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Mojiri Z, Akhavan A, Rouhani E, Zahabi SJ. Quantitative analysis of noninvasive deep temporal interference stimulation: A simulation and experimental study. Heliyon 2024; 10:e29482. [PMID: 38655334 PMCID: PMC11035070 DOI: 10.1016/j.heliyon.2024.e29482] [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: 09/17/2023] [Revised: 04/07/2024] [Accepted: 04/08/2024] [Indexed: 04/26/2024] Open
Abstract
Background Deep brain stimulation (DBS) is a method for stimulating deep regions of the brain for the treatment of various neurological and psychiatric disorders such as depression, obsessive-compulsive disorder, addiction, and Parkinson's disease. Generally, DBS can be performed using both invasive and non-invasive approaches. Invasive DBS is associated with several problems, including intracranial bleeding, infection, and changes in the position of the electrode tip. Temporal interference (TI) stimulation is a non-invasive technique used to stimulate deep regions of the brain by applying two high-frequency sinusoidal currents with slightly different frequencies. New method This paper presents insights into the response of the spiking in the Hodgkin-Huxley (HH) neuron model of the rat somatosensory cortex by changing the parameters carrier frequency, current ratio, and difference frequency of TI stimulation. Furthermore, in order to experimentally evaluate the effect of TI stimulation on the activation of the left motor cortex, an experiment was conducted to measure the motion induced by the balanced and unbalanced TI stimulation. In the experiment, a three-axis accelerometer was attached to the right hand of the animal to determine the position of the hand. Results Simulation results of the HH model showed that the frequency of the envelope of the TI stimulation is identical to the fundamental frequency of the neuron spikes. This result was obtained for difference frequencies of 6 Hz and 9 Hz in balanced and unbalanced TI stimulations. Moreover specifically, when the difference frequency is set to zero, the carrier frequency is within the range of 1300-1400 Hz, and the current range is between 140 and 250 μA/cm2, the firing rate reached to its highest value. In the experimental result, the maximum range of movement at a difference frequency of Δf = 6 Hz was approximately 1.6 mm and 5.3 mm in the z and y directions respectively. Comparison with existing method The results of the spatial spectrum of the rat hand movement were consistent with the spectrum information of the simulation results. Additionally, steering the interfering region to the left motor cortex leads to noticeable contralateral movement of the right hand while no movement was observed in the right hand during the stimulation of the right motor cortex. Conclusion This technique of stimulation for the deep regions of the brain is a promising tool to noninvasively treat various neurological and psychiatric disorders such as morphine dependence in addicted rats.
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Affiliation(s)
- Zohre Mojiri
- Department of Electrical and Computer Engineering, Isfahan University of Technology, Isfahan, 84156-83111, Iran
| | - Amir Akhavan
- Department of Electrical and Computer Engineering, Isfahan University of Technology, Isfahan, 84156-83111, Iran
| | - Ehsan Rouhani
- Department of Electrical and Computer Engineering, Isfahan University of Technology, Isfahan, 84156-83111, Iran
| | - Sayed Jalal Zahabi
- Department of Electrical and Computer Engineering, Isfahan University of Technology, Isfahan, 84156-83111, Iran
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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.
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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
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Xu W, Wang J, Li XN, Liang J, Song L, Wu Y, Liu Z, Sun B, Li WG. Neuronal and synaptic adaptations underlying the benefits of deep brain stimulation for Parkinson's disease. Transl Neurodegener 2023; 12:55. [PMID: 38037124 PMCID: PMC10688037 DOI: 10.1186/s40035-023-00390-w] [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: 08/01/2023] [Accepted: 11/19/2023] [Indexed: 12/02/2023] Open
Abstract
Deep brain stimulation (DBS) is a well-established and effective treatment for patients with advanced Parkinson's disease (PD), yet its underlying mechanisms remain enigmatic. Optogenetics, primarily conducted in animal models, provides a unique approach that allows cell type- and projection-specific modulation that mirrors the frequency-dependent stimulus effects of DBS. Opto-DBS research in animal models plays a pivotal role in unraveling the neuronal and synaptic adaptations that contribute to the efficacy of DBS in PD treatment. DBS-induced neuronal responses rely on a complex interplay between the distributions of presynaptic inputs, frequency-dependent synaptic depression, and the intrinsic excitability of postsynaptic neurons. This orchestration leads to conversion of firing patterns, enabling both antidromic and orthodromic modulation of neural circuits. Understanding these mechanisms is vital for decoding position- and programming-dependent effects of DBS. Furthermore, patterned stimulation is emerging as a promising strategy yielding long-lasting therapeutic benefits. Research on the neuronal and synaptic adaptations to DBS may pave the way for the development of more enduring and precise modulation patterns. Advanced technologies, such as adaptive DBS or directional electrodes, can also be integrated for circuit-specific neuromodulation. These insights hold the potential to greatly improve the effectiveness of DBS and advance PD treatment to new levels.
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Affiliation(s)
- Wenying Xu
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
| | - Jie Wang
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
- Department of Neurology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Xin-Ni Li
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
| | - Jingxue Liang
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
- Department of Neurology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Lu Song
- Department of Neurology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China
| | - Yi Wu
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
| | - Zhenguo Liu
- Department of Neurology, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China.
| | - Bomin Sun
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China.
| | - Wei-Guang Li
- Department of Rehabilitation Medicine, Huashan Hospital, Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology and Ministry of Education Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China.
- Ministry of Education-Shanghai Key Laboratory for Children's Environmental Health, Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, 200092, China.
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Venkatesh P, Wolfe C, Lega B. Neuromodulation of the anterior thalamus: Current approaches and opportunities for the future. CURRENT RESEARCH IN NEUROBIOLOGY 2023; 5:100109. [PMID: 38020810 PMCID: PMC10663132 DOI: 10.1016/j.crneur.2023.100109] [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: 05/14/2023] [Revised: 08/28/2023] [Accepted: 08/31/2023] [Indexed: 12/01/2023] Open
Abstract
The role of thalamocortical circuits in memory has driven a recent burst of scholarship, especially in animal models. Investigating this circuitry in humans is more challenging. And yet, the development of new recording and stimulation technologies deployed for clinical indications has created novel opportunities for data collection to elucidate the cognitive roles of thalamic structures. These technologies include stereoelectroencephalography (SEEG), deep brain stimulation (DBS), and responsive neurostimulation (RNS), all of which have been applied to memory-related thalamic regions, specifically for seizure localization and treatment. This review seeks to summarize the existing applications of neuromodulation of the anterior thalamic nuclei (ANT) and highlight several devices and their capabilities that can allow cognitive researchers to design experiments to assay its functionality. Our goal is to introduce to investigators, who may not be familiar with these clinical devices, the capabilities, and limitations of these tools for understanding the neurophysiology of the ANT as it pertains to memory and other behaviors. We also briefly cover the targeting of other thalamic regions including the centromedian (CM) nucleus, dorsomedial (DM) nucleus, and pulvinar, with associated potential avenues of experimentation.
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Affiliation(s)
- Pooja Venkatesh
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX, 75390, USA
| | - Cody Wolfe
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX, 75390, USA
| | - Bradley Lega
- Department of Neurosurgery, University of Texas Southwestern, Dallas, TX, 75390, USA
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Wang L, Li J, Pan Y, Huang P, Li D, Voon V. Subacute alpha frequency (10Hz) subthalamic stimulation for emotional processing in Parkinson's disease. Brain Stimul 2023; 16:1223-1231. [PMID: 37567462 DOI: 10.1016/j.brs.2023.08.005] [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: 01/18/2023] [Revised: 05/21/2023] [Accepted: 08/07/2023] [Indexed: 08/13/2023] Open
Abstract
BACKGROUND Psychiatric comorbidities are common in Parkinson's disease (PD) and may change with high-frequency stimulation targeting the subthalamic nucleus. Numerous accounts indicate subthalamic alpha-frequency oscillation is implicated in emotional processing. While intermittent alpha-frequency (10Hz) stimulation induces positive emotional effects, with more ventromedial contacts inducing larger effects, little is known about the subacute effect of ventral 10Hz subthalamic stimulation on emotional processing. OBJECTIVE/HYPOTHESIS To evaluate the subacute effect of 10Hz stimulation at bilateral ventral subthalamic nucleus on emotional processing in PD patients using an affective task, compared to that of clinical-frequency stimulation and off-stimulation. METHODS Twenty PD patients with bilateral subthalamic deep brain stimulation for more than six months were tested with the affective task under three stimulation conditions (10Hz, 130Hz, and off-stimulation) in a double-blinded randomized design. RESULTS While 130Hz stimulation reduced arousal ratings in all patients, 10Hz stimulation increased arousal selectively in patients with higher depression scores. Furthermore, 10Hz stimulation induced a positive shift in valence rating to negative emotional stimuli in patients with lower apathy scores, and 130Hz stimulation led to more positive valence to emotional stimuli in the patients with higher apathy scores. Notably, we found correlational relationships between stimulation site and affective rating: arousal ratings increase with stimulation from anterior to posterior site, and positive valence ratings increase with stimulation from dorsal to ventral site of the ventral subthalamic nucleus. CONCLUSIONS Our findings highlight the distinctive role of 10Hz stimulation on subjective emotional experience and unveil the spatial organization of the stimulation effect.
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Affiliation(s)
- Linbin Wang
- Institute of Science and Technology for Brain-Inspired Intelligence (ISTBI), Fudan University, Shanghai, China; Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Li
- School of Information Science and Technology, ShanghaiTech University, Shanghai, China
| | - Yixin Pan
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peng Huang
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dianyou Li
- Department of Neurosurgery, Center for Functional Neurosurgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Valerie Voon
- Institute of Science and Technology for Brain-Inspired Intelligence (ISTBI), Fudan University, Shanghai, China; Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom.
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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.
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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
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Efficacy of short pulse and conventional deep brain stimulation in Parkinson's disease: a systematic review and meta-analysis. Neurol Sci 2023; 44:815-825. [PMID: 36383263 DOI: 10.1007/s10072-022-06484-z] [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: 07/24/2022] [Accepted: 10/28/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) is a common treatment for Parkinson's disease. However, the clinical efficacy of short pulse width DBS (spDBS) compared with conventional DBS (cDBS) is still unknown. OBJECTIVE This meta-analysis investigated the effectiveness of spDBS versus cDBS in patients with PD. METHODS Four databases (PubMed, Cochrane, Web of Science, and Embase) were independently searched until October 2021 by two reviewers. We utilized the following scales and items: therapeutic windows (TW), efficacy threshold, side effect threshold, Movement Disorder Society-Sponsored Revision Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part III off-medication score, Speech Intelligence Test (SIT), and Freezing of Gait Questionnaire (FOG-Q). RESULTS The analysis included seven studies with a total of 87 patients. The results indicated that spDBS significantly widened the therapeutic windows (0.99, 95% CI = 0.61 to 1.38) while increasing the threshold amplitudes of side effects (2.25, 95% CI = 1.69 to 2.81) and threshold amplitudes of effects (1.60, 95% CI = 0.84 to 2.36). There was no statistically significant difference in UPDRS part III, SIT, and FOG-Q scores between spDBS and cDBS groups, suggesting that treatment with both cDBS and spDBS may result in similar effects of improved dysarthria and gait disorders. CONCLUSIONS Compared with cDBS, spDBS is effective in expanding TW. Both types of deep brain stimulation resulted in improved gait disorders and speech intelligibility.
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Kumar G, Ma CHE. Toward a cerebello-thalamo-cortical computational model of spinocerebellar ataxia. Neural Netw 2023; 162:541-556. [PMID: 37023628 DOI: 10.1016/j.neunet.2023.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 12/07/2022] [Accepted: 01/28/2023] [Indexed: 02/05/2023]
Abstract
Computational neural network modelling is an emerging approach for optimization of drug treatment of neurological disorders and fine-tuning of rehabilitation strategies. In the current study, we constructed a cerebello-thalamo-cortical computational neural network model to simulate a mouse model of cerebellar ataxia (pcd5J mice) by manipulating cerebellar bursts through reduction of GABAergic inhibitory input. Cerebellar output neurons were projected to the thalamus and bidirectionally connected with the cortical network. Our results showed that reduction of inhibitory input in the cerebellum orchestrated the cortical local field potential (LFP) dynamics to generate specific motor outputs of oscillations of the theta, alpha, and beta bands in the computational model as well as in mouse motor cortical neurons. The therapeutic potential of deep brain stimulation (DBS) was tested in the computational model by increasing the sensory input to restore cortical output. Ataxia mice showed normalization of the motor cortex LFP after cerebellum DBS. We provide a novel approach to computational modelling to investigate the effect of DBS by mimicking cerebellar ataxia involving degeneration of Purkinje cells. Simulated neural activity coincides with findings from neural recordings of ataxia mice. Our computational model could thus represent cerebellar pathologies and provide insight into how to improve disease symptoms by restoring neuronal electrophysiological properties using DBS.
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Affiliation(s)
- Gajendra Kumar
- Department of Neuroscience, City University of Hong Kong, Tat Chee Avenue, Hong Kong Special Administrative Region.
| | - Chi Him Eddie Ma
- Department of Neuroscience, City University of Hong Kong, Tat Chee Avenue, Hong Kong Special Administrative Region.
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Roediger J, Dembek TA, Achtzehn J, Busch JL, Krämer AP, Faust K, Schneider GH, Krause P, Horn A, Kühn AA. Automated deep brain stimulation programming based on electrode location: a randomised, crossover trial using a data-driven algorithm. Lancet Digit Health 2023; 5:e59-e70. [PMID: 36528541 DOI: 10.1016/s2589-7500(22)00214-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 09/22/2022] [Accepted: 11/01/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is highly effective in controlling motor symptoms in patients with Parkinson's disease. However, correct selection of stimulation parameters is pivotal to treatment success and currently follows a time-consuming and demanding trial-and-error process. We aimed to assess treatment effects of stimulation parameters suggested by a recently published algorithm (StimFit) based on neuroimaging data. METHODS This double-blind, randomised, crossover, non-inferiority trial was carried out at Charité - Universitätsmedizin, Berlin, Germany, and enrolled patients with Parkinson's disease treated with directional octopolar electrodes targeted at the STN. All patients had undergone DBS programming according to our centre's standard of care (SoC) treatment before study recruitment. Based on perioperative imaging data, DBS electrodes were reconstructed and StimFit was applied to suggest optimal stimulation settings. Patients underwent motor assessments using the Movement Disorder Society-Sponsored Revision of the Unified Parkinson's Disease Rating Scale part III (MDS-UPDRS-III) during OFF-medication and in OFF-stimulation and ON-stimulation states under both conditions, StimFit and SoC parameter settings. Patients were randomly assigned (1:1) to receive either StimFit-programmed DBS first and SoC-programmed DBS second, or SoC-programmed DBS first and StimFit-programmed DBS second. The allocation schedule was generated using a computerised random number generator. Both the rater and patients were masked to the sequence of SoC and StimFit stimulation conditions. All patients who participated in the study were included in the analysis. The primary endpoint of this study was the absolute mean difference between MDS-UPDRS-III scores under StimFit and SoC stimulation, with a non-inferiority margin of 5 points. The study was registered at the German Register for Clinical Trials (DRKS00023115), and is complete. FINDINGS Between July 10, 2020, and Oct 28, 2021, 35 patients were enrolled in the study; 18 received StimFit followed by SoC stimulation, and 17 received SoC followed by StimFit stimulation. Mean MDS-UPDRS-III scores improved from 47·3 (SD 17·1) at OFF-stimulation baseline to 24·7 (SD 12·4) and 26·3 (SD 12·4) under SoC and StimFit stimulation, respectively. Mean difference between motor scores was -1·6 (SD 7·1; 95% CI -4·0 to 0·9; superiority test psuperiority=0·20; n=35), establishing non-inferiority of StimFit stimulation at a margin of -5 points (non-inferiority test pnon-inferiority=0·0038). In six patients (17%), initial programming of StimFit settings resulted in acute side-effects and amplitudes were reduced until side-effects disappeared. INTERPRETATION Automated data-driven algorithms can predict stimulation parameters that lead to motor symptom control comparable to SoC treatment. This approach could significantly decrease the time necessary to obtain optimal treatment parameters. FUNDING Deutsche Forschungsgemeinschaft through NeuroCure Clinical Research Center and TRR 295.
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Affiliation(s)
- Jan Roediger
- Movement Disorders and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Till A Dembek
- Department of Neurology, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Johannes Achtzehn
- Movement Disorders and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Johannes L Busch
- Movement Disorders and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anna-Pauline Krämer
- Movement Disorders 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
| | - Gerd-Helge Schneider
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Patricia Krause
- Movement Disorders and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Andreas Horn
- Movement Disorders and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Center for Brain Circuit Therapeutics, Department of Neurology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA; MGH Neurosurgery and Center for Neurotechnology and Neurorecovery (CNTR) at MGH Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea A Kühn
- Movement Disorders and Neuromodulation Unit, Department of Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Einstein Center for Neurosciences Berlin, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; NeuroCure Clinical Research Centre, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany; Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany; DZNE, German Center for Degenerative Diseases, Berlin, Germany.
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10
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Eskandari K, Fattahi M, Yazdanian H, Haghparast A. Is Deep Brain Stimulation an Effective Treatment for Psychostimulant Dependency? A Preclinical and Clinical Systematic Review. Neurochem Res 2022; 48:1255-1268. [PMID: 36445490 DOI: 10.1007/s11064-022-03818-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 11/30/2022]
Abstract
Addiction to psychostimulants significantly affects public health. Standard medical therapy is often not curative. Deep brain stimulation (DBS) is a promising treatment that has attracted much attention for addiction treatment in recent years. The present review aimed to systematically identify the positive and adverse effects of DBS in human and animal models to evaluate the feasibility of DBS as a treatment for psychostimulant abuse. The current study also examined the possible mechanisms underlying the therapeutic effects of DBS. In February 2022, a comprehensive search of four databases, including Web of Science, PubMed, Cochrane, and Scopus, was carried out to identify all reports that DBS was a treatment for psychostimulant addiction. The selected studies were extracted, summarized, and evaluated using the appropriate methodological quality assessment tools. The results indicated that DBS could reduce relapse and the desire for the drug in human and animal subjects without any severe side effects. The underlying mechanisms of DBS are complex and likely vary from region to region in terms of stimulation parameters and patterns. DBS seems a promising therapeutic option. However, clinical experiences are currently limited to several uncontrolled case reports. Further studies with controlled, double-blind designs are needed. In addition, more research on animals and humans is required to investigate the precise role of DBS and its mechanisms to achieve optimal stimulation parameters and develop new, less invasive methods.
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11
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Brogin JAF, Faber J, Bueno DD. Estimating the Parameters of the Epileptor Model for Epileptic Seizure Suppression. Neuroinformatics 2022; 20:919-941. [PMID: 35303252 DOI: 10.1007/s12021-022-09583-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 12/31/2022]
Abstract
Epilepsy is one of the most common brain disorders worldwide, affecting millions of people every year. Given the partially successful existing treatments for epileptiform activity suppression, dynamic mathematical models have been proposed with the purpose of better understanding the factors that might trigger an epileptic seizure and how to mitigate it, among which Epileptor stands out, due to its relative simplicity and consistency with experimental observations. Recent studies using this model have provided evidence that establishing a feedback-based control approach is possible. However, for this strategy to work properly, Epileptor's parameters, which describe the dynamic characteristics of a seizure, must be known beforehand. Therefore, this work proposes a methodology for estimating such parameters based on a successive optimization technique. The results show that it is feasible to approximate their values as they converge to reference values based on different initial conditions, which are modeled by an uncertainty factor or noise addition. Also, interictal (healthy) and ictal (ongoing seizure) conditions, as well as time resolution, must be taken into account for an appropriate estimation. At last, integrating such a parameter estimation approach with observers and controllers for purposes of seizure suppression is carried out, which might provide an interesting alternative for seizure suppression in practice in the future.
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Affiliation(s)
- João Angelo Ferres Brogin
- Department of Mechanical Engineering, São Paulo State University (UNESP), 56 Brasil Avenue, Ilha Solteira, 15385-000, São Paulo, Brazil.
| | - Jean Faber
- Department of Neurology and Neurosurgery, Federal University of São Paulo, 667 Pedro de Toledo Street, São Paulo, 04039-032, São Paulo, Brazil
| | - Douglas D Bueno
- Department of Mathematics, São Paulo State University (UNESP), 56 Brasil Avenue, Ilha Solteira, 15385-000, São Paulo, Brazil
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12
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Okun MS, Hickey PT, Machado AG, Kuncel AM, Grill WM. Temporally optimized patterned stimulation (TOPS®) as a therapy to personalize deep brain stimulation treatment of Parkinson’s disease. Front Hum Neurosci 2022; 16:929509. [PMID: 36092643 PMCID: PMC9454097 DOI: 10.3389/fnhum.2022.929509] [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: 04/26/2022] [Accepted: 07/27/2022] [Indexed: 12/05/2022] Open
Abstract
Deep brain stimulation (DBS) is a well-established therapy for the motor symptoms of Parkinson’s disease (PD), but there remains an opportunity to improve symptom relief. The temporal pattern of stimulation is a new parameter to consider in DBS therapy, and we compared the effectiveness of Temporally Optimized Patterned Stimulation (TOPS) to standard DBS at reducing the motor symptoms of PD. Twenty-six subjects with DBS for PD received three different patterns of stimulation (two TOPS and standard) while on medication and using stimulation parameters optimized for standard DBS. Side effects and motor symptoms were assessed after 30 min of stimulation with each pattern. Subjects experienced similar types of side effects with TOPS and standard DBS, and TOPS were well-tolerated by a majority of the subjects. On average, the most effective TOPS was as effective as standard DBS at reducing the motor symptoms of PD. In some subjects a TOPS pattern was the most effective pattern. Finally, the TOPS pattern with low average frequency was found to be as effective or more effective in about half the subjects while substantially reducing estimated stimulation energy use. TOPS DBS may provide a new programing option to improve DBS therapy for PD by improving symptom reduction and/or increasing energy efficiency. Optimizing stimulation parameters specifically for TOPS DBS may demonstrate further clinical benefit of TOPS DBS in treating the motor symptoms of Parkinson’s disease.
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Affiliation(s)
- Michael S. Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, United States
- *Correspondence: Michael S. Okun,
| | - Patrick T. Hickey
- Department of Neurology, Movement Disorders Center, Duke University Medical Center, Durham, NC, United States
| | - Andre G. Machado
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH, United States
| | | | - Warren M. Grill
- Deep Brain Innovations, Cleveland, OH, United States
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
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13
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Johansson JD, Wardell K. DBSim and ELMA - Freeware for Simulations of Deep Brain Stimulation. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:1719-1724. [PMID: 36086324 DOI: 10.1109/embc48229.2022.9871821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Finite Element Method (FEM) simulations of the electric field is a useful tool to estimate the activated tissue around Deep Brain Stimulation (DBS) electrodes. Based on our previous research, a two-part software package named DBSim and ELMA is presented. ELMA is used to classify brain tissue into grey matter, white matter, blood, and cerebrospinal fluid and assign electric conductivities accordingly. This data is then used in DBSim to generate patient-specific simulations of the electric field around currently implemented leads Medtronic 3387 and 3389, and Abbott 6180 and 6181. The software is available for free download at https://liu.se/en/article/ne-downloads Clinical Relevance- This is a tool meant for research and educational purposes for e.g. studies on optimal target areas for DBS.
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14
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Adam EM, Brown EN, Kopell N, McCarthy MM. Deep brain stimulation in the subthalamic nucleus for Parkinson's disease can restore dynamics of striatal networks. Proc Natl Acad Sci U S A 2022; 119:e2120808119. [PMID: 35500112 PMCID: PMC9171607 DOI: 10.1073/pnas.2120808119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/25/2022] [Indexed: 12/03/2022] Open
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is highly effective in alleviating movement disability in patients with Parkinson’s disease (PD). However, its therapeutic mechanism of action is unknown. The healthy striatum exhibits rich dynamics resulting from an interaction of beta, gamma, and theta oscillations. These rhythms are essential to selection and execution of motor programs, and their loss or exaggeration due to dopamine (DA) depletion in PD is a major source of behavioral deficits. Restoring the natural rhythms may then be instrumental in the therapeutic action of DBS. We develop a biophysical networked model of a BG pathway to study how abnormal beta oscillations can emerge throughout the BG in PD and how DBS can restore normal beta, gamma, and theta striatal rhythms. Our model incorporates STN projections to the striatum, long known but understudied, found to preferentially target fast-spiking interneurons (FSI). We find that DBS in STN can normalize striatal medium spiny neuron activity by recruiting FSI dynamics and restoring the inhibitory potency of FSIs observed in normal conditions. We also find that DBS allows the reexpression of gamma and theta rhythms, thought to be dependent on high DA levels and thus lost in PD, through cortical noise control. Our study highlights that DBS effects can go beyond regularizing BG output dynamics to restoring normal internal BG dynamics and the ability to regulate them. It also suggests how gamma and theta oscillations can be leveraged to supplement DBS treatment and enhance its effectiveness.
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Affiliation(s)
- Elie M. Adam
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA 02139
| | - Emery N. Brown
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA 02139
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114
| | - Nancy Kopell
- Department of Mathematics and Statistics, Boston University, Boston, MA 02215
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15
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Silverio AA, Silverio LAA. Developments in Deep Brain Stimulators for Successful Aging Towards Smart Devices—An Overview. FRONTIERS IN AGING 2022; 3:848219. [PMID: 35821845 PMCID: PMC9261350 DOI: 10.3389/fragi.2022.848219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/15/2022] [Indexed: 12/02/2022]
Abstract
This work provides an overview of the present state-of-the-art in the development of deep brain Deep Brain Stimulation (DBS) and how such devices alleviate motor and cognitive disorders for a successful aging. This work reviews chronic diseases that are addressable via DBS, reporting also the treatment efficacies. The underlying mechanism for DBS is also reported. A discussion on hardware developments focusing on DBS control paradigms is included specifically the open- and closed-loop “smart” control implementations. Furthermore, developments towards a “smart” DBS, while considering the design challenges, current state of the art, and constraints, are also presented. This work also showcased different methods, using ambient energy scavenging, that offer alternative solutions to prolong the battery life of the DBS device. These are geared towards a low maintenance, semi-autonomous, and less disruptive device to be used by the elderly patient suffering from motor and cognitive disorders.
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Affiliation(s)
- Angelito A. Silverio
- Department of Electronics Engineering, University of Santo Tomas, Manila, Philippines
- Research Center for the Natural and Applied Sciences, University of Santo Tomas, Manila, Philippines
- *Correspondence: Angelito A. Silverio,
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16
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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.
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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
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Paulk AC, Zelmann R, Crocker B, Widge AS, Dougherty DD, Eskandar EN, Weisholtz DS, Richardson RM, Cosgrove GR, Williams ZM, Cash SS. Local and distant cortical responses to single pulse intracranial stimulation in the human brain are differentially modulated by specific stimulation parameters. Brain Stimul 2022; 15:491-508. [PMID: 35247646 PMCID: PMC8985164 DOI: 10.1016/j.brs.2022.02.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Electrical neuromodulation via direct electrical stimulation (DES) is an increasingly common therapy for a wide variety of neuropsychiatric diseases. Unfortunately, therapeutic efficacy is inconsistent, likely due to our limited understanding of the relationship between the massive stimulation parameter space and brain tissue responses. OBJECTIVE To better understand how different parameters induce varied neural responses, we systematically examined single pulse-induced cortico-cortico evoked potentials (CCEP) as a function of stimulation amplitude, duration, brain region, and whether grey or white matter was stimulated. METHODS We measured voltage peak amplitudes and area under the curve (AUC) of intracranially recorded stimulation responses as a function of distance from the stimulation site, pulse width, current injected, location relative to grey and white matter, and brain region stimulated (N = 52, n = 719 stimulation sites). RESULTS Increasing stimulation pulse width increased responses near the stimulation location. Increasing stimulation amplitude (current) increased both evoked amplitudes and AUC nonlinearly. Locally (<15 mm), stimulation at the boundary between grey and white matter induced larger responses. In contrast, for distant sites (>15 mm), white matter stimulation consistently produced larger responses than stimulation in or near grey matter. The stimulation location-response curves followed different trends for cingulate, lateral frontal, and lateral temporal cortical stimulation. CONCLUSION These results demonstrate that a stronger local response may require stimulation in the grey-white boundary while stimulation in the white matter could be needed for network activation. Thus, stimulation parameters tailored for a specific anatomical-functional outcome may be key to advancing neuromodulatory therapy.
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Affiliation(s)
- Angelique C Paulk
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | - Rina Zelmann
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Britni Crocker
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA; Harvard-MIT Health Sciences and Technology, Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Alik S Widge
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, 02129, USA
| | - Darin D Dougherty
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, 02129, USA
| | - Emad N Eskandar
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Daniel S Weisholtz
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, 02114, USA
| | - R Mark Richardson
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - G Rees Cosgrove
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02114, USA
| | - Ziv M Williams
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA
| | - Sydney S Cash
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 02114, USA; Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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18
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Naesström M, Johansson J, Hariz M, Bodlund O, Wårdell K, Blomstedt P. Distribution of electric field in patients with obsessive compulsive disorder treated with deep brain stimulation of the bed nucleus of stria terminalis. Acta Neurochir (Wien) 2022; 164:193-202. [PMID: 34652518 PMCID: PMC8761125 DOI: 10.1007/s00701-021-04991-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 08/26/2021] [Indexed: 12/20/2022]
Abstract
Background Deep brain stimulation (DBS) is being investigated as a treatment for therapy-refractory obsessive compulsive disorder (OCD). Many different brain targets are being trialled. Several of these targets such as the ventral striatum (including the nucleus accumbens (NAc)), the ventral capsule, the inferior thalamic peduncle, and the bed nucleus of stria terminalis (BNST)) belong to the same network, are anatomically very close to one another, or even overlap. Data is still missing on how various stimulation parameters in a given target will affect surrounding anatomical areas and impact the clinical outcome of DBS. Methods In a pilot study of eleven participants with DBS of the BNST, we investigate through patient-specific simulation of electric field, which anatomical areas are affected by the electric field, and if this can be related to the clinical results. Our study combined individual patient’s stimulation parameters at 12- and 24-month follow-up with image data from the preoperative MRI and postoperative CT. These data were used to calculate the distribution of electric field and create individual anatomical models of the field of stimulation. Results The individual electric stimulation fields by stimulation in the BNST were similar at both the 12- and 24-month follow-up, involving mainly anterior limb of the internal capsule (ALIC), genu of the internal capsule (IC), BNST, fornix, anteromedial globus pallidus externa (GPe), and the anterior commissure. A statistical significant correlation (p < 0.05) between clinical effect measured by the Yale-Brown Obsessive Compulsive Scale and stimulation was found at the 12-month follow-up in the ventral ALIC and anteromedial GPe. Conclusions Many of the targets under investigation for OCD are in anatomical proximity. As seen in our study, off-target effects are overlapping. Therefore, DBS in the region of ALIC, NAc, and BNST may perhaps be considered to be stimulation of the same target.
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Affiliation(s)
- Matilda Naesström
- Division of Psychiatry, Department of Clinical Sciences, Umeå University, 90187, Umeå, Sweden.
| | - Johannes Johansson
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden
| | - Marwan Hariz
- Unit of Deep Brain Stimulation, Department of Clinical Sciences, Umeå University, Umeå, Sweden
- Unit of Functional Neurosurgery, UCL Institute of Neurology, Queen Square, London, UK
| | - Owe Bodlund
- Division of Psychiatry, Department of Clinical Sciences, Umeå University, 90187, Umeå, Sweden
| | - Karin Wårdell
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden
| | - Patric Blomstedt
- Unit of Deep Brain Stimulation, Department of Clinical Sciences, Umeå University, Umeå, Sweden
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19
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Petry-Schmelzer JN, Schwarz LM, Jergas H, Reker P, Steffen JK, Dafsari HS, Baldermann JC, Fink GR, Visser-Vandewalle V, Dembek TA, Barbe MT. A Randomized, Double-Blinded Crossover Trial of Short Versus Conventional Pulse Width Subthalamic Deep Brain Stimulation in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2022; 12:1497-1505. [PMID: 35491797 PMCID: PMC9398064 DOI: 10.3233/jpd-213119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Subthalamic nucleus deep brain stimulation (STN-DBS) is a well-established treatment for patients with Parkinson's disease. Previous acute challenge studies suggested that short pulse widths might increase the therapeutic window while maintaining motor symptom control with a decrease in energy consumption. However, only little is known about the effect of short pulse width stimulation beyond the setting of an acute challenge. OBJECTIVE To compare 4 weeks of STN-DBS with conventional pulse width stimulation (60 μs) to 4 weeks of STN-DBS with short pulse width stimulation (30 μs) regarding motor symptom control. METHODS This study was a monocentric, double-blinded, randomized crossover non-inferiority trial investigating whether short pulse width stimulation with 30 μs maintains equal motor control as conventional 60 μs stimulation over a period of 4 weeks (German Clinical Trials Register No. DRKS00017528). Primary outcome was the difference in motor symptom control as assessed by a motor diary. Secondary outcomes included energy consumption measures, non-motor effects, side-effects, and quality of life. RESULTS Due to a high dropout rate, the calculated sample size of 27 patients was not met and 24 patients with Parkinson's disease and STN-DBS were included in the final analysis. However, there were no differences in any investigated outcome parameter between the two treatment conditions. CONCLUSION This study demonstrates that short pulse width settings (30 μs) provide non-inferior motor symptom control as conventional (60 μs) stimulation without significant differences in energy consumption. Future studies are warranted to evaluate a potential benefit of short pulse width settings in patients with pronounced dyskinesia.
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Affiliation(s)
- Jan Niklas Petry-Schmelzer
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lisa M. Schwarz
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Hannah Jergas
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Paul Reker
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Julia K. Steffen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Haidar S. Dafsari
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Juan Carlos Baldermann
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Psychiatry, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gereon R. Fink
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Center Jülich, Jülich, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Till A. Dembek
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael T. Barbe
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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20
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Petry-Schmelzer JN, Schwarz LM, Jergas H, Reker P, Steffen JK, Dafsari HS, Baldermann JC, Fink GR, Visser-Vandewalle V, Dembek TA, Barbe MT. A Randomized, Double-Blinded Crossover Trial of Short Versus Conventional Pulse Width Subthalamic Deep Brain Stimulation in Parkinson's Disease. JOURNAL OF PARKINSON'S DISEASE 2022; 12:1497-1505. [PMID: 35491797 DOI: 10.1101/2021.06.20.21258955] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Subthalamic nucleus deep brain stimulation (STN-DBS) is a well-established treatment for patients with Parkinson's disease. Previous acute challenge studies suggested that short pulse widths might increase the therapeutic window while maintaining motor symptom control with a decrease in energy consumption. However, only little is known about the effect of short pulse width stimulation beyond the setting of an acute challenge. OBJECTIVE To compare 4 weeks of STN-DBS with conventional pulse width stimulation (60 μs) to 4 weeks of STN-DBS with short pulse width stimulation (30 μs) regarding motor symptom control. METHODS This study was a monocentric, double-blinded, randomized crossover non-inferiority trial investigating whether short pulse width stimulation with 30 μs maintains equal motor control as conventional 60 μs stimulation over a period of 4 weeks (German Clinical Trials Register No. DRKS00017528). Primary outcome was the difference in motor symptom control as assessed by a motor diary. Secondary outcomes included energy consumption measures, non-motor effects, side-effects, and quality of life. RESULTS Due to a high dropout rate, the calculated sample size of 27 patients was not met and 24 patients with Parkinson's disease and STN-DBS were included in the final analysis. However, there were no differences in any investigated outcome parameter between the two treatment conditions. CONCLUSION This study demonstrates that short pulse width settings (30 μs) provide non-inferior motor symptom control as conventional (60 μs) stimulation without significant differences in energy consumption. Future studies are warranted to evaluate a potential benefit of short pulse width settings in patients with pronounced dyskinesia.
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Affiliation(s)
- Jan Niklas Petry-Schmelzer
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lisa M Schwarz
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Hannah Jergas
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Paul Reker
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Julia K Steffen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Haidar S Dafsari
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Juan Carlos Baldermann
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Department of Psychiatry, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Gereon R Fink
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- Cognitive Neuroscience, Institute of Neuroscience and Medicine (INM-3), Research Center Jülich, Jülich, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Till A Dembek
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Michael T Barbe
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Jeong H, Deng J, Bonmassar G. Planar figure-8 coils for ultra-focal and directional micromagnetic brain stimulation. JOURNAL OF VACUUM SCIENCE AND TECHNOLOGY. B, NANOTECHNOLOGY & MICROELECTRONICS : MATERIALS, PROCESSING, MEASUREMENT, & PHENOMENA : JVST B 2021; 39:063202. [PMID: 34692236 PMCID: PMC8516478 DOI: 10.1116/6.0001281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/13/2021] [Indexed: 06/13/2023]
Abstract
Recently, white-matter fiber tract pathways carrying neural signals through the brain were shown to follow curved, orthogonal grids. This study focuses on how these white-matter fibers may be selectively excited using micromagnetic stimulation (μMS), a new type of neuronal stimulation, which generates microscopic eddy currents capable of directionally activating neurons. One of the most remarkable properties of this novel type of stimulation is that the μMS fields provide unique directional activation of neuronal elements not seen with traditional electrical stimulation. An initial prototype built with SU-8 based photolithography technology shows that the structure can be fabricated. The coil design was optimized through electrical resistance calculations and electric field simulations to elicit the brain's maximal focal and directional neural responses.
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Affiliation(s)
- Hongbae Jeong
- A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts 02129
| | - Jiangdong Deng
- Center for Nanoscale Systems, Harvard University, Cambridge, Massachusetts 02138
| | - Giorgio Bonmassar
- A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, Massachusetts 02129
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Kumar R, Aadil KR, Mondal K, Mishra YK, Oupicky D, Ramakrishna S, Kaushik A. Neurodegenerative disorders management: state-of-art and prospects of nano-biotechnology. Crit Rev Biotechnol 2021; 42:1180-1212. [PMID: 34823433 DOI: 10.1080/07388551.2021.1993126] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Neurodegenerative disorders (NDs) are highly prevalent among the aging population. It affects primarily the central nervous system (CNS) but the effects are also observed in the peripheral nervous system. Neural degeneration is a progressive loss of structure and function of neurons, which may ultimately involve cell death. Such patients suffer from debilitating memory loss and altered motor coordination which bring up non-affordable and unavoidable socio-economic burdens. Due to the unavailability of specific therapeutics and diagnostics, the necessity to control or manage NDs raised the demand to investigate and develop efficient alternative approaches. Keeping trends and advancements in view, this report describes both state-of-the-art and challenges in nano-biotechnology-based approaches to manage NDs, toward personalized healthcare management. Sincere efforts are being made to customize nano-theragnostics to control: therapeutic cargo packaging, delivery to the brain, nanomedicine of higher efficacy, deep brain stimulation, implanted stimulation, and managing brain cell functioning. These advancements are useful to design future therapy based on the severity of the patient's neurodegenerative disease. However, we observe a lack of knowledge shared among scientists of a variety of expertise to explore this multi-disciplinary research field for NDs management. Consequently, this review will provide a guideline platform that will be useful in developing novel smart nano-therapies by considering the aspects and advantages of nano-biotechnology to manage NDs in a personalized manner. Nano-biotechnology-based approaches have been proposed as effective and affordable alternatives at the clinical level due to recent advancements in nanotechnology-assisted theragnostics, targeted delivery, higher efficacy, and minimal side effects.
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Affiliation(s)
- Raj Kumar
- Department of Pharmaceutical Sciences, Center for Drug Delivery and Nanomedicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Keshaw Ram Aadil
- Center for Basic Sciences, Pt. Ravishankar Shukla University, Raipur, India
| | - Kunal Mondal
- Materials Science and Engineering Department, Idaho National Laboratory, Idaho Falls, ID, USA
| | - Yogendra Kumar Mishra
- Mads Clausen Institute, NanoSYD, University of Southern Denmark, Sønderborg, Denmark
| | - David Oupicky
- Department of Pharmaceutical Sciences, Center for Drug Delivery and Nanomedicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Seeram Ramakrishna
- Center for Nanotechnology and Sustainability, National University of Singapore, Singapore, Singapore
| | - Ajeet Kaushik
- NanoBioTech Laboratory, Health Systems Engineering, Department of Environmental Engineering, Florida Polytechnic University, Lakeland, FL, USA
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23
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Johansson JD. Estimation of electric field impact in deep brain stimulation from axon diameter distribution in the human brain. Biomed Phys Eng Express 2021; 7. [PMID: 34619674 DOI: 10.1088/2057-1976/ac2dd4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 10/07/2021] [Indexed: 11/12/2022]
Abstract
Objective.Finite element method (FEM) simulations of the electric field magnitude (EF) are commonly used to estimate the affected tissue surrounding the active contact of deep brain stimulation (DBS) leads. Previous studies have found that DBS starts to noticeably activate axons at approximately 0.2 V mm-1, corresponding to activation of 3.4μm axons in simulations of individual axon triggering. Most axons in the brain are considerably smaller however, and the effect of the electric field is thus expected to be stronger with increasing EF as more and more axons become activated. The objective of this study is to estimate the fraction of activated axons as a function of electric field magnitude.Approach. The EF thresholds required for axon stimulation of myelinated axon diameters between 1 and 5μm were obtained from a combined cable and Hodgkin-Huxley model in a FEM-simulated electric field from a Medtronic 3389 lead. These thresholds were compared with the average axon diameter distribution from literature from several structures in the human brain to obtain an estimate of the fraction of axons activated at EF levels between 0.1 and 1.8 V mm-1.Main results. The effect of DBS is estimated to be 47·EF-8.8% starting at a threshold levelEFt0 = 0.19 V mm-1.Significance. The fraction of activated axons from DBS in a voxel is estimated to increase linearly with EF above the threshold level of 0.19 V mm-1. This means linear regression between EF above 0.19 V mm-1and clinical outcome is a suitable statistical method when doing improvement maps for DBS.
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Affiliation(s)
- Johannes D Johansson
- Department of Biomedical Engineering, Linköping University, 581 85 Linköping, Sweden
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24
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Germann J, Mameli M, Elias GJB, Loh A, Taha A, Gouveia FV, Boutet A, Lozano AM. Deep Brain Stimulation of the Habenula: Systematic Review of the Literature and Clinical Trial Registries. Front Psychiatry 2021; 12:730931. [PMID: 34484011 PMCID: PMC8415908 DOI: 10.3389/fpsyt.2021.730931] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 07/21/2021] [Indexed: 11/13/2022] Open
Abstract
The habenula is a small bilateral epithalamic structure that plays a key role in the regulation of the main monoaminergic systems. It is implicated in many aspects of behavior such as reward processing, motivational behavior, behavioral adaptation, and sensory integration. A role of the habenula has been indicated in the pathophysiology of a number of neuropsychiatric disorders such as depression, addiction, obsessive-compulsive disorder, and bipolar disorder. Neuromodulation of the habenula using deep brain stimulation (DBS) as potential treatment has been proposed and a first successful case of habenula DBS was reported a decade ago. To provide an overview of the current state of habenula DBS in human subjects for the treatment of neuropsychiatric disorders we conducted a systematic review of both the published literature using PUBMED and current and past registered clinical trials using ClinicalTrials.gov as well as the International Clinical Trials Registry Platform. Using PRISMA guidelines five articles and five registered clinical trials were identified. The published articles detailed the results of habenula DBS for the treatment of schizophrenia, depression, obsessive-compulsive disorder, and bipolar disorder. Four are single case studies; one reports findings in two patients and positive clinical outcome is described in five of the six patients. Of the five registered clinical trials identified, four investigate habenula DBS for the treatment of depression and one for obsessive-compulsive disorder. One trial is listed as terminated, one is recruiting, two are not yet recruiting and the status of the fifth is unknown. The planned enrollment varies between 2 to 13 subjects and four of the five are open label trials. While the published studies suggest a potential role of habenula DBS for a number of indications, future trials and studies are necessary. The outcomes of the ongoing clinical trials will provide further valuable insights. Establishing habenula DBS, however, will depend on successful randomized clinical trials to confirm application and clinical benefit of this promising intervention.
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Affiliation(s)
- Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Manuel Mameli
- The Department of Fundamental Neuroscience, The University of Lausanne, Lausanne, Switzerland
- INSERM, UMR-S 839, Paris, France
| | - Gavin J. B. Elias
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Alaa Taha
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
| | - Flavia Venetucci Gouveia
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Andres M. Lozano
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, ON, Canada
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Johansson JD, Zsigmond P. Comparison between patient-specific deep brain stimulation simulations and commercial system SureTune3. Biomed Phys Eng Express 2021; 7. [PMID: 34161929 DOI: 10.1088/2057-1976/ac0dcd] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/23/2021] [Indexed: 11/12/2022]
Abstract
Objective. Software to visualize estimated volume of tissue activated (VTA) in deep brain stimulation assuming a homogeneous tissue surrounding such as SureTune3 has recently become available for clinical use. The objective of this study is to compare SureTune3 with homogeneous and heterogeneous patient-specific finite element method (FEM) simulations of the VTA to elucidate how well they coincide in their estimates.Approach. FEM simulations of the VTA were performed in COMSOL Multiphysics and compared with VTA from SureTune3 with variation of voltage and current amplitude, pulse width, axon diameter, number of active contacts, and surrounding homogeneous grey or white matter. Patient-specific simulations with heterogeneous tissue were also performed.Main results. The VTAs corresponded well for voltage control in homogeneous tissue, though with the smallest VTAs being slightly larger in SureTune3 and the largest VTAs being slightly larger in the FEM simulations. In current control, FEM estimated larger VTAs in white matter and smaller VTAs in grey matter compared to SureTune3 as grey matter has higher electric conductivity than white matter and requires less voltage to reach the same current. The VTAs also corresponded well in the patient-specific cases except for one case with a cyst of highly conductive cerebrospinal fluid (CSF) near the active contacts.Significance. The VTA estimates without taking the surrounding tissue into account in SureTune3 are in good agreement with patient-specific FEM simulations when using voltage control in the absence of CSF-filled cyst. In current control or when CSF is present near the active contacts, the tissue characteristics are important for the VTA and needs consideration.Clinical. trial ethical approval: Local ethics committee at Linköping University (2012/434-31).
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Affiliation(s)
- Johannes D Johansson
- Department of Biomedical Engineering, Linköping University, 581 85 Linköping, Sweden.,Center for Medical Image Science and Visualization (CMIV), Linköping University, 581 85 Linköping, Sweden
| | - Peter Zsigmond
- Department of Neurosurgery and Department of Biomedical and Clinical Sciences, Linköping University, 581 85 Linköping, Sweden
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Louie KH, Petrucci MN, Grado LL, Lu C, Tuite PJ, Lamperski AG, MacKinnon CD, Cooper SE, Netoff TI. Semi-automated approaches to optimize deep brain stimulation parameters in Parkinson's disease. J Neuroeng Rehabil 2021; 18:83. [PMID: 34020662 PMCID: PMC8147513 DOI: 10.1186/s12984-021-00873-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 04/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is a treatment option for Parkinson's disease patients when medication does not sufficiently manage their symptoms. DBS can be a highly effect therapy, but only after a time-consuming trial-and-error stimulation parameter adjustment process that is susceptible to clinician bias. This trial-and-error process will be further prolonged with the introduction of segmented electrodes that are now commercially available. New approaches to optimizing a patient's stimulation parameters, that can also handle the increasing complexity of new electrode and stimulator designs, is needed. METHODS To improve DBS parameter programming, we explored two semi-automated optimization approaches: a Bayesian optimization (BayesOpt) algorithm to efficiently determine a patient's optimal stimulation parameter for minimizing rigidity, and a probit Gaussian process (pGP) to assess patient's preference. Quantified rigidity measurements were obtained using a robotic manipulandum in two participants over two visits. Rigidity was measured, in 5Hz increments, between 10-185Hz (total 30-36 frequencies) on the first visit and at eight BayesOpt algorithm-selected frequencies on the second visit. The participant was also asked their preference between the current and previous stimulation frequency. First, we compared the optimal frequency between visits with the participant's preferred frequency. Next, we evaluated the efficiency of the BayesOpt algorithm, comparing it to random and equal interval selection of frequency. RESULTS The BayesOpt algorithm estimated the optimal frequency to be the highest tolerable frequency, matching the optimal frequency found during the first visit. However, the participants' pGP models indicate a preference at frequencies between 70-110 Hz. Here the stimulation frequency is lowest that achieves nearly maximal suppression of rigidity. BayesOpt was efficient, estimating the rigidity response curve to stimulation that was almost indistinguishable when compared to the longer brute force method. CONCLUSIONS These results provide preliminary evidence of the feasibility to use BayesOpt for determining the optimal frequency, while pGP patient's preferences include more difficult to measure outcomes. Both novel approaches can shorten DBS programming and can be expanded to include multiple symptoms and parameters.
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Affiliation(s)
- Kenneth H. Louie
- Department of Biomedical Engineering, University of Minnesota, 312 Church St. SE, Minneapolis, MN 55455 US
| | - Matthew N. Petrucci
- Department of Neurology, University of Minnesota, 516 Delaware St. SE, 55455 Minneapoli, MN US
| | - Logan L. Grado
- Department of Biomedical Engineering, University of Minnesota, 312 Church St. SE, Minneapolis, MN 55455 US
| | - Chiahao Lu
- Department of Neurology, University of Minnesota, 516 Delaware St. SE, 55455 Minneapoli, MN US
| | - Paul J. Tuite
- Department of Neurology, University of Minnesota, 516 Delaware St. SE, 55455 Minneapoli, MN US
| | - Andrew G. Lamperski
- Department of Electrical and Computer Engineering, University of Minnesota, 200 Union St. SE, Minneapolis, MN 55455 US
| | - Colum D. MacKinnon
- Department of Neurology, University of Minnesota, 516 Delaware St. SE, 55455 Minneapoli, MN US
| | - Scott E. Cooper
- Department of Neurology, University of Minnesota, 516 Delaware St. SE, 55455 Minneapoli, MN US
| | - Theoden I. Netoff
- Department of Biomedical Engineering, University of Minnesota, 312 Church St. SE, Minneapolis, MN 55455 US
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Waldherr L, Seitanidou M, Jakešová M, Handl V, Honeder S, Nowakowska M, Tomin T, Karami Rad M, Schmidt T, Distl J, Birner‐Gruenberger R, von Campe G, Schäfer U, Berggren M, Rinner B, Asslaber M, Ghaffari‐Tabrizi‐Wizsy N, Patz S, Simon DT, Schindl R. Targeted Chemotherapy of Glioblastoma Spheroids with an Iontronic Pump. ADVANCED MATERIALS TECHNOLOGIES 2021; 6:2001302. [PMID: 34195355 PMCID: PMC8218220 DOI: 10.1002/admt.202001302] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/15/2021] [Indexed: 05/13/2023]
Abstract
Successful treatment of glioblastoma multiforme (GBM), the most lethal tumor of the brain, is presently hampered by (i) the limits of safe surgical resection and (ii) "shielding" of residual tumor cells from promising chemotherapeutic drugs such as Gemcitabine (Gem) by the blood brain barrier (BBB). Here, the vastly greater GBM cell-killing potency of Gem compared to the gold standard temozolomide is confirmed, moreover, it shows neuronal cells to be at least 104-fold less sensitive to Gem than GBM cells. The study also demonstrates the potential of an electronically-driven organic ion pump ("GemIP") to achieve controlled, targeted Gem delivery to GBM cells. Thus, GemIP-mediated Gem delivery is confirmed to be temporally and electrically controllable with pmol min-1 precision and electric addressing is linked to the efficient killing of GBM cell monolayers. Most strikingly, GemIP-mediated GEM delivery leads to the overt disintegration of targeted GBM tumor spheroids. Electrically-driven chemotherapy, here exemplified, has the potential to radically improve the efficacy of GBM adjuvant chemotherapy by enabling exquisitely-targeted and controllable delivery of drugs irrespective of whether these can cross the BBB.
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Affiliation(s)
- Linda Waldherr
- Gottfried Schatz Research Center – BiophysicsMedical University of GrazGraz8010Austria
| | - Maria Seitanidou
- Laboratory of Organic ElectronicsDepartment of Science and TechnologyLinköping UniversityNorrköping60174Sweden
| | - Marie Jakešová
- Laboratory of Organic ElectronicsDepartment of Science and TechnologyLinköping UniversityNorrköping60174Sweden
| | - Verena Handl
- Department of NeurosurgeryMedical University of GrazGraz8010Austria
| | - Sophie Honeder
- Diagnostic and Research Institute of PathologyMedical University of GrazGraz8010Austria
| | - Marta Nowakowska
- Department of NeurosurgeryMedical University of GrazGraz8010Austria
| | - Tamara Tomin
- Diagnostic and Research Institute of PathologyMedical University of GrazGraz8010Austria
- Institute of Chemical Technologies and AnalyticsTechnische Universität WienVienna1060Austria
| | - Meysam Karami Rad
- Laboratory of Organic ElectronicsDepartment of Science and TechnologyLinköping UniversityNorrköping60174Sweden
| | - Tony Schmidt
- Gottfried Schatz Research Center – BiophysicsMedical University of GrazGraz8010Austria
| | - Joachim Distl
- Gottfried Schatz Research Center – BiophysicsMedical University of GrazGraz8010Austria
| | - Ruth Birner‐Gruenberger
- Diagnostic and Research Institute of PathologyMedical University of GrazGraz8010Austria
- Institute of Chemical Technologies and AnalyticsTechnische Universität WienVienna1060Austria
| | - Gord von Campe
- Department of NeurosurgeryMedical University of GrazGraz8010Austria
| | - Ute Schäfer
- Department of NeurosurgeryMedical University of GrazGraz8010Austria
| | - Magnus Berggren
- Laboratory of Organic ElectronicsDepartment of Science and TechnologyLinköping UniversityNorrköping60174Sweden
| | - Beate Rinner
- Division of Biomedical ResearchMedical University of GrazGraz8036Austria
| | - Martin Asslaber
- Diagnostic and Research Institute of PathologyMedical University of GrazGraz8010Austria
| | | | - Silke Patz
- Department of NeurosurgeryMedical University of GrazGraz8010Austria
| | - Daniel T. Simon
- Laboratory of Organic ElectronicsDepartment of Science and TechnologyLinköping UniversityNorrköping60174Sweden
| | - Rainer Schindl
- Gottfried Schatz Research Center – BiophysicsMedical University of GrazGraz8010Austria
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Lee DJ, Drummond NM, Saha U, De Vloo P, Dallapiazza RF, Gramer R, Al-Ozzi TM, Lam J, Loh A, Elias GJB, Boutet A, Germann J, Hodaie M, Fasano A, Munhoz RP, Hutchison W, Cohn M, Chen R, Kalia SK, Lozano AM. Acute low frequency dorsal subthalamic nucleus stimulation improves verbal fluency in Parkinson's disease. Brain Stimul 2021; 14:754-760. [PMID: 33940243 DOI: 10.1016/j.brs.2021.04.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 04/12/2021] [Accepted: 04/26/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Parkinson's disease (PD) is a common neurodegenerative disorder that results in movement-related dysfunction and has variable cognitive impairment. Deep brain stimulation (DBS) of the dorsal subthalamic nucleus (STN) has been shown to be effective in improving motor symptoms; however, cognitive impairment is often unchanged, and in some cases, worsened particularly on tasks of verbal fluency. Traditional DBS strategies use high frequency gamma stimulation for motor symptoms (∼130 Hz), but there is evidence that low frequency theta oscillations (5-12 Hz) are important in cognition. METHODS We tested the effects of stimulation frequency and location on verbal fluency among patients who underwent STN DBS implantation with externalized leads. During baseline cognitive testing, STN field potentials were recorded and the individual patients' peak theta frequency power was identified during each cognitive task. Patients repeated cognitive testing at five different stimulation settings: no stimulation, dorsal contact gamma (130 Hz), ventral contact gamma, dorsal theta (peak baseline theta) and ventral theta (peak baseline theta) frequency stimulation. RESULTS Acute left dorsal peak theta frequency STN stimulation improves overall verbal fluency compared to no stimulation and to either dorsal or ventral gamma stimulation. Stratifying by type of verbal fluency probes, verbal fluency in episodic categories was improved with dorsal theta stimulation compared to all other conditions, while there were no differences between stimulation conditions in non-episodic probe conditions. CONCLUSION Here, we provide evidence that dorsal STN theta stimulation may improve verbal fluency, suggesting a potential possibility of integrating theta stimulation into current DBS paradigms to improve cognitive outcomes.
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Affiliation(s)
- Darrin J Lee
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada; Department of Neurological Surgery, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA; USC Neurorestoration Center, Keck School of Medicine of USC, 1333 San Pablo Street, McKibben Hall B51, Los Angeles, CA, 90033, USA.
| | - Neil M Drummond
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada
| | - Utpal Saha
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; USC Neurorestoration Center, Keck School of Medicine of USC, 1333 San Pablo Street, McKibben Hall B51, Los Angeles, CA, 90033, USA
| | - Philippe De Vloo
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada; Department of Neurosurgery, University Hospitals Leuven - KU Leuven, Herestraat 49, 3000, Leuven, Vlaams-Brabant, Belgium
| | - Robert F Dallapiazza
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Robert Gramer
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Tameem M Al-Ozzi
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Jordan Lam
- Department of Neurological Surgery, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA, 90033, USA; USC Neurorestoration Center, Keck School of Medicine of USC, 1333 San Pablo Street, McKibben Hall B51, Los Angeles, CA, 90033, USA
| | - Aaron Loh
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada
| | - Gavin J B Elias
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada
| | - Alexandre Boutet
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Joint Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Jurgen Germann
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada
| | - Mojgan Hodaie
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Alfonso Fasano
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada; Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada
| | - Renato P Munhoz
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada; Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada
| | - William Hutchison
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Melanie Cohn
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Department of Psychology, University of Toronto, Toronto, Canada
| | - Robert Chen
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, Canada; Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada
| | - Suneil K Kalia
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Andres M Lozano
- Krembil Research Institute, University Health Network, 60 Leonard Avenue, Toronto, ON, M5T 2S8, Canada; Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
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Ozturk M, Viswanathan A, Sheth SA, Ince NF. Electroceutically induced subthalamic high-frequency oscillations and evoked compound activity may explain the mechanism of therapeutic stimulation in Parkinson's disease. Commun Biol 2021; 4:393. [PMID: 33758361 PMCID: PMC7988171 DOI: 10.1038/s42003-021-01915-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/23/2021] [Indexed: 01/31/2023] Open
Abstract
Despite having remarkable utility in treating movement disorders, the lack of understanding of the underlying mechanisms of high-frequency deep brain stimulation (DBS) is a main challenge in choosing personalized stimulation parameters. Here we investigate the modulations in local field potentials induced by electrical stimulation of the subthalamic nucleus (STN) at therapeutic and non-therapeutic frequencies in Parkinson's disease patients undergoing DBS surgery. We find that therapeutic high-frequency stimulation (130-180 Hz) induces high-frequency oscillations (~300 Hz, HFO) similar to those observed with pharmacological treatment. Along with HFOs, we also observed evoked compound activity (ECA) after each stimulation pulse. While ECA was observed in both therapeutic and non-therapeutic (20 Hz) stimulation, the HFOs were induced only with therapeutic frequencies, and the associated ECA were significantly more resonant. The relative degree of enhancement in the HFO power was related to the interaction of stimulation pulse with the phase of ECA. We propose that high-frequency STN-DBS tunes the neural oscillations to their healthy/treated state, similar to pharmacological treatment, and the stimulation frequency to maximize these oscillations can be inferred from the phase of ECA waveforms of individual subjects. The induced HFOs can, therefore, be utilized as a marker of successful re-calibration of the dysfunctional circuit generating PD symptoms.
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Affiliation(s)
- Musa Ozturk
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - Ashwin Viswanathan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Nuri F Ince
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA.
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Miterko LN, Lin T, Zhou J, van der Heijden ME, Beckinghausen J, White JJ, Sillitoe RV. Neuromodulation of the cerebellum rescues movement in a mouse model of ataxia. Nat Commun 2021; 12:1295. [PMID: 33637754 PMCID: PMC7910465 DOI: 10.1038/s41467-021-21417-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 01/27/2021] [Indexed: 02/07/2023] Open
Abstract
Deep brain stimulation (DBS) relieves motor dysfunction in Parkinson's disease, and other movement disorders. Here, we demonstrate the potential benefits of DBS in a model of ataxia by targeting the cerebellum, a major motor center in the brain. We use the Car8 mouse model of hereditary ataxia to test the potential of using cerebellar nuclei DBS plus physical activity to restore movement. While low-frequency cerebellar DBS alone improves Car8 mobility and muscle function, adding skilled exercise to the treatment regimen additionally rescues limb coordination and stepping. Importantly, the gains persist in the absence of further stimulation. Because DBS promotes the most dramatic improvements in mice with early-stage ataxia, we postulated that cerebellar circuit function affects stimulation efficacy. Indeed, genetically eliminating Purkinje cell neurotransmission blocked the ability of DBS to reduce ataxia. These findings may be valuable in devising future DBS strategies.
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Affiliation(s)
- Lauren N. Miterko
- grid.39382.330000 0001 2160 926XDepartment of Pathology and Immunology, Baylor College of Medicine, Houston, TX USA ,grid.39382.330000 0001 2160 926XProgram in Developmental Biology, Baylor College of Medicine, Houston, TX USA ,grid.416975.80000 0001 2200 2638Jan and Dan Duncan Neurological Research Institute of Texas Children’s Hospital, Houston, TX USA
| | - Tao Lin
- grid.39382.330000 0001 2160 926XDepartment of Pathology and Immunology, Baylor College of Medicine, Houston, TX USA ,grid.416975.80000 0001 2200 2638Jan and Dan Duncan Neurological Research Institute of Texas Children’s Hospital, Houston, TX USA
| | - Joy Zhou
- grid.39382.330000 0001 2160 926XDepartment of Pathology and Immunology, Baylor College of Medicine, Houston, TX USA ,grid.416975.80000 0001 2200 2638Jan and Dan Duncan Neurological Research Institute of Texas Children’s Hospital, Houston, TX USA ,grid.39382.330000 0001 2160 926XDepartment of Neuroscience, Baylor College of Medicine, Houston, TX USA
| | - Meike E. van der Heijden
- grid.39382.330000 0001 2160 926XDepartment of Pathology and Immunology, Baylor College of Medicine, Houston, TX USA ,grid.416975.80000 0001 2200 2638Jan and Dan Duncan Neurological Research Institute of Texas Children’s Hospital, Houston, TX USA
| | - Jaclyn Beckinghausen
- grid.39382.330000 0001 2160 926XDepartment of Pathology and Immunology, Baylor College of Medicine, Houston, TX USA ,grid.416975.80000 0001 2200 2638Jan and Dan Duncan Neurological Research Institute of Texas Children’s Hospital, Houston, TX USA ,grid.39382.330000 0001 2160 926XDepartment of Neuroscience, Baylor College of Medicine, Houston, TX USA
| | - Joshua J. White
- grid.39382.330000 0001 2160 926XDepartment of Pathology and Immunology, Baylor College of Medicine, Houston, TX USA ,grid.416975.80000 0001 2200 2638Jan and Dan Duncan Neurological Research Institute of Texas Children’s Hospital, Houston, TX USA ,grid.39382.330000 0001 2160 926XDepartment of Neuroscience, Baylor College of Medicine, Houston, TX USA
| | - Roy V. Sillitoe
- grid.39382.330000 0001 2160 926XDepartment of Pathology and Immunology, Baylor College of Medicine, Houston, TX USA ,grid.39382.330000 0001 2160 926XProgram in Developmental Biology, Baylor College of Medicine, Houston, TX USA ,grid.416975.80000 0001 2200 2638Jan and Dan Duncan Neurological Research Institute of Texas Children’s Hospital, Houston, TX USA ,grid.39382.330000 0001 2160 926XDepartment of Neuroscience, Baylor College of Medicine, Houston, TX USA ,grid.39382.330000 0001 2160 926XDevelopment, Disease Models & Therapeutics Graduate Program, Baylor College of Medicine, Houston, TX USA
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31
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Göransson N, Johansson JD, Wårdell K, Zsigmond P. Postoperative Lead Movement after Deep Brain Stimulation Surgery and the Change of Stimulation Volume. Stereotact Funct Neurosurg 2020; 99:221-229. [PMID: 33326986 DOI: 10.1159/000511406] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/25/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Lead movement after deep brain stimulation may occur and influence the affected volume of stimulation. The aim of the study was to investigate differences in lead position between the day after surgery and approximately 1 month postoperatively and also simulate the electric field (EF) around the active contacts in order to investigate the impact of displacement on affected volume. METHODS Twenty-three patients with movement disorders underwent deep brain stimulation surgery (37 leads). Computed tomography at the 2 time points were co-fused respectively with the stereotactic images in Surgiplan. The coordinates (x, y, and z) of the lead tips were compared between the 2 dates. Eleven of these patients were selected for the EF simulation in Comsol Multiphysics. Postoperative changes of EF spread in the tissue due to conductivity changes in perielectrode space and due to displacement were evaluated by calculating the coverage coefficient and the Sørensen-Dice coefficient. RESULTS There was a significant displacement (mean ± SD) on the left lead: x (0.44 ± 0.72, p < 0.01), y (0.64 ± 0.54, p < 0.001), and z (0.62 ± 0.71, p < 0.001). On the right lead, corresponding values were: x (-0.11 ± 0.61, ns), y (0.71 ± 0.54, p < 0.001), and z (0.49 ± 0.81, p < 0.05). The anchoring technique was a statistically significant variable associated with displacement. No correlation was found between bilateral (n = 14) versus unilateral deep brain stimulation, gender (n = 17 male), age <60 years (n = 8), and calculated air volume. The simulated stimulation volume was reduced after 1 month because of the perielectrode space. When considering perielectrode space and displacement, the volumes calculated the day after surgery and approximately 1 month later were partly overlapped. CONCLUSION The left lead tip displayed a tendency to move lateral, anterior, and inferior and the right a tendency to move anterior and inferior. The anchoring technique was associated to displacement. New brain territory was affected due to the displacement despite considering the reduced stimulated volume after 1 month. Postoperative changes in perielectrode space and small lead movements are reasons for delaying programming to 4 weeks following surgery.
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Affiliation(s)
- Nathanael Göransson
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden, .,Department of Neurosurgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden,
| | - Johannes D Johansson
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden
| | - Karin Wårdell
- Department of Biomedical Engineering, Linköping University, Linköping, Sweden.,Center for Medical Image Science and Visualization, Linköping University, Linköping, Sweden
| | - Peter Zsigmond
- Department of Neurosurgery and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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32
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Kuelbs D, Dunefsky J, Monga B, Moehlis J. Analysis of neural clusters due to deep brain stimulation pulses. BIOLOGICAL CYBERNETICS 2020; 114:589-607. [PMID: 33296013 DOI: 10.1007/s00422-020-00850-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 11/20/2020] [Indexed: 06/12/2023]
Abstract
Deep brain stimulation (DBS) is an established method for treating pathological conditions such as Parkinson's disease, dystonia, Tourette syndrome, and essential tremor. While the precise mechanisms which underly the effectiveness of DBS are not fully understood, several theoretical studies of populations of neural oscillators stimulated by periodic pulses have suggested that this may be related to clustering, in which subpopulations of the neurons are synchronized, but the subpopulations are desynchronized with respect to each other. The details of the clustering behavior depend on the frequency and amplitude of the stimulation in a complicated way. In the present study, we investigate how the number of clusters and their stability properties, bifurcations, and basins of attraction can be understood in terms of one-dimensional maps defined on the circle. Moreover, we generalize this analysis to stimuli that consist of pulses with alternating properties, which provide additional degrees of freedom in the design of DBS stimuli. Our results illustrate how the complicated properties of clustering behavior for periodically forced neural oscillator populations can be understood in terms of a much simpler dynamical system.
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Affiliation(s)
| | | | - Bharat Monga
- Department of Mechanical Engineering, University of California, Santa Barbara, CA, 93106, USA
| | - Jeff Moehlis
- Department of Mechanical Engineering, Program in Dynamical Neuroscience, University of California, Santa Barbara, CA, 93106, USA.
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Aubignat M, Lefranc M, Tir M, Krystkowiak P. Deep brain stimulation programming in Parkinson's disease: Introduction of current issues and perspectives. Rev Neurol (Paris) 2020; 176:770-779. [DOI: 10.1016/j.neurol.2020.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 01/28/2020] [Accepted: 02/12/2020] [Indexed: 12/11/2022]
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Devaluez M, Tir M, Krystkowiak P, Aubignat M, Lefranc M. Selection of deep brain stimulation contacts using volume of tissue activated software following subthalamic nucleus stimulation. J Neurosurg 2020; 135:611-618. [PMID: 33096524 DOI: 10.3171/2020.6.jns192157] [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: 08/10/2019] [Accepted: 06/09/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE High-frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN) is effective in the treatment of motor symptoms of Parkinson's disease. Using a patient-specific lead and volume of tissue activated (VTA) software, it is possible to visualize contact positions in the context of the patient's own anatomy. In this study, the authors' aim was to demonstrate that VTA software can be used in clinical practice to help determine the clinical effectiveness of stimulation in patients with Parkinson's disease undergoing DBS of the STN. METHODS Brain images of 26 patients undergoing STN DBS were analyzed using VTA software. Preoperative clinical and neuropsychological data were collected. Contacts were chosen by two experts in DBS blinded to the clinical data. A therapeutic window of amplitude was determined. These results were compared with the parameter settings for each patient. Data were obtained at 3 months and 1 year postsurgery. RESULTS In 90.4% (95% CI 82%-98%) of the patients, the contacts identified by the VTA software were concordant with the clinically effective contacts or with an effective contact in contact-by-contact testing. The therapeutic window of amplitude selected virtually included 81.3% of the clinical amplitudes. CONCLUSIONS VTA software appears to present significant concordance with clinical data for selecting contacts and stimulation parameters that could help in postoperative follow-up and programming.
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Affiliation(s)
| | | | | | | | - Michel Lefranc
- 2Neurosurgery, Amiens University Hospital Center, Amiens, France
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35
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Schmidt SL, Brocker DT, Swan BD, Turner DA, Grill WM. Evoked potentials reveal neural circuits engaged by human deep brain stimulation. Brain Stimul 2020; 13:1706-1718. [PMID: 33035726 DOI: 10.1016/j.brs.2020.09.028] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is an effective therapy for reducing the motor symptoms of Parkinson's disease, but the mechanisms of action of DBS and neural correlates of symptoms remain unknown. OBJECTIVE To use the neural response to DBS to reveal connectivity of neural circuits and interactions between groups of neurons as potential mechanisms for DBS. METHODS We recorded activity evoked by DBS of the subthalamic nucleus (STN) in humans with Parkinson's disease. In follow up experiments we also simultaneously recorded activity in the contralateral STN or the ipsilateral globus pallidus from both internal (GPi) and external (GPe) segments. RESULTS DBS local evoked potentials (DLEPs) were stereotyped across subjects, and a biophysical model of reciprocal connections between the STN and the GPe recreated DLEPs. Simultaneous STN and GP recordings during STN DBS demonstrate that DBS evoked potentials were present throughout the basal ganglia and confirmed that DLEPs arose from the reciprocal connections between the STN and GPe. The shape and amplitude of the DLEPs were dependent on the frequency and duration of DBS and were correlated with resting beta band oscillations. In the frequency domain, DLEPs appeared as a 350 Hz high frequency oscillation (HFO) independent of the frequency of DBS. CONCLUSIONS DBS evoked potentials suggest that the intrinsic dynamics of the STN and GP are highly interlinked and may provide a promising new biomarker for adaptive DBS.
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Affiliation(s)
- Stephen L Schmidt
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - David T Brocker
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Brandon D Swan
- Department of Biomedical Engineering, Duke University, Durham, NC, USA
| | - Dennis A Turner
- Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Neurobiology, Duke University Medical Center, Durham, NC, USA; Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Warren M Grill
- Department of Biomedical Engineering, Duke University, Durham, NC, USA; Department of Neurobiology, Duke University Medical Center, Durham, NC, USA; Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.
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36
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Dayal V, De Roquemaurel A, Grover T, Ferreira F, Salazar M, Milabo C, Candelario‐McKeown J, Zrinzo L, Akram H, Limousin P, Foltynie T. Novel Programming Features Help Alleviate Subthalamic Nucleus Stimulation‐Induced Side Effects. Mov Disord 2020; 35:2261-2269. [DOI: 10.1002/mds.28252] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/01/2020] [Accepted: 08/03/2020] [Indexed: 11/07/2022] 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
| | - Alexis De Roquemaurel
- 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
| | - Francisca Ferreira
- Department of Clinical and Movement Neurosciences University College London Institute of Neurology London United Kingdom
| | - Maricel Salazar
- Unit of Functional Neurosurgery National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Catherine Milabo
- Unit of Functional Neurosurgery National Hospital for Neurology and Neurosurgery London United Kingdom
| | - Joseph Candelario‐McKeown
- 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
| | - 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
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37
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Brogin JAF, Faber J, Bueno DD. An Efficient Approach to Define the Input Stimuli to Suppress Epileptic Seizures Described by the Epileptor Model. Int J Neural Syst 2020; 30:2050062. [PMID: 32938259 DOI: 10.1142/s0129065720500628] [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] [Indexed: 11/18/2022]
Abstract
Epilepsy affects about 70 million people in the world. Every year, approximately 2.4 million people are diagnosed with epilepsy, two-thirds of them will not know the etiology of their disease, and 1% of these individuals will decease as a consequence of it. Due to the inherent complexity of predicting and explaining it, the mathematical model Epileptor was recently developed to reproduce seizure-like events, also providing insights to improve the understanding of the neural dynamics in the interictal and ictal periods, although the physics behind each parameter and variable of the model is not fully established in the literature. This paper introduces an approach to design a feedback-based controller for suppressing epileptic seizures described by Epileptor. Our work establishes how the nonlinear dynamics of this disorder can be written in terms of a combination of linear sub-models employing an exact solution. Additionally, we show how a feedback control gain can be computed to suppress seizures, as well as how specific shapes applied as input stimuli for this purpose can be obtained. The practical application of the approach is discussed and the results show that the proposed technique is promising for developing controllers in this field.
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Affiliation(s)
- João Angelo Ferres Brogin
- Department of Mechanical Engineering, São Paulo State University (UNESP), School of Engineering of Ilha Solteira, 56 Brasil Avenue, Ilha Solteira, São Paulo 15385-000, Brazil
| | - Jean Faber
- Department of Neurology and Neurosurgery, Federal University of São Paulo (UNIFESP), 667 Pedro de Toledo Street, São Paulo 04039-032, Brazil
| | - Douglas Domingues Bueno
- Department of Mathematics, São Paulo State University (UNESP), School of Engineering of Ilha Solteira, 56 Brasil Avenue, Ilha Solteira, São Paulo 15385-000, Brazil
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Doughty PT, Hossain I, Gong C, Ponder KA, Pati S, Arumugam PU, Murray TA. Novel microwire-based biosensor probe for simultaneous real-time measurement of glutamate and GABA dynamics in vitro and in vivo. Sci Rep 2020; 10:12777. [PMID: 32728074 PMCID: PMC7392771 DOI: 10.1038/s41598-020-69636-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 07/07/2020] [Indexed: 12/21/2022] Open
Abstract
Glutamate (GLU) and γ-aminobutyric acid (GABA) are the major excitatory (E) and inhibitory (I) neurotransmitters in the brain, respectively. Dysregulation of the E/I ratio is associated with numerous neurological disorders. Enzyme-based microelectrode array biosensors present the potential for improved biocompatibility, localized sample volumes, and much faster sampling rates over existing measurement methods. However, enzymes degrade over time. To overcome the time limitation of permanently implanted microbiosensors, we created a microwire-based biosensor that can be periodically inserted into a permanently implanted cannula. Biosensor coatings were based on our previously developed GLU and reagent-free GABA shank-type biosensor. In addition, the microwire biosensors were in the same geometric plane for the improved acquisition of signals in planar tissue including rodent brain slices, cultured cells, and brain regions with laminar structure. We measured real-time dynamics of GLU and GABA in rat hippocampal slices and observed a significant, nonlinear shift in the E/I ratio from excitatory to inhibitory dominance as electrical stimulation frequency increased from 10 to 140 Hz, suggesting that GABA release is a component of a homeostatic mechanism in the hippocampus to prevent excitotoxic damage. Additionally, we recorded from a freely moving rat over fourteen weeks, inserting fresh biosensors each time, thus demonstrating that the microwire biosensor overcomes the time limitation of permanently implanted biosensors and that the biosensors detect relevant changes in GLU and GABA levels that are consistent with various behaviors.
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Affiliation(s)
- P Timothy Doughty
- Center for Biomedical Engineering and Rehabilitation Sciences, Louisiana Tech University, Ruston, LA, USA
| | - Imran Hossain
- Institute for Micromanufacturing, Louisiana Tech University, Ruston, LA, USA
| | - Chenggong Gong
- Institute for Micromanufacturing, Louisiana Tech University, Ruston, LA, USA
| | - Kayla A Ponder
- Center for Biomedical Engineering and Rehabilitation Sciences, Louisiana Tech University, Ruston, LA, USA
| | - Sandipan Pati
- UAB Epilepsy Center/Department of Neurology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Prabhu U Arumugam
- Center for Biomedical Engineering and Rehabilitation Sciences, Louisiana Tech University, Ruston, LA, USA. .,Institute for Micromanufacturing, Louisiana Tech University, Ruston, LA, USA.
| | - Teresa A Murray
- Center for Biomedical Engineering and Rehabilitation Sciences, Louisiana Tech University, Ruston, LA, USA.
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Zheng L, Feng Z, Hu H, Wang Z, Yuan Y, Wei X. The Appearance Order of Varying Intervals Introduces Extra Modulation Effects on Neuronal Firing Through Non-linear Dynamics of Sodium Channels During High-Frequency Stimulations. Front Neurosci 2020; 14:397. [PMID: 32528237 PMCID: PMC7263357 DOI: 10.3389/fnins.2020.00397] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
Electrical pulse stimulation in the brain has shown success in treating several brain disorders with constant pulse frequency or constant inter-pulse interval (IPI). Varying IPI may offer a variety of novel stimulation paradigms and may extend the clinical applications. However, a lack of understanding of neuronal responses to varying IPI limits its informed applications. In this study, to investigate the effects of varying IPI, we performed both rat experiments and computational modeling by applying high-frequency stimulation (HFS) to efferent axon fibers of hippocampal pyramidal cells. Antidromically evoked population spikes (PSs) were used to evaluate the neuronal responses to pulse stimulations with different IPI patterns including constant IPI, gradually varying IPI, and randomly varying IPI. All the varying IPI sequences were uniformly distributed in the same interval range of 10 to 5 ms (i.e., 100 to 200 Hz). The experimental results showed that the mean correlation coefficient of PS amplitudes to the lengths of preceding IPI during HFS with random IPI (0.72 ± 0.04, n = 7 rats) was significantly smaller than the corresponding correlation coefficient during HFS with gradual IPI (0.92 ± 0.03, n = 7 rats, P < 0.001, t-test). The PS amplitudes induced by the random IPI covered a wider range, over twice as much as that induced by the gradual IPI, indicating additional effects induced by merely changing the appearance order of IPI. The computational modeling reproduced these experimental results and provided insights into these modulatory effects through the mechanism of non-linear dynamics of sodium channels and potassium accumulation in the narrow peri-axonal space. The simulation results showed that the HFS-induced increase of extracellular potassium ([K+] o ) elevated the membrane potential of axons, delayed the recovery course of sodium channels that were repeatedly activated and inactivated during HFS, and resulted in intermittent neuronal firing. Because of non-linear membrane dynamics, random IPI recruited more neurons to fire together following specific sub-sequences of pulses than gradual IPI, thereby widening the range of PS amplitudes. In conclusion, the study demonstrated novel HFS effects of neuronal modulation induced by merely changing the appearance order of the same group of IPI of pulses, which may inform the development of new stimulation patterns to meet different demands for treating various brain diseases.
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Affiliation(s)
- Lvpiao Zheng
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Zhouyan Feng
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Hanhan Hu
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Zhaoxiang Wang
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Yue Yuan
- Key Laboratory of Biomedical Engineering for Ministry of Education, College of Biomedical Engineering and Instrument Science, Zhejiang University, Hangzhou, China
| | - Xuefeng Wei
- Department of Biomedical Engineering, The College of New Jersey, Ewing, NJ, United States
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40
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Anderson CJ, Anderson DN, Pulst SM, Butson CR, Dorval AD. Neural selectivity, efficiency, and dose equivalence in deep brain stimulation through pulse width tuning and segmented electrodes. Brain Stimul 2020; 13:1040-1050. [PMID: 32278715 DOI: 10.1016/j.brs.2020.03.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Achieving deep brain stimulation (DBS) dose equivalence is challenging, especially with pulse width tuning and directional contacts. Further, the precise effects of pulse width tuning are unknown, and recent reports of the effects of pulse width tuning on neural selectivity are at odds with classic biophysical studies. METHODS We created multicompartment neuron models for two axon diameters and used finite element modeling to determine extracellular influence from standard and segmented electrodes. We analyzed axon activation profiles and calculated volumes of tissue activated. RESULTS We find that long pulse widths focus the stimulation effect on small, nearby fibers, suppressing distant white matter tract activation (responsible for some DBS side effects) and improving battery utilization when equivalent activation is maintained for small axons. Directional leads enable similar benefits to a greater degree. Reexamining previous reports of short pulse stimulation reducing side effects, we explore a possible alternate explanation: non-dose equivalent stimulation may have resulted in reduced spread of neural activation. Finally, using internal capsule avoidance as an example in the context of subthalamic stimulation, we present a patient-specific model to show how long pulse widths could help increase the biophysical therapeutic window. DISCUSSION We find agreement with classic studies and predict that long pulse widths may focus the stimulation effect on small, nearby fibers and improve power consumption. While future pre-clinical and clinical work is necessary regarding pulse width tuning, it is clear that future studies must ensure dose equivalence, noting that energy- and charge-equivalent amplitudes do not result in equivalent spread of neural activation when changing pulse width.
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Affiliation(s)
- Collin J Anderson
- University of Utah Department of Neurology, Salt Lake City, UT, USA.
| | - Daria Nesterovich Anderson
- University of Utah Department of Biomedical Engineering, Salt Lake City, UT, USA; University of Utah Department of Neurosurgery, Salt Lake City, UT, USA; University of Utah Scientific Computing and Imaging Institute, Salt Lake City, UT, USA
| | - Stefan M Pulst
- University of Utah Department of Neurology, Salt Lake City, UT, USA
| | - Christopher R Butson
- University of Utah Department of Neurology, Salt Lake City, UT, USA; University of Utah Department of Biomedical Engineering, Salt Lake City, UT, USA; University of Utah Department of Neurosurgery, Salt Lake City, UT, USA; University of Utah Scientific Computing and Imaging Institute, Salt Lake City, UT, USA; University of Utah Department of Psychiatry, Salt Lake City, UT, USA
| | - Alan D Dorval
- University of Utah Department of Biomedical Engineering, Salt Lake City, UT, USA
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41
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Yousif N, Bain PG, Nandi D, Borisyuk R. A Population Model of Deep Brain Stimulation in Movement Disorders From Circuits to Cells. Front Hum Neurosci 2020; 14:55. [PMID: 32210779 PMCID: PMC7066497 DOI: 10.3389/fnhum.2020.00055] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 02/05/2020] [Indexed: 01/04/2023] Open
Abstract
For more than 30 years, deep brain stimulation (DBS) has been used to target the symptoms of a number of neurological disorders and in particular movement disorders such as Parkinson’s disease (PD) and essential tremor (ET). It is known that the loss of dopaminergic neurons in the substantia nigra leads to PD, while the exact impact of this on the brain dynamics is not fully understood, the presence of beta-band oscillatory activity is thought to be pathological. The cause of ET, however, remains uncertain, however pathological oscillations in the thalamocortical-cerebellar network have been linked to tremor. Both of these movement disorders are treated with DBS, which entails the surgical implantation of electrodes into a patient’s brain. While DBS leads to an improvement in symptoms for many patients, the mechanisms underlying this improvement is not clearly understood, and computational modeling has been used extensively to improve this. Many of the models used to study DBS and its effect on the human brain have mainly utilized single neuron and single axon biophysical models. We have previously shown in separate models however, that the use of population models can shed much light on the mechanisms of the underlying pathological neural activity in PD and ET in turn, and on the mechanisms underlying DBS. Together, this work suggested that the dynamics of the cerebellar-basal ganglia thalamocortical network support oscillations at frequency range relevant to movement disorders. Here, we propose a new combined model of this network and present new results that demonstrate that both Parkinsonian oscillations in the beta band and oscillations in the tremor frequency range arise from the dynamics of such a network. We find regions in the parameter space demonstrating the different dynamics and go on to examine the transition from one oscillatory regime to another as well as the impact of DBS on these different types of pathological activity. This work will allow us to better understand the changes in brain activity induced by DBS, and allow us to optimize this clinical therapy, particularly in terms of target selection and parameter setting.
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Affiliation(s)
- Nada Yousif
- School of Engineering and Computer Science, University of Hertfordshire, Hatfield, United Kingdom
| | - Peter G Bain
- Division of Brain Sciences, Imperial College Healthcare NHS Trust, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Dipankar Nandi
- Division of Brain Sciences, Imperial College Healthcare NHS Trust, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Roman Borisyuk
- College of Engineering, Mathematics and Physical Sciences, University of Exeter, Exeter, United Kingdom.,Institute of Mathematical Problems of Biology, The Branch of Keldysh Institute of Applied Mathematics of Russian Academy of Sciences, Pushchino, Russia
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42
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Wong JK, Hess CW, Almeida L, Middlebrooks EH, Christou EA, Patrick EE, Shukla AW, Foote KD, Okun MS. Deep brain stimulation in essential tremor: targets, technology, and a comprehensive review of clinical outcomes. Expert Rev Neurother 2020; 20:319-331. [PMID: 32116065 DOI: 10.1080/14737175.2020.1737017] [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] [Indexed: 12/20/2022]
Abstract
Introduction: Essential tremor (ET) is a common movement disorder with an estimated prevalence of 0.9% worldwide. Deep brain stimulation (DBS) is an established therapy for medication refractory and debilitating tremor. With the arrival of next generation technology, the implementation and delivery of DBS has been rapidly evolving. This review will highlight the current applications and constraints for DBS in ET.Areas covered: The mechanism of action, targets for neuromodulation, next generation guidance techniques, symptom-specific applications, and long-term efficacy will be reviewed.Expert opinion: The posterior subthalamic area and zona incerta are alternative targets to thalamic DBS in ET. However, they may be associated with additional stimulation-induced side effects. Novel stimulation paradigms and segmented electrodes provide innovative approaches to DBS programming and stimulation-induced side effects.
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Affiliation(s)
- Joshua K Wong
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Christopher W Hess
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Leonardo Almeida
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
| | | | - Evangelos A Christou
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - Erin E Patrick
- Department of Electrical and Computer Engineering, University of Florida, Gainesville, FL, USA
| | - Aparna Wagle Shukla
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
| | - Kelly D Foote
- Fixel Institute for Neurological Diseases, Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Fixel Institute for Neurological Diseases, Department of Neurology, University of Florida, Gainesville, FL, USA
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Dayal V, Akram H, Zrinzo L, Limousin P, Foltynie T. Subthalamic Nucleus Deep Brain Stimulation in Parkinson's Disease: Valuable Programming Insights from Anecdotal Observations. Stereotact Funct Neurosurg 2020; 98:62-64. [PMID: 32045920 DOI: 10.1159/000505701] [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: 10/08/2019] [Accepted: 12/30/2019] [Indexed: 11/19/2022]
Abstract
In this article, we use a case to illustrate and discuss some practically important learning points about programming subthalamic nucleus deep brain stimulation for Parkinson's disease patients and highlight clinically relevant issues resulting from anatomical and device-related anomalies. These include the phenomenon of a dominant subthalamic nucleus, clinical variability with delayed response to stimulation, equivalence of electrical charge when using short-pulse settings, and issues regarding conversion of settings between constant-current and constant-voltage devices that are increasingly common with the use of device components from multiple manufacturers.
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Affiliation(s)
- 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,
| | - 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
| | - 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
| | - 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
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Yu Y, Hao Y, Wang Q. Model-based optimized phase-deviation deep brain stimulation for Parkinson 's disease. Neural Netw 2019; 122:308-319. [PMID: 31739269 DOI: 10.1016/j.neunet.2019.11.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/21/2019] [Accepted: 11/01/2019] [Indexed: 01/09/2023]
Abstract
High-frequency deep brain stimulation (HF-DBS) of the subthalamic nucleus (STN), globus pallidus interna (GPi) and globus pallidus externa (GPe) are often considered as effective methods for the treatment of Parkinson's disease (PD). However, the stimulation of a single nucleus by HF-DBS can cause specific physical damage, produce side effects and usually consume more electrical energy. Therefore, we use a biophysically-based model of basal ganglia-thalamic circuits to explore more effective stimulation patterns to reduce adverse effects and save energy. In this paper, we computationally investigate the combined DBS of two nuclei with the phase deviation between two stimulation waveforms (CDBS). Three different stimulation combination strategies are proposed, i.e., STN and GPe CDBS (SED), STN and GPi CDBS (SID), as well as GPi and GPe CDBS (GGD). Resultantly, it is found that anti-phase CDBS is more effective in improving parkinsonian dynamical properties, including desynchronization of neurons and the recovery of the thalamus relay ability. Detailed simulation investigation shows that anti-phase SED and GGD are superior to SID. Besides, the energy consumption can be largely reduced by SED and GGD (72.5% and 65.5%), compared to HF-DBS. These results provide new insights into the optimal stimulation parameter and target choice of PD, which may be helpful for the clinical practice.
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Affiliation(s)
- Ying Yu
- Department of Dynamics and Control, Beihang University, 100191, Beijing, China
| | - Yuqing Hao
- Department of Dynamics and Control, Beihang University, 100191, Beijing, China
| | - Qingyun Wang
- Department of Dynamics and Control, Beihang University, 100191, Beijing, China.
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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
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Anderson DN, Osting B, Vorwerk J, Dorval AD, Butson CR. Optimized programming algorithm for cylindrical and directional deep brain stimulation electrodes. J Neural Eng 2019; 15:026005. [PMID: 29235446 DOI: 10.1088/1741-2552/aaa14b] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) is a growing treatment option for movement and psychiatric disorders. As DBS technology moves toward directional leads with increased numbers of smaller electrode contacts, trial-and-error methods of manual DBS programming are becoming too time-consuming for clinical feasibility. We propose an algorithm to automate DBS programming in near real-time for a wide range of DBS lead designs. APPROACH Magnetic resonance imaging and diffusion tensor imaging are used to build finite element models that include anisotropic conductivity. The algorithm maximizes activation of target tissue and utilizes the Hessian matrix of the electric potential to approximate activation of neurons in all directions. We demonstrate our algorithm's ability in an example programming case that targets the subthalamic nucleus (STN) for the treatment of Parkinson's disease for three lead designs: the Medtronic 3389 (four cylindrical contacts), the direct STNAcute (two cylindrical contacts, six directional contacts), and the Medtronic-Sapiens lead (40 directional contacts). MAIN RESULTS The optimization algorithm returns patient-specific contact configurations in near real-time-less than 10 s for even the most complex leads. When the lead was placed centrally in the target STN, the directional leads were able to activate over 50% of the region, whereas the Medtronic 3389 could activate only 40%. When the lead was placed 2 mm lateral to the target, the directional leads performed as well as they did in the central position, but the Medtronic 3389 activated only 2.9% of the STN. SIGNIFICANCE This DBS programming algorithm can be applied to cylindrical electrodes as well as novel directional leads that are too complex with modern technology to be manually programmed. This algorithm may reduce clinical programming time and encourage the use of directional leads, since they activate a larger volume of the target area than cylindrical electrodes in central and off-target lead placements.
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Affiliation(s)
- Daria Nesterovich Anderson
- Department of Bioengineering, University of Utah, Salt Lake City, UT, United States of America. Scientific Computing & Imaging (SCI) Institute, University of Utah, Salt Lake City, UT, United States of America
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Adaptive delivery of continuous and delayed feedback deep brain stimulation - a computational study. Sci Rep 2019; 9:10585. [PMID: 31332226 PMCID: PMC6646395 DOI: 10.1038/s41598-019-47036-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Accepted: 07/09/2019] [Indexed: 12/15/2022] Open
Abstract
Adaptive deep brain stimulation (aDBS) is a closed-loop method, where high-frequency DBS is turned on and off according to a feedback signal, whereas conventional high-frequency DBS (cDBS) is delivered permanently. Using a computational model of subthalamic nucleus and external globus pallidus, we extend the concept of adaptive stimulation by adaptively controlling not only continuous, but also demand-controlled stimulation. Apart from aDBS and cDBS, we consider continuous pulsatile linear delayed feedback stimulation (cpLDF), specifically designed to induce desynchronization. Additionally, we combine adaptive on-off delivery with continuous delayed feedback modulation by introducing adaptive pulsatile linear delayed feedback stimulation (apLDF), where cpLDF is turned on and off using pre-defined amplitude thresholds. By varying the stimulation parameters of cDBS, aDBS, cpLDF, and apLDF we obtain optimal parameter ranges. We reveal a simple relation between the thresholds of the local field potential (LFP) for aDBS and apLDF, the extent of the stimulation-induced desynchronization, and the integral stimulation time required. We find that aDBS and apLDF can be more efficient in suppressing abnormal synchronization than continuous simulation. However, apLDF still remains more efficient and also causes a stronger reduction of the LFP beta burst length. Hence, adaptive on-off delivery may further improve the intrinsically demand-controlled pLDF.
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Johansson JD, Alonso F, Wardell K. Patient-Specific Simulations of Deep Brain Stimulation Electric Field with Aid of In-house Software ELMA. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2019; 2019:5212-5216. [PMID: 31947033 DOI: 10.1109/embc.2019.8856307] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Deep brain stimulation (DBS) is an established technique for reduction of symptoms in movement disorders. Finite element method (FEM) simulations of the electric field magnitude (EF) are useful for estimating the affected tissue around the DBS lead and this can help optimize the therapy. This paper describes how patient-specific FEM models can be set up with the aid of the Matlab-based in-house software tool ELMA. Electrode placement is determined from two coordinates in postoperative medical imaging and electric conductivity is assigned from preoperative magnetic resonance imaging (MRI) and patient-specific DBS data. Simulations are performed using the equation for steady currents in Comsol Multiphysics (CM). The simulated EF is superimposed on the preoperative MRI for evaluation of affected structures. The method is demonstrated with patient-specific simulations in the zona incerta and a globus pallidus example containing cysts with higher conductive which causes considerable distortion of the EF. The improved software modules and precise lead positioning simplifies and reduces the time for DBS EF modelling and simulation.
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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: 111] [Impact Index Per Article: 22.2] [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).
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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
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50
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Modulation of inhibitory plasticity in basal ganglia output nuclei of patients with Parkinson's disease. Neurobiol Dis 2019; 124:46-56. [DOI: 10.1016/j.nbd.2018.10.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/17/2018] [Accepted: 10/31/2018] [Indexed: 01/07/2023] Open
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