorder and Neuromodulation Unit, Department of Neurology, Charité-Universitätsmedizin Berlin, corporate member of Free University of Berlin and Humboldt University of Berlin, Berlin, Germany.,MGH Neurosurgery & Center for Neurotechnology and Neurorecovery (CNTR), MGH Neurology Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Center for Brain Circuit Therapeutics Department of Neurology Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
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22
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Kondapavulur S, Silva AB, Wang DD. Ventral Intermediate Nucleus of the Thalamus versus Posterior Subthalamic Area: Network Meta-Analysis of DBS Target Site Efficacy for Essential Tremor. Stereotact Funct Neurosurg 2022; 100:224-235. [PMID: 35350022 DOI: 10.1159/000522573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/03/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) targeting the ventral intermediate nucleus (Vim) of the thalamus or the posterior subthalamic area (PSA) are effective treatments for essential tremor (ET). However, their relative efficacy is unknown. OBJECTIVE Here, we present the first systematic review and network meta-analysis, examining the efficacy of Vim versus PSA DBS for treating medically refractory ET. METHODS We included all primary studies that reported validated Fahn-Tolosa-Marin Tremor Rating Scale (FTM-TRS) scores pre-/postimplantation or on-/off-stimulation postimplantation, for patients receiving either Vim or PSA DBS. The primary outcome was FTM-TRS score reduction; the secondary outcome was percent reduction in score. We categorized all outcomes as short-term (≤12 months) or long-term (>12 months). RESULTS For pre-/postimplantation comparisons, 19 and 11 studies met inclusion criteria for short- and long-term follow-ups, respectively. For on-/off-stimulation tremor score comparisons, 8 studies met inclusion criteria for short-term follow-up. Network meta-analysis of pre-/postimplantation tremor scores showed greater tremor reduction with PSA implantation short-term (absolute tremor reduction: PSA: -30.94 [95% confidence interval (CI): -34.93, -26.95]; Vim: -26.26 [95% CI: -33.39, -19.12]; relative tremor reduction: PSA: 63.3% [95% CI: 61.8%-64.8%]; Vim: 57.8% [95% CI: 56.5%-59.0%]). However, there was no difference in efficacy between PSA and Vim DBS when comparing tremor on-versus off-stimulation at short-term follow-up or pre- versus postimplantation tremor reduction long-term. CONCLUSION Our systematic review highlighted both heterogeneity in scoring systems used and lack of transparency in reporting total scores, limiting direct comparison across studies. We found a modestly superior efficacy with PSA stimulation in the short term, but no difference in tremor reduction long-term.
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Affiliation(s)
- Sravani Kondapavulur
- Department of Neurological Surgery, UCSF, San Francisco, California, USA.,Medical Scientist Training Program, UCSF, San Francisco, California, USA
| | - Alexander B Silva
- Department of Neurological Surgery, UCSF, San Francisco, California, USA.,Medical Scientist Training Program, UCSF, San Francisco, California, USA
| | - Doris D Wang
- Department of Neurological Surgery, UCSF, San Francisco, California, USA
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23
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Wong JK, Patel B, Middlebrooks EH, Hilliard JD, Foote KD, Okun MS, Almeida L. Connectomic analysis of unilateral dual lead thalamic deep brain stimulation for treatment of multiple sclerosis tremor. Brain Commun 2022; 4:fcac063. [PMID: 35368612 PMCID: PMC8971897 DOI: 10.1093/braincomms/fcac063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 01/24/2022] [Accepted: 03/14/2022] [Indexed: 11/12/2022] Open
Abstract
Tremor is a common symptom in multiple sclerosis and can present as a severe postural and action tremor, leading to significant disability. Owing to the diffuse and progressive nature of the disease, it has been challenging to characterize the pathophysiology underlying multiple sclerosis tremor. Deep brain stimulation of the ventralis intermedius and the ventralis oralis posterior thalamic nuclei has been used to treat medically refractory multiple sclerosis tremors with variable results. The aim of this study was to characterize multiple sclerosis tremor at the network level by applying modern connectomic techniques to data from a previously completed single-centre, randomized, single-blind prospective trial of 12 subjects who were treated with unilateral dual-lead (ventralis intermedius + ventralis oralis posterior) thalamic deep brain stimulation. Preoperative T1-weighted MRI and postoperative head CTs were used, along with applied programming settings, to estimate the volume of tissue activated for each patient. The volumes of tissue activated were then used to make voxel-wise and structural connectivity correlations with clinically observed tremor suppression. The volume of the tissue-activated analyses identified the optimal region of stimulation at the ventralis oralis posterior ventralis intermedius border intersecting with the dentato-rubro-thalamic tract. A regression model showed strong connectivity to the supplemental motor area was positively associated with tremor suppression (r = 0.66) in this cohort, whereas connectivity to the primary motor cortex was negatively associated with tremor suppression (r = −0.69), a finding opposite to that seen in ventralis intermedius deep brain stimulation for essential tremor. Comparing the structural connectivity to that of an essential tremor cohort revealed a distinct network that lies anterior to the essential tremor network. Overall, the volumes of tissue activated and connectivity observations converge to suggest that optimal suppression of multiple sclerosis tremor will likely be achieved by directing stimulation more anteriorly toward the ventralis oralis posterior and that a wide field of stimulation synergistically modulating the ventralis oralis posterior and ventralis intermedius nuclei may be more effective than traditional ventralis intermedius deep brain stimulation at suppressing the severe tremors commonly seen in complex tremor syndromes such as multiple sclerosis tremor.
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Affiliation(s)
- Joshua K. Wong
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL 32608, USA
- Correspondence to: Joshua K. Wong, MD 3009 Williston Road Gainesville, FL 32608, USA E-mail:
| | - Bhavana Patel
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL 32608, USA
| | | | - Justin D. Hilliard
- Fixel Institute for Neurological Diseases, Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Kelly D. Foote
- Fixel Institute for Neurological Diseases, Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
| | - Michael S. Okun
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL 32608, USA
| | - Leonardo Almeida
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL 32608, USA
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24
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Chandra V, Hilliard JD, Foote KD. Deep brain stimulation for the treatment of tremor. J Neurol Sci 2022; 435:120190. [DOI: 10.1016/j.jns.2022.120190] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 02/07/2022] [Accepted: 02/17/2022] [Indexed: 01/15/2023]
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25
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Tao S, Zhou X, Westerhold EM, Middlebrooks EH, Lin C. Optimization of fast gray matter acquisition T1 inversion recovery (FGATIR) on 7T MRI for deep brain stimulation targeting. Neuroimage 2022; 252:119043. [PMID: 35235838 DOI: 10.1016/j.neuroimage.2022.119043] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 02/24/2022] [Accepted: 02/26/2022] [Indexed: 10/19/2022] Open
Abstract
Deep brain stimulation (DBS) is an increasingly utilized treatment for multiple neurological disorders. Continued improvements in DBS outcome are, in part, related to increasing ability to directly visualize stimulation targets by MRI. However, it is challenging to image DBS targets with conventional MRI techniques due to limited contrast. Fast Gray Matter Acquisition T1 Inversion Recovery (FGATIR) is a commonly used MRI sequence that improves visualization of several key DBS targets by suppressing white matter (WM) signal to better reveal deep-brain gray matter (GM) structures. Due to increased signal level at high field strength, application of FGATIR on 7T MRI may allow higher spatial resolution and better DBS targeting accuracy. However, successful utilization of FGATIR requires meticulous sequence optimization involving multiple parameters to maximize GM signal while suppressing WM. This is further complicated by the transmit RF field (B1+) inhomogeneity on 7T, which can cause severe contrast degradation. In this work, we introduce a systematic approach to optimize FGATIR and to improve visualization of thalamic DBS targets on 7T. FGATIR optimization is cast into a constrained optimization problem whose objective function and constraints are designed to maximize the GM-WM contrast-to-noise ratio (CNR) while accounting for B1+ inhomogeneity. This approach allows a systematic search for optimal parameters across the multi-dimensional parametric space while limiting the negative effect of B1+ variation. Bloch equation simulations were performed to solve the proposed optimization problem and to compare the sequence derived from this method against the sequence optimized without considering B1+ inhomogeneity. The results showed that this approach can improve GM-WM CNR in the presence of B1+ inhomogeneity, especially in some high relative B1+ areas where several key thalamic DBS targets are located. Additionally, in vivo images were acquired on a clinical 7T MRI to further validate this approach. Severe contrast degradation in the thalamus was observed when B1+ effect was not considered in sequence optimization, while the proposed approach yielded improved image contrast in the thalamus with key DBS targets well-defined. These results demonstrated that the proposed method allowed optimization of FGATIR on 7T to better visualize thalamic DBS targets, which may lead to improved DBS targeting accuracy as well as treatment outcome.
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Affiliation(s)
- Shengzhen Tao
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA.
| | - Xiangzhi Zhou
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | | | | | - Chen Lin
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
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26
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Fra̧czek TM, Ferleger BI, Brown TE, Thompson MC, Haddock AJ, Houston BC, Ojemann JG, Ko AL, Herron JA, Chizeck HJ. Closing the Loop With Cortical Sensing: The Development of Adaptive Deep Brain Stimulation for Essential Tremor Using the Activa PC+S. Front Neurosci 2021; 15:749705. [PMID: 34955714 PMCID: PMC8695120 DOI: 10.3389/fnins.2021.749705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022] Open
Abstract
Deep Brain Stimulation (DBS) is an important tool in the treatment of pharmacologically resistant neurological movement disorders such as essential tremor (ET) and Parkinson's disease (PD). However, the open-loop design of current systems may be holding back the true potential of invasive neuromodulation. In the last decade we have seen an explosion of activity in the use of feedback to "close the loop" on neuromodulation in the form of adaptive DBS (aDBS) systems that can respond to the patient's therapeutic needs. In this paper we summarize the accomplishments of a 5-year study at the University of Washington in the use of neural feedback from an electrocorticography strip placed over the sensorimotor cortex. We document our progress from an initial proof of hardware all the way to a fully implanted adaptive stimulation system that leverages machine-learning approaches to simplify the programming process. In certain cases, our systems out-performed current open-loop approaches in both power consumption and symptom suppression. Throughout this effort, we collaborated with neuroethicists to capture patient experiences and take them into account whilst developing ethical aDBS approaches. Based on our results we identify several key areas for future work. "Graded" aDBS will allow the system to smoothly tune the stimulation level to symptom severity, and frequent automatic calibration of the algorithm will allow aDBS to adapt to the time-varying dynamics of the disease without additional input from a clinician. Additionally, robust computational models of the pathophysiology of ET will allow stimulation to be optimized to the nuances of an individual patient's symptoms. We also outline the unique advantages of using cortical electrodes for control and the remaining hardware limitations that need to be overcome to facilitate further development in this field. Over the course of this study we have verified the potential of fully-implanted, cortically driven aDBS as a feasibly translatable treatment for pharmacologically resistant ET.
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Affiliation(s)
- Tomasz M. Fra̧czek
- Neuroscience Program, University of Washington, Seattle, WA, United States
| | - Benjamin I. Ferleger
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, United States
| | - Timothy E. Brown
- Department of Philosophy, University of Washington, Seattle, WA, United States
| | - Margaret C. Thompson
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, United States
| | - Andrew J. Haddock
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, United States
| | - Brady C. Houston
- Neuroscience Program, University of Washington, Seattle, WA, United States
| | - Jeffrey G. Ojemann
- Department of Neurological Surgery, University of Washington, Seattle, WA, United States
| | - Andrew L. Ko
- Department of Neurological Surgery, University of Washington, Seattle, WA, United States
| | - Jeffrey A. Herron
- Department of Neurological Surgery, University of Washington, Seattle, WA, United States
| | - Howard J. Chizeck
- Department of Electrical and Computer Engineering, University of Washington, Seattle, WA, United States
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