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Ricci A, Rubino E, Serra GP, Wallén-Mackenzie Å. Concerning neuromodulation as treatment of neurological and neuropsychiatric disorder: Insights gained from selective targeting of the subthalamic nucleus, para-subthalamic nucleus and zona incerta in rodents. Neuropharmacology 2024; 256:110003. [PMID: 38789078 DOI: 10.1016/j.neuropharm.2024.110003] [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: 02/06/2024] [Revised: 04/26/2024] [Accepted: 05/14/2024] [Indexed: 05/26/2024]
Abstract
Neuromodulation such as deep brain stimulation (DBS) is advancing as a clinical intervention in several neurological and neuropsychiatric disorders, including Parkinson's disease, dystonia, tremor, and obsessive-compulsive disorder (OCD) for which DBS is already applied to alleviate severely afflicted individuals of symptoms. Tourette syndrome and drug addiction are two additional disorders for which DBS is in trial or proposed as treatment. However, some major remaining obstacles prevent this intervention from reaching its full therapeutic potential. Side-effects have been reported, and not all DBS-treated individuals are relieved of their symptoms. One major target area for DBS electrodes is the subthalamic nucleus (STN) which plays important roles in motor, affective and associative functions, with impact on for example movement, motivation, impulsivity, compulsivity, as well as both reward and aversion. The multifunctionality of the STN is complex. Decoding the anatomical-functional organization of the STN could enhance strategic targeting in human patients. The STN is located in close proximity to zona incerta (ZI) and the para-subthalamic nucleus (pSTN). Together, the STN, pSTN and ZI form a highly heterogeneous and clinically important brain area. Rodent-based experimental studies, including opto- and chemogenetics as well as viral-genetic tract tracings, provide unique insight into complex neuronal circuitries and their impact on behavior with high spatial and temporal precision. This research field has advanced tremendously over the past few years. Here, we provide an inclusive review of current literature in the pre-clinical research fields centered around STN, pSTN and ZI in laboratory mice and rats; the three highly heterogeneous and enigmatic structures brought together in the context of relevance for treatment strategies. Specific emphasis is placed on methods of manipulation and behavioral impact.
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Affiliation(s)
- Alessia Ricci
- Uppsala University, Department of Organism Biology, 756 32 Uppsala, Sweden; Aligning Science Across Parkinson's (ASAP) Collaborative Research Network, Chevy Chase, MD 20815, USA
| | - Eleonora Rubino
- Uppsala University, Department of Organism Biology, 756 32 Uppsala, Sweden; Aligning Science Across Parkinson's (ASAP) Collaborative Research Network, Chevy Chase, MD 20815, USA
| | - Gian Pietro Serra
- Uppsala University, Department of Organism Biology, 756 32 Uppsala, Sweden; Aligning Science Across Parkinson's (ASAP) Collaborative Research Network, Chevy Chase, MD 20815, USA
| | - Åsa Wallén-Mackenzie
- Uppsala University, Department of Organism Biology, 756 32 Uppsala, Sweden; Aligning Science Across Parkinson's (ASAP) Collaborative Research Network, Chevy Chase, MD 20815, USA.
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Huang Z, Meng L, Bi X, Xie Z, Liang W, Huang J. Efficacy and safety of robot-assisted deep brain stimulation for Parkinson's disease: a meta-analysis. Front Aging Neurosci 2024; 16:1419152. [PMID: 38882524 PMCID: PMC11176545 DOI: 10.3389/fnagi.2024.1419152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 05/20/2024] [Indexed: 06/18/2024] Open
Abstract
Objective This meta-analysis aims to assess the effectiveness and safety of robot-assisted deep brain stimulation (DBS) surgery for Parkinson's disease(PD). Methods Four databases (Medline, Embase, Web of Science and CENTRAL) were searched from establishment of database to 23 March 2024, for articles studying robot-assisted DBS in patients diagnosed with PD. Meta-analyses of vector error, complication rate, levodopa-equivalent daily dose (LEDD), Unified Parkinson's Disease Rating Scale (UPDRS), UPDRS II, UPDRS III, and UPDRS IV were performed. Results A total of 15 studies were included in this meta-analysis, comprising 732 patients with PD who received robot-assisted DBS. The pooled results revealed that the vector error was measured at 1.09 mm (95% CI: 0.87 to 1.30) in patients with Parkinson's disease who received robot-assisted DBS. The complication rate was 0.12 (95% CI, 0.03 to 0.24). The reduction in LEDD was 422.31 mg (95% CI: 68.69 to 775.94). The improvement in UPDRS, UPDRS III, and UPDRS IV was 27.36 (95% CI: 8.57 to 46.15), 14.09 (95% CI: 4.67 to 23.52), and 3.54 (95% CI: -2.35 to 9.43), respectively. Conclusion Robot-assisted DBS is a reliable and safe approach for treating PD. Robot-assisted DBS provides enhanced accuracy in contrast to conventional frame-based stereotactic techniques. Nevertheless, further investigation is necessary to validate the advantages of robot-assisted DBS in terms of enhancing motor function and decreasing the need for antiparkinsonian medications, in comparison to traditional frame-based stereotactic techniques.Clinical trial registration: PROSPERO(CRD42024529976).
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Affiliation(s)
- Zhilong Huang
- The First Affiliated Hospital of Guangxi University of Science and Technology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Lian Meng
- The First Affiliated Hospital of Guangxi University of Science and Technology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Xiongjie Bi
- The First Affiliated Hospital of Guangxi University of Science and Technology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Zhengde Xie
- The First Affiliated Hospital of Guangxi University of Science and Technology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Weiming Liang
- The First Affiliated Hospital of Guangxi University of Science and Technology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
| | - Jinyu Huang
- The First Affiliated Hospital of Guangxi University of Science and Technology, Guangxi University of Science and Technology, Liuzhou, Guangxi, China
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Mensah-Brown KG, Naylor RM, Graepel S, Brinjikji W. Neuromodulation: What the neurointerventionalist needs to know. Interv Neuroradiol 2024:15910199231224554. [PMID: 38454831 DOI: 10.1177/15910199231224554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2024] Open
Abstract
Neuromodulation is the alteration of neural activity in the central, peripheral, or autonomic nervous systems. Consequently, this term lends itself to a variety of organ systems including but not limited to the cardiac, nervous, and even gastrointestinal systems. In this review, we provide a primer on neuromodulation, examining the various technological systems employed and neurological disorders targeted with this technology. Ultimately, we undergo a historical analysis of the field's development, pivotal discoveries and inventions gearing this review to neuro-adjacent subspecialties with a specific focus on neurointerventionalists.
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Affiliation(s)
| | - Ryan M Naylor
- Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA
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Sandoval-Pistorius SS, Hacker ML, Waters AC, Wang J, Provenza NR, de Hemptinne C, Johnson KA, Morrison MA, Cernera S. Advances in Deep Brain Stimulation: From Mechanisms to Applications. J Neurosci 2023; 43:7575-7586. [PMID: 37940596 PMCID: PMC10634582 DOI: 10.1523/jneurosci.1427-23.2023] [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: 07/27/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 11/10/2023] Open
Abstract
Deep brain stimulation (DBS) is an effective therapy for various neurologic and neuropsychiatric disorders, involving chronic implantation of electrodes into target brain regions for electrical stimulation delivery. Despite its safety and efficacy, DBS remains an underutilized therapy. Advances in the field of DBS, including in technology, mechanistic understanding, and applications have the potential to expand access and use of DBS, while also improving clinical outcomes. Developments in DBS technology, such as MRI compatibility and bidirectional DBS systems capable of sensing neural activity while providing therapeutic stimulation, have enabled advances in our understanding of DBS mechanisms and its application. In this review, we summarize recent work exploring DBS modulation of target networks. We also cover current work focusing on improved programming and the development of novel stimulation paradigms that go beyond current standards of DBS, many of which are enabled by sensing-enabled DBS systems and have the potential to expand access to DBS.
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Affiliation(s)
| | - Mallory L Hacker
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee 37232
| | - Allison C Waters
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York 10029
- Department of Neuroscience, Icahn School of Medicine at Mount Sinai, New York, New York 10029
| | - Jing Wang
- Department of Neurology, University of Minnesota, Minneapolis, Minnesota 55455
| | - Nicole R Provenza
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas 77030
| | - Coralie de Hemptinne
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, Florida 32608
| | - Kara A Johnson
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, Florida 32608
| | - Melanie A Morrison
- Department of Radiology and Biomedical Imaging, University of California-San Francisco, San Francisco, California 94143
| | - Stephanie Cernera
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California 94143
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Artusi CA, Ledda C, Rinaldi D, Montanaro E, Romagnolo A, Imbalzano G, Rizzone MG, Zibetti M, Lopiano L, Bozzali M. Axial symptoms as main predictors of short-term subthalamic stimulation outcome in Parkinson's disease. J Neurol Sci 2023; 453:120818. [PMID: 37774562 DOI: 10.1016/j.jns.2023.120818] [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: 04/18/2023] [Revised: 09/21/2023] [Accepted: 09/24/2023] [Indexed: 10/01/2023]
Abstract
Deep brain stimulation (DBS) is an established therapeutic option for Parkinson's disease (PD) patients; however, a clear-cut definition of subthalamic (STN) DBS predictors in PD is lacking. We analyzed a cohort of 181 STN-treated PD patients and compared pre- vs. 1-year post-surgical motor, dyskinesia, Off time, and daily-life activities (ADL) scores. A multivariate linear regression analysis was used to evaluate the association between clinical/demographic characteristics and the extent of STN-DBS response for outcomes proving a significant change after surgery. After STN-DBS, we observed a significant improvement of motor symptoms (P < 0.001), dyskinesia (P < 0.001), and daily Off time (P < 0.001). Sex, PD duration, cognitive status, and the motor and axial response to levodopa significantly explained the motor improvement (R = 0.360, P = 0.002), with presurgical response of axial symptoms (Beta = 0.203, P = 0.025) and disease duration (Beta = 0.205, P = 0.013) being the strongest predictors. Considering the daily Off time improvement, motor and axial response at the levodopa challenge test and disease duration explained 10.6% of variance (R = 0.326, p < 0.001), with disease duration being the strongest predictor of improvement (Beta = 0.253, p: 0.001) and axial levodopa response showing a trend of significance in explaining the change (Beta = 0.173, p: 0.056). Dyskinesia improvement was not significantly explained by the model. Our findings highlight the emerging role of axial symptoms in PD and their response to levodopa as potentially pivotal also in the DBS selection process.
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Affiliation(s)
- Carlo Alberto Artusi
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy.
| | - Claudia Ledda
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy
| | - Domiziana Rinaldi
- Dipartimento di Neuroscienze, Salute Mentale e Organi di Senso, Sapienza Università di Roma, Via di Grottarossa, 1035-00189 Roma, Italy
| | - Elisa Montanaro
- SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy
| | - Alberto Romagnolo
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy
| | - Gabriele Imbalzano
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy
| | - Mario Giorgio Rizzone
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy
| | - Maurizio Zibetti
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy
| | - Leonardo Lopiano
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy
| | - Marco Bozzali
- Department of Neuroscience "Rita Levi Montalcini", University of Turin, Turin, Italy; SC Neurologia 2U, AOU Città della Salute e della Scienza, Turin, Italy
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Bilateral deep brain stimulation of the subthalamic nucleus: Targeting differences between the first and second side. NEUROCIRUGIA (ENGLISH EDITION) 2023:S2529-8496(22)00100-9. [PMID: 36775743 DOI: 10.1016/j.neucie.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/18/2022] [Indexed: 02/12/2023]
Abstract
INTRODUCTION AND OBJECTIVES Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a recognized treatment for drug-refractory Parkinson's disease (PD). However, the therapeutic success depends on the accuracy of targeting. This study aimed to evaluate potential accuracy differences in the placement of the first and second electrodes implanted, by comparing chosen electrode trajectories, STN activity detected during microelectrode recording (MER), and the mismatch between the initially planned and final electrode positions on each side. MATERIALS AND METHODS In this retrospective cohort study, we analyzed data from 30 patients who underwent one-stage bilateral DBS. For most patients, three arrays of microelectrodes were used to determine the physiological location of the STN. Final target location depended also on the results of intraoperative stimulation. The choice of central versus non-central channels was compared. The Euclidean vector deviation was calculated using the initially planned coordinates and the final position of the tip of the electrode according to a CT scan taken at least a month after the surgery. RESULTS The central channel was chosen in 70% of cases on the first side and 40% of cases on the second side. The mean length of high-quality STN activity recorded in the central channel was longer on the first side than the second (3.07±1.85mm vs. 2.75±1.94mm), while in the anterior channel there were better MER recordings on the second side (1.59±2.07mm on the first side vs. 2.78±2.14mm on the second). Regarding the mismatch between planned versus final electrode position, electrodes on the first side were placed on average 0.178±0.917mm lateral, 0.126±1.10mm posterior and 1.48±1.64mm inferior to the planned target, while the electrodes placed on the second side were 0.251±1.08mm medial, 0.355±1.29mm anterior and 2.26±1.47mm inferior to the planned target. CONCLUSION There was a tendency for the anterior trajectory to be chosen more frequently than the central on the second side. There was also a statistically significant deviation of the second electrodes in the anterior and inferior directions, when compared to the electrodes on the first side, suggesting that another cause other than brain shift may be responsible. We should therefore factor this during planning for the second implanted side. It might be useful to plan the second side more anteriorly, possibly reducing the number of MER trajectories tested and the duration of surgery.
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de Oliveira F, Vaz R, Chamadoira C, Rosas MJ, Ferreira-Pinto MJ. Bilateral deep brain stimulation of the subthalamic nucleus: Targeting differences between the first and second side. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Fenoy AJ, Conner CR. Frameless Robot-Assisted vs Frame-Based Awake Deep Brain Stimulation Surgery: An Evaluation of Technique and New Challenges. Oper Neurosurg (Hagerstown) 2022; 22:171-178. [PMID: 34989699 DOI: 10.1227/ons.0000000000000059] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 09/13/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Methodological approaches to deep brain stimulation (DBS) continue to evolve from awake frame-based to asleep frameless procedures with robotic assistance, primarily directed to optimize operative efficiency, lead accuracy, and patient comfort. Comparison between the 2 is scarce. OBJECTIVE To analyze the impacts of methodological differences on operative efficiency and stereotactic accuracy using a frame compared with a frameless robotic platform while maintaining the awake state and use of multiple microelectrode recording (MER) trajectories. METHODS Thirty-four consecutive patients who underwent bilateral awake frameless robot-assisted DBS were compared with a previous cohort of 30 patients who underwent frame-based surgery. Patient demographics, operative times, and MER data were collected for both cohorts. Two-dimensional radial errors of lead placements were calculated. RESULTS Preoperative setup, surgical, and total operating room times were all significantly greater for the robot-assisted cohort (P < .001). The need for computed tomography imaging when referencing the robotic fiducials led to increased setup duration because of patient transport, unnecessary for the frame-based cohort. Multiple simultaneous MER trajectories increased surgical time (mean 26 min) for the robot-assisted cohort only. The mean radial errors in the robot-assisted and frame cohorts were 0.98 ± 0.66 and 0.74 ± 0.49 mm (P = .03), respectively. CONCLUSION The use of a truly frameless robotic platform such as the Mazor Renaissance (Mazor Robotics Ltd) presented challenges when implementing techniques used during awake frame-based surgery. Maintaining good accuracy, intraoperative reference imaging, and limited MER trajectories will help integrate frameless robot assistance into the awake DBS surgical workflow.
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Affiliation(s)
- Albert J Fenoy
- Department of Neurosurgery, McGovern Medical School, The University of Texas Health Science Center at Houston (UT Health), Houston, Texas, USA
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Rocha MSG, de Freitas JL, Costa CDM, de Oliveira MO, Terzian PR, Queiroz JWM, Ferraz JB, Tatsch JFS, Soriano DC, Hamani C, Godinho F. Fields of Forel Brain Stimulation Improves Levodopa-Unresponsive Gait and Balance Disorders in Parkinson's Disease. Neurosurgery 2021; 89:450-459. [PMID: 34161592 DOI: 10.1093/neuros/nyab195] [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: 12/02/2020] [Accepted: 04/03/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Gait and balance disturbance are challenging symptoms in advanced Parkinson's disease (PD). Anatomic and clinical data suggest that the fields of Forel may be a potential surgical target to treat these symptoms. OBJECTIVE To test whether bilateral stimulation centered at the fields of Forel improves levodopa unresponsive freezing of gait (FOG), balance problems, postural instability, and falls in PD. METHODS A total of 13 patients with levodopa-unresponsive gait disturbance (Hoehn and Yahr stage ≥3) were included. Patients were evaluated before (on-medication condition) and 1 yr after surgery (on-medication-on-stimulation condition). Motor symptoms and quality of life were assessed with the Unified Parkinson's Disease Rating scale (UPDRS III) and Quality of Life scale (PDQ-39). Clinical and instrumented analyses assessed gait, balance, postural instability, and falls. RESULTS Surgery improved balance by 43% (95% confidence interval [CI]: 21.2-36.4 to 35.2-47.1; P = .0012), reduced FOG by 35% (95% CI: 15.1-20.3 to 8.1-15.3; P = .0021), and the monthly number of falls by 82.2% (95% CI: 2.2-6.9 to -0.2-1.7; P = .0039). Anticipatory postural adjustments, velocity to turn, and postural sway measurements also improved 1 yr after deep brain stimulation (DBS). UPDRS III motor scores were reduced by 27.2% postoperatively (95% CI: 42.6-54.3 to 30.2-40.5; P < .0001). Quality of life improved 27.5% (95% CI: 34.6-48.8 to 22.4-37.9; P = .0100). CONCLUSION Our results suggest that DBS of the fields of Forel improved motor symptoms in PD, as well as the FOG, falls, balance, postural instability, and quality of life.
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Affiliation(s)
- Maria Sheila Guimarães Rocha
- Hospital Santa Marcelina, Neurology and Functional Neurosurgery Department, São Paulo, Brazil.,Faculdade Santa Marcelina, Internal Medicine Division, São Paulo, Brazil
| | | | | | - Maira Okada de Oliveira
- Hospital Santa Marcelina, Neurology and Functional Neurosurgery Department, São Paulo, Brazil.,Global Brain Health Institute, University of California-San Francisco, San Francisco, California, USA
| | - Paulo Roberto Terzian
- Hospital Santa Marcelina, Neurology and Functional Neurosurgery Department, São Paulo, Brazil
| | | | - Jamana Barbosa Ferraz
- Hospital Santa Marcelina, Neurology and Functional Neurosurgery Department, São Paulo, Brazil.,Faculdade Santa Marcelina, Internal Medicine Division, São Paulo, Brazil
| | | | - Diogo Coutinho Soriano
- Modeling and Applied Social Sciences, Federal University of ABC, São Bernardo do Campo, Brazil
| | - Clement Hamani
- Sunnybrook Health Sciences Centre, Harquail Centre for Neuromodulation, Division of Neurosurgery, University of Toronto, Toronto, Canada
| | - Fabio Godinho
- Hospital Santa Marcelina, Neurology and Functional Neurosurgery Department, São Paulo, Brazil.,Modeling and Applied Social Sciences, Federal University of ABC, São Bernardo do Campo, Brazil.,Institute of Psychiatry, Hospital das Clínicas, Functional Neurosurgery Division, University of São Paulo, São Paulo, Brazil
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de Roquemaurel A, Wirth T, Vijiaratnam N, Ferreira F, Zrinzo L, Akram H, Foltynie T, Limousin P. Stimulation Sweet Spot in Subthalamic Deep Brain Stimulation - Myth or Reality? A Critical Review of Literature. Stereotact Funct Neurosurg 2021; 99:425-442. [PMID: 34120117 DOI: 10.1159/000516098] [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: 12/02/2020] [Accepted: 03/23/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION While deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been extensively used for more than 20 years in Parkinson's disease (PD), the optimal area of stimulation to relieve motor symptoms remains elusive. OBJECTIVE We aimed at localizing the sweet spot within the subthalamic region by performing a systematic review of the literature. METHOD PubMed database was searched for published studies exploring optimal stimulation location for STN DBS in PD, published between 2000 and 2019. A standardized assessment procedure based on methodological features was applied to select high-quality publications. Studies conducted more than 3 months after the DBS procedure, employing lateralized scores and/or stimulation condition, and reporting the volume of tissue activated or the position of the stimulating contact within the subthalamic region were considered in the final analysis. RESULTS Out of 439 references, 24 were finally retained, including 21 studies based on contact location and 3 studies based on volume of tissue activated (VTA). Most studies (all VTA-based studies and 13 of the 21 contact-based studies) suggest the superior-lateral STN and the adjacent white matter as the optimal sites for stimulation. Remaining contact-based studies were either inconclusive (5/21), favoured the caudal zona incerta (1/21), or suggested a better outcome of STN stimulation than adjacent white matter stimulation (2/21). CONCLUSION Using a standardized methodological approach, our review supports the presence of a sweet spot located within the supero-lateral STN and extending to the adjacent white matter.
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Affiliation(s)
- Alexis de Roquemaurel
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Thomas Wirth
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Neurology department, Strasbourg University Hospital, Strasbourg, France.,INSERM-U964/CNRS-UMR7104/University of Strasbourg, Illkirch-Graffenstaden, France
| | - Nirosen Vijiaratnam
- Unit of Functional Neurosurgery, Department of Clinical and Movement Neurosciences, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - Francisca Ferreira
- Unit of Functional Neurosurgery, 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
- Unit of Functional Neurosurgery, 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
- Unit of Functional Neurosurgery, 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
- Unit of Functional Neurosurgery, 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
- Unit of Functional Neurosurgery, 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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Martin T, Peralta M, Gilmore G, Sauleau P, Haegelen C, Jannin P, Baxter JS. Extending convolutional neural networks for localizing the subthalamic nucleus from micro-electrode recordings in Parkinson’s disease. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2021.102529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Zavala B, Mirzadeh Z, Chen T, Lambert M, Chapple KM, Dhall R, Ponce FA. Electrophysiologic Mapping for Target Acquisition in Deep Brain Stimulation May Become Unnecessary in the Era of Intraoperative Imaging. World Neurosurg 2021; 152:e51-e61. [PMID: 33905908 DOI: 10.1016/j.wneu.2021.04.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Electrophysiologic mapping (EM) has been instrumental in advancing neuroscience and ensuring accurate lead placement for deep brain stimulation. However, EM is associated with increased operative time, expense, and potential risk. Intraoperative imaging to verify lead placement provides an opportunity to reassess the clinical role of EM. We investigated whether EM 1) provides new information that corrects suboptimal preoperative target selection by the physician or 2) simply corrects intraoperative stereotactic error, which can instead be quickly corrected with intraoperative imaging. METHODS Deep brain stimulation lead location errors were evaluated by measuring whether repositioning leads based on EM directed the final lead placement 1) away from or 2) toward the original target. We retrospectively identified 50 patients with 61 leads that required repositioning directed by EM. The stereotactic coordinates of each lead were determined with intraoperative computed tomography. RESULTS In 45 of 61 leads (74%), the electrophysiologically directed repositioning moved the lead toward the initial target. The mean radial errors between the preoperative plan and targeted contact coordinates before and after repositioning were 2.2 and 1.5 mm, respectively (P < 0.001). Microelectrode recording was more likely than test stimulation to direct leads toward the initial target (88% vs. 63%; P = 0.03). The nucleus targeted was associated with the likelihood of moving toward the initial target. CONCLUSIONS Electrophysiologic mapping corrected primarily for errors in lead placement rather than providing new information regarding errors in target selection. Thus, intraoperative imaging and improvements in stereotactic techniques may reduce or even eliminate dependence on EM.
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Affiliation(s)
- Baltazar Zavala
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Zaman Mirzadeh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tsinsue Chen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Margaret Lambert
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kristina M Chapple
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Rohit Dhall
- Department of Neurology, University of Arkansas, Little Rock, Arkansas, USA
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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13
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Quirin T, Féry C, Vogel D, Vergne C, Sarracanie M, Salameh N, Madec M, Hemm S, Hébrard L, Pascal J. Towards Tracking of Deep Brain Stimulation Electrodes Using an Integrated Magnetometer. SENSORS (BASEL, SWITZERLAND) 2021; 21:2670. [PMID: 33920125 PMCID: PMC8068940 DOI: 10.3390/s21082670] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 11/16/2022]
Abstract
This paper presents a tracking system using magnetometers, possibly integrable in a deep brain stimulation (DBS) electrode. DBS is a treatment for movement disorders where the position of the implant is of prime importance. Positioning challenges during the surgery could be addressed thanks to a magnetic tracking. The system proposed in this paper, complementary to existing procedures, has been designed to bridge preoperative clinical imaging with DBS surgery, allowing the surgeon to increase his/her control on the implantation trajectory. Here the magnetic source required for tracking consists of three coils, and is experimentally mapped. This mapping has been performed with an in-house three-dimensional magnetic camera. The system demonstrates how magnetometers integrated directly at the tip of a DBS electrode, might improve treatment by monitoring the position during and after the surgery. The three-dimensional operation without line of sight has been demonstrated using a reference obtained with magnetic resonance imaging (MRI) of a simplified brain model. We observed experimentally a mean absolute error of 1.35 mm and an Euclidean error of 3.07 mm. Several areas of improvement to target errors below 1 mm are also discussed.
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Affiliation(s)
- Thomas Quirin
- Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland (FHNW), 4132 Muttenz, Switzerland; (C.F.); (D.V.); (C.V.); (S.H.); (J.P.)
- Icube laboratory, UMR 7357 (University of Strasbourg/CNRS), 67412 Illkirch, France; (M.M.); (L.H.)
| | - Corentin Féry
- Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland (FHNW), 4132 Muttenz, Switzerland; (C.F.); (D.V.); (C.V.); (S.H.); (J.P.)
| | - Dorian Vogel
- Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland (FHNW), 4132 Muttenz, Switzerland; (C.F.); (D.V.); (C.V.); (S.H.); (J.P.)
- Department of Biomedical Engineering, Linköping University, 581 83 Linköping, Sweden
| | - Céline Vergne
- Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland (FHNW), 4132 Muttenz, Switzerland; (C.F.); (D.V.); (C.V.); (S.H.); (J.P.)
- Icube laboratory, UMR 7357 (University of Strasbourg/CNRS), 67412 Illkirch, France; (M.M.); (L.H.)
| | - Mathieu Sarracanie
- Center for Adaptable MRI Technology, Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland; (M.S.); (N.S.)
| | - Najat Salameh
- Center for Adaptable MRI Technology, Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland; (M.S.); (N.S.)
| | - Morgan Madec
- Icube laboratory, UMR 7357 (University of Strasbourg/CNRS), 67412 Illkirch, France; (M.M.); (L.H.)
| | - Simone Hemm
- Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland (FHNW), 4132 Muttenz, Switzerland; (C.F.); (D.V.); (C.V.); (S.H.); (J.P.)
- Department of Biomedical Engineering, Linköping University, 581 83 Linköping, Sweden
| | - Luc Hébrard
- Icube laboratory, UMR 7357 (University of Strasbourg/CNRS), 67412 Illkirch, France; (M.M.); (L.H.)
| | - Joris Pascal
- Institute for Medical Engineering and Medical Informatics, School of Life Sciences, University of Applied Sciences and Arts Northwestern Switzerland (FHNW), 4132 Muttenz, Switzerland; (C.F.); (D.V.); (C.V.); (S.H.); (J.P.)
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14
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Artusi CA, Romagnolo A, Imbalzano G, Montanaro E, Zibetti M, Rizzone MG, Lopiano L. Deep brain stimulation outcomes in the malignant end of Parkinson's disease spectrum. Parkinsonism Relat Disord 2021; 86:5-9. [PMID: 33812276 DOI: 10.1016/j.parkreldis.2021.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Heterogeneity of Parkinson's Disease (PD) phenotype may influence deep brain stimulation (DBS) outcome. However, DBS response in the malignant end of the PD spectrum has been poorly investigated. OBJECTIVE To evaluate and compare DBS outcomes in malignant and benign PD patients, defined according to motor and non-motor symptom presentation at the presurgical selection. METHODS We categorized a cohort of 154 parkinsonian patients fulfilling criteria for subthalamic nucleus (STN)-DBS into malignant, benign, and intermediate subtypes, according to a recently validated clinical PD classification. DBS efficacy on daily living independence (Schwab and England -S&E-score ≥70%), motor symptoms, and motor fluctuations (Unified Parkinson's Disease Rating Scale -UPDRS- part-III and -IV, and Ambulatory Capacity Measure) were compared between malignant and benign patients, using corrected binary logistic regressions and repeated measure general linear model. RESULTS One year after surgery, the probability of losing daily life independence was 16-fold higher in malignant patients, even after adjusting for age at PD onset, PD duration, and percentage of motor improvement after STN-DBS (OR: 16.233; p: 0.035). Conversely, malignant and benign patients showed a similar extent of improvement after STN-DBS (p > 0.05) in motor symptoms, motor fluctuations, and ambulatory capacity, both in medication-ON and medication-OFF conditions. CONCLUSION DBS candidates in the malignant end of the PD spectrum may profit from a similar improvement of motor symptoms and fluctuations after STN-DBS when compared to benign PD. However, patients of the malignant group have a lower probability of maintaining independence in daily life early after surgery.
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Affiliation(s)
- Carlo Alberto Artusi
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy; Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Corso Bramante 88, 10124, Torino, Italy.
| | - Alberto Romagnolo
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy; Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Corso Bramante 88, 10124, Torino, Italy
| | - Gabriele Imbalzano
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy; Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Corso Bramante 88, 10124, Torino, Italy
| | - Elisa Montanaro
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy; Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Corso Bramante 88, 10124, Torino, Italy
| | - Maurizio Zibetti
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy; Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Corso Bramante 88, 10124, Torino, Italy
| | - Mario Giorgio Rizzone
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy; Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Corso Bramante 88, 10124, Torino, Italy
| | - Leonardo Lopiano
- Department of Neuroscience "Rita Levi Montalcini", University of Torino, Torino, Italy; Neurology 2 Unit, A.O.U. Città Della Salute e Della Scienza di Torino, Corso Bramante 88, 10124, Torino, Italy
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15
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Godinho F, Fim Neto A, Bianqueti BL, de Luccas JB, Varjão E, Terzian Filho PR, Figueiredo EG, Almeida TP, Yoneyama T, Takahata AK, Rocha MS, Soriano DC. Spectral characteristics of subthalamic nucleus local field potentials in Parkinson's disease: Phenotype and movement matter. Eur J Neurosci 2021; 53:2804-2818. [PMID: 33393163 DOI: 10.1111/ejn.15103] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 12/23/2020] [Accepted: 12/24/2020] [Indexed: 02/07/2023]
Abstract
Parkinson's disease (PD) is clinically heterogeneous across patients and may be classified in three motor phenotypes: tremor dominant (TD), postural instability and gait disorder (PIGD), and undetermined. Despite the significant clinical characterization of motor phenotypes, little is known about how electrophysiological data, particularly subthalamic nucleus local field potentials (STN-LFP), differ between TD and PIGD patients. This is relevant since increased STN-LFP bandpower at α-β range (8-35 Hz) is considered a potential PD biomarker and, therefore, a critical setpoint to drive adaptive deep brain stimulation. Acknowledging STN-LFP differences between phenotypes, mainly in rest and movement states, would better fit DBS to clinical and motor demands. We studied this issue through spectral analyses on 35 STN-LFP in TD and PIGD patients during rest and movement. We demonstrated that higher β2 activity (22-35 Hz) was observed in PIGD only during rest. Additionally, bandpower differences between rest and movement occurred at the α-β range, but with different patterns as per phenotypes: movement-induced desynchronization concerned lower frequencies in TD (10-20 Hz) and higher frequencies in PIGD patients (21-28 Hz). Finally, when supervised learning algorithms were employed aiming to discriminate PD phenotypes based on STN-LFP bandpower features, movement information had improved the classification accuracy, achieving peak performances when TD and PIGD movement-induced desynchronization ranges were considered. These results suggest that STN-LFP β-band encodes phenotype-movement dependent information in PD patients.
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Affiliation(s)
- Fabio Godinho
- Center of Engineering, Modeling and Applied Social Sciences, Federal University of ABC, São Bernardo do Campo, Brazil.,Department of Functional Neurosurgery, Santa Marcelina Hospital, São Paulo, Brazil.,Division of Functional Neurosurgery of Institute of Psychiatry, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Arnaldo Fim Neto
- Center of Engineering, Modeling and Applied Social Sciences, Federal University of ABC, São Bernardo do Campo, Brazil.,Brazilian Institute of Neuroscience and Neurotechnology, Campinas, Brazil.,Department of Cosmic Rays and Chronology, Institute of Physics, University of Campinas, Campinas, Brazil
| | - Bruno Leonardo Bianqueti
- Center of Engineering, Modeling and Applied Social Sciences, Federal University of ABC, São Bernardo do Campo, Brazil.,Brazilian Institute of Neuroscience and Neurotechnology, Campinas, Brazil
| | - Julia Baldi de Luccas
- Center of Engineering, Modeling and Applied Social Sciences, Federal University of ABC, São Bernardo do Campo, Brazil.,Brazilian Institute of Neuroscience and Neurotechnology, Campinas, Brazil
| | - Eduardo Varjão
- Department of Functional Neurosurgery, Santa Marcelina Hospital, São Paulo, Brazil
| | | | | | - Tiago Paggi Almeida
- Center of Engineering, Modeling and Applied Social Sciences, Federal University of ABC, São Bernardo do Campo, Brazil.,Division of Electronic Engineering, Technological Institute of Aeronautics, São José dos Campos, Brazil.,Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Takashi Yoneyama
- Division of Electronic Engineering, Technological Institute of Aeronautics, São José dos Campos, Brazil
| | - André Kazuo Takahata
- Center of Engineering, Modeling and Applied Social Sciences, Federal University of ABC, São Bernardo do Campo, Brazil.,Brazilian Institute of Neuroscience and Neurotechnology, Campinas, Brazil
| | | | - Diogo Coutinho Soriano
- Center of Engineering, Modeling and Applied Social Sciences, Federal University of ABC, São Bernardo do Campo, Brazil.,Brazilian Institute of Neuroscience and Neurotechnology, Campinas, Brazil
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16
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Eiber CD, Delbeke J, Cardoso J, de Neeling M, John SE, Lee CW, Skefos J, Sun A, Prodanov D, McKinney Z. Preliminary Minimum Reporting Requirements for In-Vivo Neural Interface Research: I. Implantable Neural Interfaces. IEEE OPEN JOURNAL OF ENGINEERING IN MEDICINE AND BIOLOGY 2021; 2:74-83. [PMID: 33997788 PMCID: PMC8118094 DOI: 10.1109/ojemb.2021.3060919] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 01/04/2021] [Accepted: 02/08/2021] [Indexed: 01/10/2023] Open
Abstract
The pace of research and development in neuroscience, neurotechnology, and neurorehabilitation is rapidly accelerating, with the number of publications doubling every 4.2 years. Maintaining this progress requires technological standards and scientific reporting guidelines to provide frameworks for communication and interoperability. The present lack of such neurotechnology standards limits the transparency, repro-ducibility, and meta-analysis of this growing body of literature, posing an ongoing barrier to research, clinical, and commercial objectives. Continued neurotechnological innovation requires the development of some minimal standards to promote integration between this broad spectrum of technologies and therapies. To preserve design freedom and accelerate the translation of research into safe and effective technologies with maximal user benefit, such standards must be collaboratively co-developed by the full range of neuroscience and neurotechnology stakeholders. This paper summarizes the preliminary recommendations of IEEE P2794 Standards Working Group, developing a Reporting Standard for in-vivo Neural Interface Research (RSNIR).
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Affiliation(s)
| | | | - Jorge Cardoso
- Instituto de Medicina MolecularFaculdade de Medicina, Universidade de LisboaLisbon1649-028Portugal
| | | | - Sam E. John
- University of MelbourneMelbourne3010Australia
| | | | | | - Argus Sun
- University of CaliforniaLos AngelesCA90095USA
| | | | - Zach McKinney
- BioRobotics Institute and Center for Excellence in Robotics and AIScuola Superiore Sant'Anna56127PisaItaly
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17
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Malaga KA, Costello JT, Chou KL, Patil PG. Atlas-independent, N-of-1 tissue activation modeling to map optimal regions of subthalamic deep brain stimulation for Parkinson disease. NEUROIMAGE-CLINICAL 2020; 29:102518. [PMID: 33333464 PMCID: PMC7736726 DOI: 10.1016/j.nicl.2020.102518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/25/2020] [Accepted: 11/27/2020] [Indexed: 01/13/2023]
Abstract
Neuroanatomical variations among patients are obscured in atlas-based VTA modeling. N-of-1 neuroanatomical and VTA modeling enables patient-level precision. Mean optimal stimulation is dorsomedial to the STN, near its posterior half. Individual VTAs deviate from optimal stimulation sites to varying degrees. Optimal stimulation sites for rigidity, bradykinesia, and tremor partially overlap.
Background Motor outcomes after subthalamic deep brain stimulation (STN DBS) for Parkinson disease (PD) vary considerably among patients and strongly depend on stimulation location. The objective of this retrospective study was to map the regions of optimal STN DBS for PD using an atlas-independent, fully individualized (N-of-1) tissue activation modeling approach and to assess the relationship between patient-level therapeutic volumes of tissue activation (VTAs) and motor improvement. Methods The stimulation-induced electric field for 40 PD patients treated with bilateral STN DBS was modeled using finite element analysis. Neurostimulation models were generated for each patient, incorporating their individual STN anatomy, DBS lead position and orientation, anisotropic tissue conductivity, and clinical stimulation settings. A voxel-based analysis of the VTAs was then used to map the optimal location of stimulation. The amount of stimulation in specific regions relative to the STN was measured and compared between STNs with more and less optimal stimulation, as determined by their motor improvement scores and VTA. The relationship between VTA location and motor outcome was then assessed using correlation analysis. Patient variability in terms of STN anatomy, active contact position, and VTA location were also evaluated. Results from the N-of-1 model were compared to those from a simplified VTA model. Results Tissue activation modeling mapped the optimal location of stimulation to regions medial, posterior, and dorsal to the STN centroid. These regions extended beyond the STN boundary towards the caudal zona incerta (cZI). The location of the VTA and active contact position differed significantly between STNs with more and less optimal stimulation in the dorsal-ventral and anterior-posterior directions. Therapeutic stimulation spread noticeably more in the dorsal and posterior directions, providing additional evidence for cZI as an important DBS target. There were significant linear relationships between the amount of dorsal and posterior stimulation, as measured by the VTA, and motor improvement. These relationships were more robust than those between active contact position and motor improvement. There was high variability in STN anatomy, active contact position, and VTA location among patients. Spherical VTA modeling was unable to reproduce these results and tended to overestimate the size of the VTA. Conclusion Accurate characterization of the spread of stimulation is needed to optimize STN DBS for PD. High variability in neuroanatomy, stimulation location, and motor improvement among patients highlights the need for individualized modeling techniques. The atlas-independent, N-of-1 tissue activation modeling approach presented in this study can be used to develop and evaluate stimulation strategies to improve clinical outcomes on an individual basis.
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Affiliation(s)
- Karlo A Malaga
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Joseph T Costello
- Department of Electrical Engineering, University of Michigan, Ann Arbor, MI, USA
| | - Kelvin L Chou
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, USA; Department of Neurology, University of Michigan, Ann Arbor, MI, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
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18
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Krauss P, Oertel MF, Baumann-Vogel H, Imbach L, Baumann CR, Sarnthein J, Regli L, Stieglitz LH. Intraoperative Neurophysiologic Assessment in Deep Brain Stimulation Surgery and its Impact on Lead Placement. J Neurol Surg A Cent Eur Neurosurg 2020; 82:18-26. [PMID: 33049794 DOI: 10.1055/s-0040-1716329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES While the efficacy of deep brain stimulation (DBS) to treat various neurological disorders is undisputed, the surgical methods differ widely and the importance of intraoperative microelectrode recording (MER) or macrostimulation (MS) remains controversially debated. The objective of this study is to evaluate the impact of MER and MS on intraoperative lead placement. PATIENTS AND METHODS We included 101 patients who underwent awake bilateral implantation of electrodes in the subthalamic nucleus with MER and MS for Parkinson's disease from 2009 to 2017 in a retrospective observational study. We analyzed intraoperative motor outcomes between anatomically planned stimulation point (PSP) and definite stimulation point (DSP), lead adjustments and Unified Parkinson's Disease Rating Scale Item III (UPDRS-III), levodopa equivalent daily dose (LEDD), and adverse events (AE) after 6 months. RESULTS We adjusted 65/202 leads in 47/101 patients. In adjusted leads, MS results improved significantly when comparing PSP and DSP (p < 0.001), resulting in a number needed to treat of 9.6. After DBS, UPDRS-III and LEDD improved significantly after 6 months in adjusted and nonadjusted patients (p < 0.001). In 87% of leads, the active contact at 6 months still covered the optimal stimulation point during surgery. In total, 15 AE occurred. CONCLUSION MER and MS have a relevant impact on the intraoperative decision of final lead placement and prevent from a substantial rate of poor stimulation outcome. The optimal stimulation points during surgery and chronic stimulation strongly overlap. Follow-up UPDRS-III results, LEDD reductions, and DBS-related AE correspond well to previously published data.
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Affiliation(s)
- Philipp Krauss
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Germany
| | - Markus Florian Oertel
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Heide Baumann-Vogel
- Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Lukas Imbach
- Department of Neurology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Johannes Sarnthein
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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19
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Ho AL, Pendharkar AV, Brewster R, Martinez DL, Jaffe RA, Xu LW, Miller KJ, Halpern CH. Frameless Robot-Assisted Deep Brain Stimulation Surgery: An Initial Experience. Oper Neurosurg (Hagerstown) 2020; 17:424-431. [PMID: 30629245 DOI: 10.1093/ons/opy395] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 12/07/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Modern robotic-assist surgical systems have revolutionized stereotaxy for a variety of procedures by increasing operative efficiency while preserving and even improving accuracy and safety. However, experience with robotic systems in deep brain stimulation (DBS) surgery is scarce. OBJECTIVE To present an initial series of DBS surgery performed utilizing a frameless robotic solution for image-guided stereotaxy, and report on operative efficiency, stereotactic accuracy, and complications. METHODS This study included the initial 20 consecutive patients undergoing bilateral robot-assisted DBS. The prior 20 nonrobotic, frameless cohort of DBS cases was sampled as a baseline historic control. For both cohorts, patient demographic and clinical data were collected including postoperative complications. Intraoperative duration and number of Microelectrode recording (MER) and final lead passes were recorded. For the robot-assisted cohort, 2D radial errors were calculated. RESULTS Mean case times (total operating room, anesthesia, and operative times) were all significantly decreased in the robot-assisted cohort (all P-values < .02) compared to frameless DBS. When looking at trends in case times, operative efficiency improved over time in the robot-assisted cohort across all time assessment points. Mean radial error in the robot-assisted cohort was 1.40 ± 0.11 mm, and mean depth error was 1.05 ± 0.18 mm. There was a significant decrease in the average number of MER passes in the robot-assisted cohort (1.05) compared to the nonrobotic cohort (1.45, P < .001). CONCLUSION This is the first report of application of frameless robotic-assistance with the Mazor Renaissance platform (Mazor Robotics Ltd, Caesarea, Israel) for DBS surgery, and our findings reveal that an initial experience is safe and can have a positive impact on operative efficiency, accuracy, and safety.
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Affiliation(s)
- Allen L Ho
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Arjun V Pendharkar
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Ryan Brewster
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Derek L Martinez
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Richard A Jaffe
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, California
| | - Linda W Xu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Kai J Miller
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
| | - Casey H Halpern
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, California
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20
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Park HR, Lim YH, Song EJ, Lee JM, Park K, Park KH, Lee WW, Kim HJ, Jeon B, Paek SH. Bilateral Subthalamic Nucleus Deep Brain Stimulation under General Anesthesia: Literature Review and Single Center Experience. J Clin Med 2020; 9:jcm9093044. [PMID: 32967337 PMCID: PMC7564882 DOI: 10.3390/jcm9093044] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023] Open
Abstract
Bilateral subthalamic nucleus (STN) Deep brain stimulation (DBS) is a well-established treatment in patients with Parkinson's disease (PD). Traditionally, STN DBS for PD is performed by using microelectrode recording (MER) and/or intraoperative macrostimulation under local anesthesia (LA). However, many patients cannot tolerate the long operation time under LA without medication. In addition, it cannot be even be performed on PD patients with poor physical and neurological condition. Recently, it has been reported that STN DBS under general anesthesia (GA) can be successfully performed due to the feasible MER under GA, as well as the technical advancement in direct targeting and intraoperative imaging. The authors reviewed the previously published literature on STN DBS under GA using intraoperative imaging and MER, focused on discussing the technique, clinical outcome, and the complication, as well as introducing our single-center experience. Based on the reports of previously published studies and ours, GA did not interfere with the MER signal from STN. STN DBS under GA without intraoperative stimulation shows similar or better clinical outcome without any additional complication compared to STN DBS under LA. Long-term follow-up with a large number of the patients would be necessary to validate the safety and efficacy of STN DBS under GA.
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Affiliation(s)
- Hye Ran Park
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul 04401, Korea;
| | - Yong Hoon Lim
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (Y.H.L.); (E.J.S.)
| | - Eun Jin Song
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (Y.H.L.); (E.J.S.)
| | - Jae Meen Lee
- Department of Neurosurgery, Pusan National University Hospital, Busan 49241, Korea;
| | - Kawngwoo Park
- Department of Neurosurgery, Gachon University Gil Medical Center, Incheon 21565, Korea;
| | - Kwang Hyon Park
- Department of Neurosurgery, Chuungnam National University Sejong Hospital, Sejong 30099, Korea;
| | - Woong-Woo Lee
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul 01830, Korea;
| | - Han-Joon Kim
- Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea; (H.-J.K.); (B.J.)
| | - Beomseok Jeon
- Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea; (H.-J.K.); (B.J.)
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University Hospital, Seoul 03080, Korea; (Y.H.L.); (E.J.S.)
- Correspondence: ; Tel.: +82-22-072-2876
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21
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Lin S, Zhang C, Wu Y, Sun B, Li D. Letter: Modulation of Nigrofugal and Pallidofugal Pathways in Deep Brain Stimulation for Parkinson Disease. Neurosurgery 2020; 87:E420-E422. [PMID: 32497187 DOI: 10.1093/neuros/nyaa228] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Suzhen Lin
- Department of Neurology & Institute of Neurology Ruijin Hospital Shanghai Jiaotong University School of Medicine Shanghai, China
| | - Chencheng Zhang
- Department of Neurosurgery Ruijin Hospital Shanghai Jiaotong University School of Medicine Shanghai, China
| | - Yiwen Wu
- Department of Neurology & Institute of Neurology Ruijin Hospital Shanghai Jiaotong University School of Medicine Shanghai, China
| | - Bomin Sun
- Department of Neurosurgery Ruijin Hospital Shanghai Jiaotong University School of Medicine Shanghai, China
| | - Dianyou Li
- Department of Neurosurgery Ruijin Hospital Shanghai Jiaotong University School of Medicine Shanghai, China
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22
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Mottaghi S, Afshari N, Buchholz O, Liebana S, Hofmann UG. Modular Current Stimulation System for Pre-clinical Studies. Front Neurosci 2020; 14:408. [PMID: 32425752 PMCID: PMC7203490 DOI: 10.3389/fnins.2020.00408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/03/2020] [Indexed: 11/13/2022] Open
Abstract
Electric stimulators with precise and reliable outputs are an indispensable part of electrophysiological research. From single cells to deep brain or neuromuscular tissue, there are diverse targets for electrical stimulation. Even though commercial systems are available, we state the need for a low-cost, high precision, functional, and modular (hardware, firmware, and software) current stimulation system with the capacity to generate stable and complex waveforms for pre-clinical research. The system presented in this study is a USB controlled 4-channel modular current stimulator that can be expanded and generate biphasic arbitrary waveforms with 16-bit resolution, high temporal precision (μs), and passive charge balancing: the NES STiM (Neuro Electronic Systems Stimulator). We present a detailed description of the system's structural design, the controlling software, reliability test, and the pre-clinical studies [deep brain stimulation (DBS) in hemi-PD rat model] in which it was utilized. The NES STiM has been tested with MacOS and Windows operating systems. Interfaces to MATLAB source codes are provided. The system is inexpensive, relatively easy to build and can be assembled quickly. We hope that the NES STiM will be used in a wide variety of neurological applications such as Functional Electrical Stimulation (FES), DBS and closed loop neurophysiological research.
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Affiliation(s)
- Soheil Mottaghi
- Section for Neuroelectronic Systems, Department of Neurosurgery, Medical Center University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Technical Faculty, University of Freiburg, Freiburg, Germany
| | - Niloofar Afshari
- Section for Neuroelectronic Systems, Department of Neurosurgery, Medical Center University of Freiburg, Freiburg, Germany
| | - Oliver Buchholz
- Section for Neuroelectronic Systems, Department of Neurosurgery, Medical Center University of Freiburg, Freiburg, Germany
| | - Samuel Liebana
- Department of Engineering, University of Cambridge, Cambridge, United Kingdom
| | - Ulrich G. Hofmann
- Section for Neuroelectronic Systems, Department of Neurosurgery, Medical Center University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Technical Faculty, University of Freiburg, Freiburg, Germany
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23
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Ossowska K. Zona incerta as a therapeutic target in Parkinson's disease. J Neurol 2020; 267:591-606. [PMID: 31375987 PMCID: PMC7035310 DOI: 10.1007/s00415-019-09486-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 07/25/2019] [Accepted: 07/26/2019] [Indexed: 12/21/2022]
Abstract
The zona incerta has recently become an important target for deep-brain stimulation (DBS) in Parkinson's disease (PD). The present review summarizes clinical, animal and anatomical data which have indicated an important role of this structure in PD, and discusses potential mechanisms involved in therapeutic effects of DBS. Animal studies have suggested initially some role of neurons as well as GABAergic and glutamatergic receptors of the zona incerta in locomotion and generation of PD signs. Anatomical data have indicated that thanks to its multiple interconnections with the basal ganglia, thalamus, cerebral cortex, brainstem, spinal cord and cerebellum, the zona incerta is an important link in a neuronal chain transmitting impulses involved in PD pathology. Finally, clinical studies have shown that DBS of this structure alleviates parkinsonian bradykinesia, muscle rigidity and tremor. DBS of caudal zona incerta seemed to be the most effective therapeutic intervention, especially with regard to reduction of PD tremor as well as other forms of tremor.
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Affiliation(s)
- Krystyna Ossowska
- Department of Neuropsychopharmacology, Maj Institute of Pharmacology, Polish Academy of Sciences, 12 Smętna St, 31-343, Kraków, Poland.
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24
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Nguyen AA, Maia PD, Gao X, Damasceno PF, Raj A. Dynamical Role of Pivotal Brain Regions in Parkinson Symptomatology Uncovered with Deep Learning. Brain Sci 2020; 10:E73. [PMID: 32019067 PMCID: PMC7071401 DOI: 10.3390/brainsci10020073] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 01/22/2020] [Accepted: 01/26/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The release of a broad, longitudinal anatomical dataset by the Parkinson's Progression Markers Initiative promoted a surge of machine-learning studies aimed at predicting disease onset and progression. However, the excessive number of features used in these models often conceals their relationship to the Parkinsonian symptomatology. OBJECTIVES The aim of this study is two-fold: (i) to predict future motor and cognitive impairments up to four years from brain features acquired at baseline; and (ii) to interpret the role of pivotal brain regions responsible for different symptoms from a neurological viewpoint. METHODS We test several deep-learning neural network configurations, and report our best results obtained with an autoencoder deep-learning model, run on a 5-fold cross-validation set. Comparison with Existing Methods: Our approach improves upon results from standard regression and others. It also includes neuroimaging biomarkers as features. RESULTS The relative contributions of pivotal brain regions to each impairment change over time, suggesting a dynamical reordering of culprits as the disease progresses. Specifically, the Putamen is initially the most critical region accounting for the overall cognitive state, only being surpassed by the Substantia Nigra in later years. The Pallidum is the first region to influence motor scores, followed by the parahippocampal and ambient gyri, and the anterior orbital gyrus. CONCLUSIONS While the causal link between regional brain atrophy and Parkinson symptomatology is poorly understood, our methods demonstrate that the contributions of pivotal regions to cognitive and motor impairments are more dynamical than generally appreciated.
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Affiliation(s)
- Alex A. Nguyen
- Department of Radiology and Biomedical Imaging, UC San Francisco, San Francisco, CA 94107, USA; (A.A.N.); (X.G.); (P.F.D.)
| | - Pedro D. Maia
- Department of Radiology and Biomedical Imaging, UC San Francisco, San Francisco, CA 94107, USA; (A.A.N.); (X.G.); (P.F.D.)
| | - Xiao Gao
- Department of Radiology and Biomedical Imaging, UC San Francisco, San Francisco, CA 94107, USA; (A.A.N.); (X.G.); (P.F.D.)
| | - Pablo F. Damasceno
- Department of Radiology and Biomedical Imaging, UC San Francisco, San Francisco, CA 94107, USA; (A.A.N.); (X.G.); (P.F.D.)
- Bakar Computational Health Sciences Institute, UC San Francisco, San Francisco, CA 94158, USA
- Center for Intelligent Imaging, UC San Francisco, San Francisco, CA 94107, USA
| | - Ashish Raj
- Department of Radiology and Biomedical Imaging, UC San Francisco, San Francisco, CA 94107, USA; (A.A.N.); (X.G.); (P.F.D.)
- Bakar Computational Health Sciences Institute, UC San Francisco, San Francisco, CA 94158, USA
- Center for Intelligent Imaging, UC San Francisco, San Francisco, CA 94107, USA
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25
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Liu Z, He S, Li L. General Anesthesia versus Local Anesthesia for Deep Brain Stimulation in Parkinson’s Disease: A Meta-Analysis. Stereotact Funct Neurosurg 2020; 97:381-390. [DOI: 10.1159/000505079] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/22/2019] [Indexed: 11/19/2022]
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26
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Ponce FA. Intraoperative Magnetic Resonance Imaging and Computed Tomography. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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27
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Wang J, Ponce FA, Tao J, Yu HM, Liu JY, Wang YJ, Luan GM, Ou SW. Comparison of Awake and Asleep Deep Brain Stimulation for Parkinson's Disease: A Detailed Analysis Through Literature Review. Neuromodulation 2019; 23:444-450. [PMID: 31830772 DOI: 10.1111/ner.13061] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 08/22/2019] [Accepted: 09/11/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Deep brain stimulation (DBS) for Parkinson's disease (PD) has been applied to clinic for approximately 30 years. The goal of this review is to explore the similarities and differences between "awake" and "asleep" DBS techniques. METHODS A comprehensive literature review was carried out to identify relevant studies and review articles describing applications of "awake" or "asleep" DBS for Parkinson's disease. The surgical procedures, clinical outcomes, costs and complications of each technique were compared in detail through literature review. RESULTS The surgical procedures of awake and asleep DBS surgeries rely upon different methods for verification of intended target acquisition. The existing research results demonstrated that the stereotactic targeting accuracy of lead placement obtained by either method is reliable. There were no significant differences in clinical outcomes, costs, or complications between the two techniques. CONCLUSION The surgical and clinical outcomes of asleep DBS for PD are comparable to those of awake DBS.
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Affiliation(s)
- Jun Wang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Jun Tao
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Hong-Mei Yu
- Department of Neurology, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Ji-Yuan Liu
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Yun-Jie Wang
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
| | - Guo-Ming Luan
- Department of Neurosurgery, Beijing Sanbo Brain Hospital, Capital Medical University, Beijing, P. R., China
| | - Shao-Wu Ou
- Department of Neurosurgery, The First Hospital of China Medical University, Shenyang, P. R., China
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28
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Kochanski RB, Bus S, Brahimaj B, Borghei A, Kraimer KL, Keppetipola KM, Beehler B, Pal G, Metman LV, Sani S. The Impact of Microelectrode Recording on Lead Location in Deep Brain Stimulation for the Treatment of Movement Disorders. World Neurosurg 2019; 132:e487-e495. [DOI: 10.1016/j.wneu.2019.08.092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 08/11/2019] [Accepted: 08/14/2019] [Indexed: 10/26/2022]
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29
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Anderson DN, Anderson C, Lanka N, Sharma R, Butson CR, Baker BW, Dorval AD. The μDBS: Multiresolution, Directional Deep Brain Stimulation for Improved Targeting of Small Diameter Fibers. Front Neurosci 2019; 13:1152. [PMID: 31736693 PMCID: PMC6828644 DOI: 10.3389/fnins.2019.01152] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 10/11/2019] [Indexed: 11/25/2022] Open
Abstract
Directional deep brain stimulation (DBS) leads have recently been approved and used in patients, and growing evidence suggests that directional contacts can increase the therapeutic window by redirecting stimulation to the target region while avoiding side-effect-inducing regions. We outline the design, fabrication, and testing of a novel directional DBS lead, the μDBS, which utilizes microscale contacts to increase the spatial resolution of stimulation steering and improve the selectivity in targeting small diameter fibers. We outline the steps of fabrication of the μDBS, from an integrated circuit design to post-processing and validation testing. We tested the onboard digital circuitry for programming fidelity, characterized impedance for a variety of electrode sizes, and demonstrated functionality in a saline bath. In a computational experiment, we determined that reduced electrode sizes focus the stimulation effect on small, nearby fibers. Smaller electrode sizes allow for a relative decrease in small-diameter axon thresholds compared to thresholds of large-diameter fibers, demonstrating a focusing of the stimulation effect within small, and possibly therapeutic, fibers. This principle of selectivity could be useful in further widening the window of therapy. The μDBS offers a unique, multiresolution design in which any combination of microscale contacts can be used together to function as electrodes of various shapes and sizes. Multiscale electrodes could be useful in selective neural targeting for established neurological targets and in exploring novel treatment targets for new neurological indications.
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Affiliation(s)
- Daria Nesterovich Anderson
- Department of Biomedical Engineering, College of Engineering, University of Utah, Salt Lake City, UT, United States
- Department of Neurosurgery, School of Medicine, University of Utah, Salt Lake City, UT, United States
- Scientific Computing and Imaging (SCI) Institute, University of Utah, Salt Lake City, UT, United States
| | - Connor Anderson
- Department of Biomedical Engineering, College of Engineering, University of Utah, Salt Lake City, UT, United States
| | - Nikhita Lanka
- Department of Electrical and Computer Engineering, University of Utah, Salt Lake City, UT, United States
| | - Rohit Sharma
- Department of Electrical and Computer Engineering, University of Utah, Salt Lake City, UT, United States
| | - Christopher R. Butson
- Department of Biomedical Engineering, College of Engineering, University of Utah, Salt Lake City, UT, United States
- Department of Neurosurgery, School of Medicine, University of Utah, Salt Lake City, UT, United States
- Scientific Computing and Imaging (SCI) Institute, University of Utah, Salt Lake City, UT, United States
- Department of Neurology, School of Medicine, University of Utah, Salt Lake City, UT, United States
- Department of Psychiatry, School of Medicine, University of Utah, Salt Lake City, UT, United States
| | - Brian W. Baker
- Utah Nanofab, University of Utah, Salt Lake City, UT, United States
| | - Alan D. Dorval
- Department of Biomedical Engineering, College of Engineering, University of Utah, Salt Lake City, UT, United States
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30
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Geraedts V, van Ham R, Marinus J, van Hilten J, Mosch A, Hoffmann C, van der Gaag N, Contarino M. Intraoperative test stimulation of the subthalamic nucleus aids postoperative programming of chronic stimulation settings in Parkinson's disease. Parkinsonism Relat Disord 2019; 65:62-66. [DOI: 10.1016/j.parkreldis.2019.05.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/08/2019] [Accepted: 05/10/2019] [Indexed: 11/29/2022]
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31
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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: 114] [Impact Index Per Article: 22.8] [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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32
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Deep brain stimulation of the subthalamic nucleus in Parkinson's disease: Relationship between the electrode trajectory and cognitive decline. Parkinsonism Relat Disord 2019; 61:45-49. [DOI: 10.1016/j.parkreldis.2018.12.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 11/18/2022]
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33
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Kaptan H, EkmekÇİ H. Long-term Results for Single Channel-Guided Deep Brain Stimulation Used to Treat Parkinson's Disease. ACTA ACUST UNITED AC 2019; 57:290-293. [PMID: 33354120 DOI: 10.29399/npa.23090] [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: 01/12/2018] [Accepted: 08/28/2018] [Indexed: 11/07/2022]
Abstract
Introduction The optimal method for targeting the subthalamic nucleus (STN) and positioning the deep brain stimulation (DBS) electrode is still controversial. In this study, single channel-guided stimulations were used in order to determine the most proper way to target the STN. Findings were synthesised for use in clinical situations. This paper presents the long-term results of DBS applied using single-channel guidance. Methods We retrospectively reviewed 15 patients who had undergone STN-DBS to treat Parkinson's disease in-between 2010 and 2017. All patients were examined preoperatively, and they were routinely followed-up 2-7 years postoperatively. Results The use of single-channel guidance resulted in better outcomes of motor complaints of Parkinson's patients. Moreover, a significantly greater improvement in Unified Parkinson's Disease Rating Scale Score (UPDRS) was achieved in either ON or OFF periods of patients. Conclusion Single channel-guided STN-DBS is a safe procedure and it results in improved motor outcomes in advanced Parkinson's Disease.
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Affiliation(s)
- Hulagu Kaptan
- Department of Brain Surgery, Dokuz Eylül University School of Medicine, İzmir, Turkey
| | - Hakan EkmekÇİ
- Department of Neurology, Selçuk University School of Medicine, Konya, Turkey
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34
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Milchenko M, Snyder AZ, Campbell MC, Dowling JL, Rich KM, Brier LM, Perlmutter JS, Norris SA. ESM-CT: a precise method for localization of DBS electrodes in CT images. J Neurosci Methods 2018; 308:366-376. [PMID: 30201271 PMCID: PMC6205293 DOI: 10.1016/j.jneumeth.2018.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) of the subthalamic nucleus produces variable effects in Parkinson disease. Variation may result from different electrode positions relative to target. Thus, precise electrode localization is crucial when investigating DBS effects. NEW METHOD We developed a semi-automated method, Electrode Shaft Modeling in CT images (ESM-CT) to reconstruct DBS lead trajectories and contact locations. We evaluated methodological sensitivity to operator-dependent steps, robustness to image resampling, and test-retest replicability. ESM-CT was applied in 56 patients to study electrode position change (and relation to time between scans, postoperative subdural air volume, and head tilt during acquisition) between images acquired immediately post-implantation (DBS-CT) and months later (DEL-CT). RESULTS Electrode tip localization was robust to image resampling and replicable to within ∼ 0.2 mm on test-retest comparisons. Systematic electrode displacement occurred rostral-ventral-lateral between DBS-CT and DEL-CT scans. Head angle was a major explanatory factor (p < 0.001,Pearson's r = 0.46, both sides) and volume of subdural air weakly predicted electrode displacement (p = 0.02,r = 0.29:p = 0.1,r = 0.25 for left:right). Modeled shaft curvature was slightly greater in DEL-CT. Magnitude of displacement and degree of curvature were independent of elapsed time between scans. COMPARISON WITH EXISTING METHODS Comparison of ESM-CT against two existing methods revealed systematic differences in one coordinate (1 ± 0.3 mm,p < 0.001) for one method and in three coordinates for another method (x:0.1 ± 0.1 mm, y:0.4 ± 0.2 mm, z:0.4 ± 0.2 mm, p < 10-10). Within-method coordinate variability across participants is similar. CONCLUSION We describe a robust and precise method for CT DBS contact localization. Application revealed that acquisition head angle significantly impacts electrode position. DBS localization schemes should account for head angle.
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Affiliation(s)
- Mikhail Milchenko
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Abraham Z Snyder
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Meghan C Campbell
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Joshua L Dowling
- Department of Neurosurgical Surgery, Washington University School of Medicine, (CB 8057), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Keith M Rich
- Department of Neurosurgical Surgery, Washington University School of Medicine, (CB 8057), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Lindsey M Brier
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Joel S Perlmutter
- Mallinckrodt Institute of Radiology, Department of Radiology, Washington University School of Medicine, (CB 8225), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neurosurgical Surgery, Washington University School of Medicine, (CB 8057), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Neuroscience, Washington University School of Medicine, (CB 8108), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA; Department of Occupational Therapy, CB 8505, 4444 Forest Park Ave, St. Louis, MO 63108, USA; Department of Physical Therapy, CB 8502, 4444 Forest Park Ave, St. Louis, MO, 63108, USA
| | - Scott A Norris
- Department of Neurology, Washington University School of Medicine, (CB 8111), 660 S. Euclid Avenue, St. Louis, MO, 63110, USA.
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Telkes I, Viswanathan A, Jimenez-Shahed J, Abosch A, Ozturk M, Gupte A, Jankovic J, Ince NF. Local field potentials of subthalamic nucleus contain electrophysiological footprints of motor subtypes of Parkinson's disease. Proc Natl Acad Sci U S A 2018; 115:E8567-E8576. [PMID: 30131429 PMCID: PMC6130371 DOI: 10.1073/pnas.1810589115] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Although motor subtypes of Parkinson's disease (PD), such as tremor dominant (TD) and postural instability and gait difficulty (PIGD), have been defined based on symptoms since the mid-1990s, no underlying neural correlates of these clinical subtypes have yet been identified. Very limited data exist regarding the electrophysiological abnormalities within the subthalamic nucleus (STN) that likely accompany the symptom severity or the phenotype of PD. Here, we show that activity in subbands of local field potentials (LFPs) recorded with multiple microelectrodes from subterritories of STN provide distinguishing neurophysiological information about the motor subtypes of PD. We studied 24 patients with PD and found distinct patterns between TD (n = 13) and PIGD (n = 11) groups in high-frequency oscillations (HFOs) and their nonlinear interactions with beta band in the superior and inferior regions of the STN. Particularly, in the superior region of STN, the power of the slow HFO (sHFO) (200-260 Hz) and the coupling of its amplitude with beta-band phase were significantly stronger in the TD group. The inferior region of STN exhibited fast HFOs (fHFOs) (260-450 Hz), which have a significantly higher center frequency in the PIGD group. The cross-frequency coupling between fHFOs and beta band in the inferior region of STN was significantly stronger in the PIGD group. Our results indicate that the spatiospectral dynamics of STN-LFPs can be used as an objective method to distinguish these two motor subtypes of PD. These observations might lead to the development of sensing and stimulation strategies targeting the subterritories of STN for the personalization of deep-brain stimulation (DBS).
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Affiliation(s)
- Ilknur Telkes
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060
| | - Ashwin Viswanathan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX 77030
| | - Joohi Jimenez-Shahed
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX 77030
| | - Aviva Abosch
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO 80045
| | - Musa Ozturk
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060
| | - Akshay Gupte
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN 55455
| | - Joseph Jankovic
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, TX 77030
| | - Nuri F Ince
- Department of Biomedical Engineering, University of Houston, Houston, TX 77204-5060;
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36
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Conrad E, Mossner J, Chou K, Patil P. Atlas-Independent, Electrophysiological Mapping of the Optimal Locus of Subthalamic Deep Brain Stimulation for the Motor Symptoms of Parkinson Disease. Stereotact Funct Neurosurg 2018; 96:91-99. [DOI: 10.1159/000486643] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 01/08/2018] [Indexed: 11/19/2022]
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37
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McGovern RA, Alomar S, Bingaman WE, Gonzalez-Martinez J. Robot-Assisted Responsive Neurostimulator System Placement in Medically Intractable Epilepsy: Instrumentation and Technique. Oper Neurosurg (Hagerstown) 2018; 16:455-464. [DOI: 10.1093/ons/opy112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 04/17/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
The management of medically refractory epilepsy patients who are not surgical candidates has remained challenging. Closed loop—or responsive—neurostimulation (RNS) is now an established therapy for the treatment of epilepsy with specific indications. The RNS® system (NeuroPace Inc, Mountainview, California) has recently been shown to be effective in reducing the seizure frequency of partial onset seizures. The electrode design consists of either intracerebral depth electrodes or subdural strip electrodes, and stereotaxis is typically used to guide placement into the EZ. Details on the operative techniques used to place these electrodes have been lacking.
OBJECTIVE
To address the advantage of using a robotic-assisted technique to place depth electrodes for RNS® system placement compared to the typical frame-based or frameless stereotactic systems.
METHODS
We retrospectively reviewed our single center, technical operative experience with RNS® system placement using robotic assistance from 2014 to 2016 via chart review.
RESULTS
Twelve patients underwent RNS® system placement using robotic assistance. Mean operative time was 121 min for a median of 2 depth electrodes with mean deviation from intended target of ∼3 mm in x, y, and z planes. Two patients developed wound infections, 1 of whom was reimplanted. Seizures were reduced by ∼40% at 2 yr, similar to the results seen in the open label portion of the pivotal RNS trial.
CONCLUSION
Robotic-assisted stereotaxis can be used to provide a stable and accurate stereotactic platform for insertion of intracerebral RNS electrodes, representing a safe, efficient and accurate procedure.
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Affiliation(s)
- Robert A McGovern
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Soha Alomar
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
- King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - William E Bingaman
- Epilepsy Center, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
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Artusi CA, Zibetti M, Romagnolo A, Rizzone MG, Merola A, Lopiano L. Subthalamic deep brain stimulation and trunk posture in Parkinson's disease. Acta Neurol Scand 2018; 137:481-487. [PMID: 29285760 DOI: 10.1111/ane.12889] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We sought to assess the efficacy of subthalamic nucleus deep brain stimulation (STN-DBS) in Parkinson's disease (PD)-associated trunk posture abnormalities retrospectively analyzing data from 101 patients reporting mild-to-severe trunk posture abnormalities of a cohort of 216 PD patients treated with STN-DBS at our center. METHODS Abnormal trunk posture was rated on a scale of 0 (normal) to 4 (marked flexion with an extreme abnormality of posture) as per the grading score reported in the Unified Parkinson's Disease Rating Scale. The independent effect of STN-DBS on trunk posture was assessed comparing Medication-Off (presurgery) vs Stimulation-On/Medication-Off (post-surgery). The combined effect of STN-DBS plus levodopa was evaluated comparing Medication-On (presurgery) vs Stimulation-On/Medication-On (post-surgery). Analyses were conducted considering both the entire cohort of patients and the subgroup with camptocormia (CMC) and Pisa syndrome (PS). RESULTS The independent effect of STN-DBS resulted in a 41.4% improvement in abnormal trunk posture severity (P < .001), with 78.2% of patients (n = 79) reporting an improvement of at least 1 point. The combined effect of STN-DBS and levodopa resulted in a 30.9% improvement (P = .061), with 54.5% of patients (n = 55) reporting an improvement of at least 1 point. The subanalysis of patients with CMC (n = 23) and PS (n = 5) showed a 42.7% improvement in abnormal posture severity when considering the independent effect of STN-DBS (P < .001) and 30.5% when considering the combined effect of STN-DBS and levodopa (P < .001). CONCLUSIONS STN-DBS may have the potential for improving posture in patients with advanced PD.
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Affiliation(s)
- C. A. Artusi
- Department of Neuroscience “Rita Levi Montalcini”; University of Turin; Turin Italy
| | - M. Zibetti
- Department of Neuroscience “Rita Levi Montalcini”; University of Turin; Turin Italy
| | - A. Romagnolo
- Department of Neuroscience “Rita Levi Montalcini”; University of Turin; Turin Italy
| | - M. G. Rizzone
- Department of Neuroscience “Rita Levi Montalcini”; University of Turin; Turin Italy
| | - A. Merola
- Department of Neurology; Gardner Family Center for Parkinson's Disease and Movement Disorders; University of Cincinnati; Cincinnati OH USA
| | - L. Lopiano
- Department of Neuroscience “Rita Levi Montalcini”; University of Turin; Turin Italy
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39
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Brahimaj B, Kochanski RB, Sani S. Microelectrode accuracy in deep brain stimulation surgery. J Clin Neurosci 2018; 50:58-61. [DOI: 10.1016/j.jocn.2018.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 01/08/2018] [Indexed: 10/18/2022]
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40
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Chen T, Mirzadeh Z, Chapple KM, Lambert M, Shill HA, Moguel-Cobos G, Tröster AI, Dhall R, Ponce FA. Clinical outcomes following awake and asleep deep brain stimulation for Parkinson disease. J Neurosurg 2018; 130:109-120. [PMID: 29547091 DOI: 10.3171/2017.8.jns17883] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 08/21/2017] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Recent studies have shown similar clinical outcomes between Parkinson disease (PD) patients treated with deep brain stimulation (DBS) under general anesthesia without microelectrode recording (MER), so-called “asleep” DBS, and historical cohorts undergoing “awake” DBS with MER guidance. However, few studies include internal controls. This study aims to compare clinical outcomes after globus pallidus internus (GPi) and subthalamic nucleus (STN) DBS using awake and asleep techniques at a single institution. METHODS PD patients undergoing awake or asleep bilateral GPi or STN DBS were prospectively monitored. The primary outcome measure was stimulation-induced change in motor function off medication 6 months postoperatively, measured using the Unified Parkinson’s Disease Rating Scale part III (UPDRS-III). Secondary outcomes included change in quality of life, measured by the 39-item Parkinson’s Disease Questionnaire (PDQ-39), change in levodopa equivalent daily dosage (LEDD), stereotactic accuracy, stimulation parameters, and adverse events. RESULTS Six-month outcome data were available for 133 patients treated over 45 months (78 GPi [16 awake, 62 asleep] and 55 STN [14 awake, 41 asleep]). UPDRS-III score improvement with stimulation did not differ between awake and asleep groups for GPi (awake, 20.8 points [38.5%]; asleep, 18.8 points [37.5%]; p = 0.45) or STN (awake, 21.6 points [40.3%]; asleep, 26.1 points [48.8%]; p = 0.20) targets. The percentage improvement in PDQ-39 and LEDD was similar for awake and asleep groups for both GPi (p = 0.80 and p = 0.54, respectively) and STN cohorts (p = 0.85 and p = 0.49, respectively). CONCLUSIONS In PD patients, bilateral GPi and STN DBS using the asleep method resulted in motor, quality-of-life, and medication reduction outcomes that were comparable to those of the awake method.
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Affiliation(s)
| | | | | | | | | | | | - Alexander I Tröster
- 3Clinical Neuropsychology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
| | - Rohit Dhall
- 4Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
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41
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Goubareva NN, Fedorova NV, Bril' EV, Tomskiy AA, Gamaleya AA, Poddubskaya AA, Shabalov VA, Omarova SM. [Effects of bilateral deep brain stimulation in the subthalamic nucleus using two methods of target structure verification]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:24-30. [PMID: 29265083 DOI: 10.17116/jnevro201711711124-30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To evaluate the efficacy of deep brain stimulation in the subthalamic nucleus (DBS STN) in patients with Parkinson's disease (PD) using different methods of targeting according to the dynamics of motor symptoms of PD. MATERIAL AND METHODS The study involved 90 patients treated with DBS STN. In 30 cases intraoperative microelectrode recording (MER) was used. MER was not performed in 30 patients of the comparison group. The control group consisted of 30 patients with PD who received conservative treatment. Hoehn and Yahr scale, Tinetti Balance and Mobility Scale (TBMS), Unified Parkinson's Disease Rating Scale (UPDRS), Parkinson's Disease Quality of Life-39 Scoring System (РDQ-39), Schwab & England ADL Scale were used. Levodopa equivalent daily dose (LEDD, 2010) was calculated for each patient. RESULTS AND CONCLUSION The effect of DBS STN using intraoperative microelectrode recording on the main motor symptoms, motor complications, walking as well as indicators of quality of life and daily activities was shown. In both DBS STN groups, there was a significant reduction in the LEDD and marked improvement of the control of motor symptoms of PD. A significant reduction in the severity of motor fluctuations (50%) and drug-induced dyskinesia (51%) was observed. Quality of life and daily activity in off-medication condition were significantly improved in both DBS STN groups of patients, irrespective of the method of target planning (75-100%), compared with the control group.
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Affiliation(s)
- N N Goubareva
- Russian Medical Academy of Postgraduate Education, Centre for Extrapyramidal Disorders, Moscow, Russia
| | - N V Fedorova
- Russian Medical Academy of Postgraduate Education, Centre for Extrapyramidal Disorders, Moscow, Russia
| | - E V Bril'
- Russian Medical Academy of Postgraduate Education, Centre for Extrapyramidal Disorders, Moscow, Russia
| | - A A Tomskiy
- Burdenko National Research Neurosurgery Institute, Moscow, Russia
| | - A A Gamaleya
- Burdenko National Research Neurosurgery Institute, Moscow, Russia
| | - A A Poddubskaya
- Burdenko National Research Neurosurgery Institute, Moscow, Russia
| | - V A Shabalov
- Burdenko National Research Neurosurgery Institute, Moscow, Russia
| | - S M Omarova
- Russian Medical Academy of Postgraduate Education, Centre for Extrapyramidal Disorders, Moscow, Russia
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42
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Ispierto L, Muñoz J, Cladellas JM, Cuadras P, Capellades J, Latorre P, Dávalos A, Vancamp T, Álvarez R. Post-Operative Localization of Deep Brain Stimulation Electrodes in the Subthalamus Using Transcranial Sonography. Neuromodulation 2017; 21:574-581. [PMID: 29178240 DOI: 10.1111/ner.12733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/19/2017] [Accepted: 06/16/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The correct positioning of deep brain stimulation electrodes determines the success of surgery. In this study, we attempt to validate transcranial sonography (TCS) as a method for early postoperative confirmation of electrode location in the subthalamic nucleus (STN). MATERIALS AND METHODS Nineteen patients diagnosed with Parkinson's disease were enrolled in the study. Postoperative TCS was applied to measure the distance between the implanted electrodes and the third ventricle in the axial plane. Whether the electrodes were positioned within or outside the substantia nigra (SN) was evaluated through measurements in the coronal plane. The obtained metrics through TCS were compared with those from postoperative computed tomography (CT) and magnetic resonance imaging (MRI). RESULTS A statistically significant correlation between distances from electrode to third ventricle by TCS and CT/MRI (r = 0.75, p < 0.01) was observed. Distances from third ventricle to electrodes tips were different when sonographically they showed to be inside or outside the SN (p < 0.01). A cut-off value of 8.85mm in these distances was the most sensitive (100%) and specific (90.5%) to predict if electrodes were positioned inside the SN (CI 95% 0.81-10.30, p = 0.001). CONCLUSIONS Transcranial sonography is a useful technique to reliably identify targeted positioning of deep brain stimulation electrodes in or out of the SN.
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Affiliation(s)
- Lourdes Ispierto
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Jorge Muñoz
- Department of Neurosurgery and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Josep Maria Cladellas
- Department of Neurosurgery and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Patricia Cuadras
- Department of Radiology, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Jaume Capellades
- Image Diagnosis Institute, Badalona, Spain.,Department of Medical Imaging Consorci MAR Parc de Salut, Barcelona, Spain
| | - Pilar Latorre
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Antoni Dávalos
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
| | - Tim Vancamp
- BRAI2N, St. Augustinus Hospital, Wilrijk, Belgium
| | - Ramiro Álvarez
- Department of Neurology and Neurosciences, University Hospital Germans Trias i Pujol, Badalona, Spain
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Neudorfer C, Maarouf M. Neuroanatomical background and functional considerations for stereotactic interventions in the H fields of Forel. Brain Struct Funct 2017; 223:17-30. [DOI: 10.1007/s00429-017-1570-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 11/13/2017] [Indexed: 11/29/2022]
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Rizzone MG, Ferrarin M, Lanotte MM, Lopiano L, Carpinella I. The Dominant-Subthalamic Nucleus Phenomenon in Bilateral Deep Brain Stimulation for Parkinson's Disease: Evidence from a Gait Analysis Study. Front Neurol 2017; 8:575. [PMID: 29163340 PMCID: PMC5670355 DOI: 10.3389/fneur.2017.00575] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 10/13/2017] [Indexed: 01/26/2023] Open
Abstract
Background It has been suggested that parkinsonian [Parkinson’s disease (PD)] patients might have a “dominant” (DOM) subthalamic nucleus (STN), whose unilateral electrical stimulation [deep brain stimulation (DBS)] could lead to an improvement in PD symptoms similar to bilateral STN-DBS. Objectives Since disability in PD patients is often related to gait problems, in this study, we wanted to investigate in a group of patients bilaterally implanted for STN-DBS: (1) if it was possible to identify a subgroup of subjects with a dominant STN; (2) in the case, if the unilateral stimulation of the dominant STN was capable to improve gait abnormalities, as assessed by instrumented multifactorial gait analysis, similarly to what observed with bilateral stimulation. Methods We studied 10 PD patients with bilateral STN-DBS. A clinical evaluation and a kinematic, kinetic, and electromyographic (EMG) analysis of overground walking were performed—off medication—in four conditions: without stimulation, with bilateral stimulation, with unilateral right or left STN-DBS. Through a hierarchical agglomerative cluster analysis based on motor Unified Parkinson’s Disease Rating Scale scores, it was possible to separate patients into two groups, based on the presence (six patients, DOM group) or absence (four patients, NDOM group) of a dominant STN. Results In the DOM group, both bilateral and unilateral stimulation of the dominant STN significantly increased gait speed, stride length, range of motion of lower limb joints, and peaks of moment and power at the ankle joint; moreover, the EMG activation pattern of distal leg muscles was improved. The unilateral stimulation of the non-dominant STN did not produce any significant effect. In the NDOM group, only bilateral stimulation determined a significant improvement of gait parameters. Conclusion In the DOM group, the effect of unilateral stimulation of the dominant STN determined an improvement of gait parameters similar to bilateral stimulation. The pre-surgical identification of these patients, if possible, could allow to reduce the surgical risks and side effects of DBS adopting a unilateral approach.
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Affiliation(s)
| | - Maurizio Ferrarin
- Biomedical Technology Department, IRCCS Don Carlo Gnocchi Foundation, Milan, Italy
| | | | - Leonardo Lopiano
- Department of Neuroscience Rita Levi Montalcini, University of Turin, Turin, Italy
| | - Ilaria Carpinella
- Biomedical Technology Department, IRCCS Don Carlo Gnocchi Foundation, Milan, Italy
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45
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Enrici I, Mitkova A, Castelli L, Lanotte M, Lopiano L, Adenzato M. Deep Brain Stimulation of the subthalamic nucleus does not negatively affect social cognitive abilities of patients with Parkinson's disease. Sci Rep 2017; 7:9413. [PMID: 28842656 PMCID: PMC5573348 DOI: 10.1038/s41598-017-09737-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 06/19/2017] [Indexed: 12/19/2022] Open
Abstract
Bilateral deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a treatment option for patients with advanced idiopathic PD successful at alleviating disabling motor symptoms. Nevertheless, the effects of STN-DBS on cognitive functions remain controversial and few studies have investigated modification of social cognitive abilities in patients with PD treated with STN-DBS. Here we expanded the typically-investigated spectrum of these abilities by simultaneously examining emotion recognition, and both affective and cognitive Theory of Mind (ToM). By means of a cross-sectional study, 20 patients with PD under dopaminergic replacement therapy, 18 patients with PD treated with STN-DBS, and 20 healthy controls performed the Ekman 60-Faces test, the full version of the Reading the Mind in the Eyes test, and the Protocol for the Attribution of Communicative Intentions. There were no differences between the PD groups (treated and not treated with STN-DBS) on any of the social cognitive tests. Our results suggest that patients with PD who are treated with STN-DBS do not experience detrimental effects on their social cognitive abilities. The present study, the first one examining a wide spectrum of social cognitive abilities after DBS of the STN, suggests that this surgical procedure can be considered safe from this standpoint.
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Affiliation(s)
- Ivan Enrici
- Department of Philosophy and Educational Sciences, University of Turin, Turin, Italy.,Center for Cognitive Science, University of Turin, Turin, Italy.,Neuroscience Institute of Turin, Turin, Italy
| | - Antonia Mitkova
- Psychology Research Laboratory, IRCCS Istituto Auxologico Italiano, Ospedale S. Giuseppe, Piancavallo, VCO, Italy
| | - Lorys Castelli
- Department of Psychology, University of Turin, Turin, Italy.
| | - Michele Lanotte
- Department of Neuroscience, University of Turin, Turin, Italy
| | | | - Mauro Adenzato
- Center for Cognitive Science, University of Turin, Turin, Italy.,Neuroscience Institute of Turin, Turin, Italy.,Department of Psychology, University of Turin, Turin, Italy
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47
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van Wijk BCM, Pogosyan A, Hariz MI, Akram H, Foltynie T, Limousin P, Horn A, Ewert S, Brown P, Litvak V. Localization of beta and high-frequency oscillations within the subthalamic nucleus region. NEUROIMAGE-CLINICAL 2017; 16:175-183. [PMID: 28794978 PMCID: PMC5540829 DOI: 10.1016/j.nicl.2017.07.018] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 07/05/2017] [Accepted: 07/22/2017] [Indexed: 12/01/2022]
Abstract
Parkinsonian bradykinesia and rigidity are typically associated with excessive beta band oscillations in the subthalamic nucleus. Recently another spectral peak has been identified that might be implicated in the pathophysiology of the disease: high-frequency oscillations (HFO) within the 150–400 Hz range. Beta-HFO phase-amplitude coupling (PAC) has been found to correlate with severity of motor impairment. However, the neuronal origin of HFO and its usefulness as a potential target for deep brain stimulation remain to be established. For example, it is unclear whether HFO arise from the same neural populations as beta oscillations. We intraoperatively recorded local field potentials from the subthalamic nucleus while advancing DBS electrodes in 2 mm steps from 4 mm above the surgical target point until 2 mm below, resulting in 4 recording sites. Data from 26 nuclei from 14 patients were analysed. For each trajectory, we identified the recording site with the largest spectral peak in the beta range (13–30 Hz), and the largest peak in the HFO range separately. In addition, we identified the recording site with the largest beta-HFO PAC. Recording sites with largest beta power and largest HFO power coincided in 50% of cases. In the other 50%, HFO was more likely to be detected at a more superior recording site in the target area. PAC followed more closely the site with largest HFO (45%) than beta power (27%). HFO are likely to arise from spatially close, but slightly more superior neural populations than beta oscillations. Further work is necessary to determine whether the different activities can help fine-tune deep brain stimulation targeting. LFPs were recorded from multiple sites within and around the subthalamic nucleus. Sites with largest beta and high-frequency oscillations (HFO) were identified. HFO were located slightly more superior than beta oscillations. Phase-amplitude coupling more closely followed the site with largest HFO. This work hints at different neural generators for beta and HFO.
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Affiliation(s)
- B C M van Wijk
- Department of Neurology, Charité - University Medicine Berlin, Berlin, Germany.,Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, London, United Kingdom
| | - A Pogosyan
- Nuffield Department of Clinical Neuroscience, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - M I Hariz
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom.,Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - H Akram
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom.,Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, United Kingdom
| | - T Foltynie
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom
| | - P Limousin
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, United Kingdom
| | - A Horn
- Department of Neurology, Charité - University Medicine Berlin, Berlin, Germany.,Berenson-Allen Center for Non-Invasive Brain Stimulation and Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - S Ewert
- Department of Neurology, Charité - University Medicine Berlin, Berlin, Germany.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - P Brown
- Nuffield Department of Clinical Neuroscience, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom.,Medical Research Council Brain Network Dynamics Unit at the University of Oxford, Oxford, United Kingdom
| | - V Litvak
- Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, London, United Kingdom
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48
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Akram H, Sotiropoulos SN, Jbabdi S, Georgiev D, Mahlknecht P, Hyam J, Foltynie T, Limousin P, De Vita E, Jahanshahi M, Hariz M, Ashburner J, Behrens T, Zrinzo L. Subthalamic deep brain stimulation sweet spots and hyperdirect cortical connectivity in Parkinson's disease. Neuroimage 2017; 158:332-345. [PMID: 28711737 DOI: 10.1016/j.neuroimage.2017.07.012] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 07/05/2017] [Accepted: 07/09/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVES Firstly, to identify subthalamic region stimulation clusters that predict maximum improvement in rigidity, bradykinesia and tremor, or emergence of side-effects; and secondly, to map-out the cortical fingerprint, mediated by the hyperdirect pathways which predict maximum efficacy. METHODS High angular resolution diffusion imaging in twenty patients with advanced Parkinson's disease was acquired prior to bilateral subthalamic nucleus deep brain stimulation. All contacts were screened one-year from surgery for efficacy and side-effects at different amplitudes. Voxel-based statistical analysis of volumes of tissue activated models was used to identify significant treatment clusters. Probabilistic tractography was employed to identify cortical connectivity patterns associated with treatment efficacy. RESULTS All patients responded well to treatment (46% mean improvement off medication UPDRS-III [p < 0.0001]) without significant adverse events. Cluster corresponding to maximum improvement in tremor was in the posterior, superior and lateral portion of the nucleus. Clusters corresponding to improvement in bradykinesia and rigidity were nearer the superior border in a further medial and posterior location. The rigidity cluster extended beyond the superior border to the area of the zona incerta and Forel-H2 field. When the clusters where averaged, the coordinates of the area with maximum overall efficacy was X = -10(-9.5), Y = -13(-1) and Z = -7(-3) in MNI(AC-PC) space. Cortical connectivity to primary motor area was predictive of higher improvement in tremor; whilst that to supplementary motor area was predictive of improvement in bradykinesia and rigidity; and connectivity to prefrontal cortex was predictive of improvement in rigidity. INTERPRETATION These findings support the presence of overlapping stimulation sites within the subthalamic nucleus and its superior border, with different cortical connectivity patterns, associated with maximum improvement in tremor, rigidity and bradykinesia.
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Affiliation(s)
- Harith Akram
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK; Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.
| | - Stamatios N Sotiropoulos
- Centre for Functional MRI of the Brain (FMRIB), John Radcliffe Hospital, Oxford, OX3 9DU, UK; Sir Peter Mansfield Imaging Centre, School of Medicine, University of Nottingham, UK
| | - Saad Jbabdi
- Centre for Functional MRI of the Brain (FMRIB), John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Dejan Georgiev
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Philipp Mahlknecht
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Jonathan Hyam
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK; Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Thomas Foltynie
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Patricia Limousin
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Enrico De Vita
- Neuroradiological Academic Unit, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK; Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, University College London NHS Foundation Trust, London, UK
| | - Marjan Jahanshahi
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Marwan Hariz
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK; Department of Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - John Ashburner
- Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK
| | - Tim Behrens
- Wellcome Trust Centre for Neuroimaging, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK; Centre for Functional MRI of the Brain (FMRIB), John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Ludvic Zrinzo
- Unit of Functional Neurosurgery, Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, Queen Square, London, WC1N 3BG, UK; Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
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49
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Chen T, Mirzadeh Z, Ponce FA. "Asleep" Deep Brain Stimulation Surgery: A Critical Review of the Literature. World Neurosurg 2017; 105:191-198. [PMID: 28526642 DOI: 10.1016/j.wneu.2017.05.042] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 05/05/2017] [Accepted: 05/06/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Although performing deep brain stimulation (DBS) with the patient under general anesthesia without microelectrode recording (MER) or intraoperative test stimulation (ITS) for movement disorders ("asleep" DBS) has become increasingly popular, its feasibility is based on the untested assumption that stereotactic accuracy correlates with positive clinical outcomes. To investigate outcomes after asleep DBS without MER or neurophysiological testing, we reviewed the medical literature on the topic. METHODS We searched PubMed to identify all studies reporting clinical outcomes for patients who underwent DBS without MER or ITS for Parkinson disease (PD) or essential tremor (ET). RESULTS We identified 9 studies with level 3b (n = 3) or level 4 evidence (n = 6). Eight PD studies (220 patients) reported asleep placement of 431 electrodes (341 subthalamic nucleus, 90 globus pallidus interna). Unified Parkinson Disease Rating Scale motor examination-III scores for 208 patients demonstrated significant improvement (40.2%-65%) at 6-12 months. The levodopa equivalent daily dose for 115 patients was significantly reduced (14%-49.3%) at 6-12 months in 103 patients. Two studies with a comparison cohort undergoing "awake" DBS with MER found no differences in postoperative Unified Parkinson Disease Rating Scale-III improvement or levodopa equivalent daily dose reduction. One study of asleep DBS for ET found no difference in functional outcomes between 17 patients undergoing asleep ventral intermediate nucleus DBS and 40 patients undergoing awake placement with ITS. CONCLUSIONS Initial evidence suggests that asleep DBS can be performed safely for PD and ET with good clinical outcomes. Long-term follow-up, larger cohorts, and double-armed studies are needed to validate these initial results.
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Affiliation(s)
- Tsinsue Chen
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Zaman Mirzadeh
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Francisco A Ponce
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Targeting of the Subthalamic Nucleus for Deep Brain Stimulation: A Survey Among Parkinson Disease Specialists. World Neurosurg 2016; 99:41-46. [PMID: 27838430 DOI: 10.1016/j.wneu.2016.11.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 10/30/2016] [Accepted: 11/01/2016] [Indexed: 11/24/2022]
Abstract
BACKGROUND Deep brain stimulation within or adjacent to the subthalamic nucleus (STN) represents the most common stereotactic procedure performed for Parkinson disease. Better STN imaging is often regarded as a requirement for improving stereotactic targeting. However, it is unclear whether there is consensus about the optimal target. METHODS To obtain an expert opinion on the site regarded optimal for "STN stimulation," movement disorder specialists were asked to indicate their preferred position for an active contact on hard copies of the Schaltenbrand and Wahren atlas depicting the STN in all 3 planes. This represented an idealized setting, and it mimicked optimal imaging for direct target definition in a perfectly delineated STN. RESULTS The suggested targets were heterogeneous, although some clustering was observed in the dorsolateral STN and subthalamic area. In particular, in the anteroposterior direction, the intended targets differed to a great extent. Most of the indicated targets are thought to also result in concomitant stimulation of structures adjacent to the STN, including the zona incerta, fields of Forel, and internal capsule. CONCLUSIONS This survey illustrates that most sites regarded as optimal for STN stimulation are close to each other, but there appears to be no uniform perception of the optimal anatomic target, possibly influencing surgical results. The anatomic sweet zone for STN stimulation needs further specification, as this information is likely to make magnetic resonance imaging-based target definition less variable when applied to individual patients.
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