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Patel R, Burroughs L, Higgins A, Zauber SE, Isbaine F, Schneider D, Hohman R, Gupta K. Bilateral Deep Brain Stimulation of the Ventral Intermediate Nucleus of the Thalamus Improves Objective Acoustic Measures of Essential Vocal Tremor. Neurosurgery 2024:00006123-990000000-01134. [PMID: 38787392 DOI: 10.1227/neu.0000000000002955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/28/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Deep brain stimulation of the ventral intermediate nucleus of the thalamus (VIM-DBS) is an established treatment for medically refractory essential tremor. However, the effect of VIM-DBS on vocal tremor remains poorly understood, with results varying by method of vocal tremor assessment and stimulation laterality. This single-center study measures the effect of bilateral VIM-DBS on essential vocal tremor using blinded objective acoustic voice analysis. METHODS Ten patients with consecutive essential tremor with comorbid vocal tremor receiving bilateral VIM-DBS underwent voice testing before and after implantation of DBS in this prospective cohort study. Objective acoustic measures were extracted from the middle one second of steady-state phonation including cepstral peak prominence, signal-to-noise ratio, percentage voicing, tremor rate, extent of fundamental frequency modulation, and extent of intensity modulation. DBS surgery was performed awake with microelectrode recording and intraoperative testing. Postoperative voice testing was performed after stable programming. RESULTS Patients included 6 female and 4 male, with a mean age of 67 ± 6.7 years. The VIM was targeted with the following coordinates relative to the mid-anterior commissure:posterior commissure point: 13.2 ± 0.6 mm lateral, 6.2 ± 0.7 mm posterior, and 0.0 mm below. Mean programming parameters were amplitude 1.72.0 ± 0.6 mA, pulse width 63.0 ± 12.7 µs, and rate 130.6 ± 0.0 Hz. VIM-DBS significantly improved tremor rate from 4.43 ± 0.8 Hz to 3.2 ± 0.8 Hz (P = .001) CI (0.546, 1.895), jitter from 1 ± 0.94 to 0.53 ± 0.219 (P = .02) CI (-0.124, 1.038), cepstral peak prominence from 13.6 ± 3.9 to 18.8 ± 2.9 (P = .016) CI (-4.100, -0.235), signal-to-noise ratio from 15.7 ± 3.9 to 18.5 ± 3.7 (P = .02) CI (-5.598, -0.037), and articulation rate from 0.77 ± 0.2 to 0.82 ± .14 (P = .04) CI (-0.097, 0.008). There were no major complications in this series. CONCLUSION Objective acoustic voice analyses suggest that bilateral VIM-DBS effectively reduces vocal tremor rate and improves voicing. Further studies using objective acoustic analyses and laryngeal imaging may help refine surgical and stimulation techniques and evaluate the effect of laterality on vocal tremor.
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Affiliation(s)
- Rita Patel
- Department of Otolaryngology Head & Neck Surgery, Indiana University School of Medicine, Indianapolis/Indiana University Bloomington, Bloomington, Indiana, USA
| | - Leah Burroughs
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Alexis Higgins
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - S Elizabeth Zauber
- Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Faical Isbaine
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Dylan Schneider
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ryane Hohman
- Department of Speech, Language and Hearing Sciences, Indiana University Bloomington, Bloomington, Indiana, USA
| | - Kunal Gupta
- Department of Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Martinez-Nunez AE, Sarmento FP, Chandra V, Hess CW, Hilliard JD, Okun MS, Wong JK. Management of essential tremor deep brain stimulation-induced side effects. Front Hum Neurosci 2024; 18:1353150. [PMID: 38454907 PMCID: PMC10918853 DOI: 10.3389/fnhum.2024.1353150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 02/01/2024] [Indexed: 03/09/2024] Open
Abstract
Deep brain stimulation (DBS) is an effective surgical therapy for carefully selected patients with medication refractory essential tremor (ET). The most popular anatomical targets for ET DBS are the ventral intermedius nucleus (VIM) of the thalamus, the caudal zona incerta (cZI) and the posterior subthalamic area (PSA). Despite extensive knowledge in DBS programming for tremor suppression, it is not uncommon to experience stimulation induced side effects related to DBS therapy. Dysarthria, dysphagia, ataxia, and gait impairment are common stimulation induced side effects from modulation of brain tissue that surround the target of interest. In this review, we explore current evidence about the etiology of stimulation induced side effects in ET DBS and provide several evidence-based strategies to troubleshoot, reprogram and retain tremor suppression.
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Affiliation(s)
- Alfonso Enrique Martinez-Nunez
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Filipe P. Sarmento
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
| | - Vyshak Chandra
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Christopher William Hess
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Justin David Hilliard
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurosurgery, University of Florida, Gainesville, FL, United States
| | - Michael S. Okun
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
| | - Joshua K. Wong
- Norman Fixel Institute for Neurological Diseases, Gainesville, FL, United States
- Department of Neurology, University of Florida, Gainesville, FL, United States
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Hvingelby VS, Pavese N. Surgical Advances in Parkinson's Disease. Curr Neuropharmacol 2024; 22:1033-1046. [PMID: 36411569 DOI: 10.2174/1570159x21666221121094343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/24/2022] [Accepted: 10/29/2022] [Indexed: 11/23/2022] Open
Abstract
While symptomatic pharmacological therapy remains the main therapeutic strategy for Parkinson's disease (PD), over the last two decades, surgical approaches have become more commonly used to control levodopa-induced motor complications and dopamine-resistant and non-motor symptoms of PD. In this paper, we discuss old and new surgical treatments for PD and the many technological innovations in this field. We have initially reviewed the relevant surgical anatomy as well as the pathological signaling considered to be the underlying cause of specific symptoms of PD. Subsequently, early attempts at surgical symptom control will be briefly reviewed. As the most well-known surgical intervention for PD is deep brain stimulation, this subject is discussed at length. As deciding on whether a patient stands to benefit from DBS can be quite difficult, the different proposed paradigms for precisely this are covered. Following this, the evidence regarding different targets, especially the subthalamic nucleus and internal globus pallidus, is reviewed as well as the evidence for newer proposed targets for specific symptoms. Due to the rapidly expanding nature of knowledge and technological capabilities, some of these new and potential future capabilities are given consideration in terms of their current and future use. Following this, we have reviewed newer treatment modalities, especially magnetic resonance-guided focused ultrasound and other potential surgical therapies, such as spinal cord stimulation for gait symptoms and others. As mentioned, the field of surgical alleviation of symptoms of PD is undergoing a rapid expansion, and this review provides a general overview of the current status and future directions in the field.
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Affiliation(s)
- Victor S Hvingelby
- Department of Clinical Medicine, Nuclear Medicine and PET Center, Aarhus University, Aarhus, Denmark
| | - Nicola Pavese
- Department of Clinical Medicine, Nuclear Medicine and PET Center, Aarhus University, Aarhus, Denmark
- Clinical Ageing Research Unit, Newcastle Upon Tyne, Newcastle University, United Kingdom
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Ferreira Felloni Borges Y, Cheyuo C, Lozano AM, Fasano A. Essential Tremor - Deep Brain Stimulation vs. Focused Ultrasound. Expert Rev Neurother 2023; 23:603-619. [PMID: 37288812 DOI: 10.1080/14737175.2023.2221789] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 06/01/2023] [Indexed: 06/09/2023]
Abstract
INTRODUCTION Essential Tremor (ET) is one of the most common tremor syndromes typically presented as action tremor, affecting mainly the upper limbs. In at least 30-50% of patients, tremor interferes with quality of life, does not respond to first-line therapies and/or intolerable adverse effects may occur. Therefore, surgery may be considered. AREAS COVERED In this review, the authors discuss and compare unilateral ventral intermedius nucleus deep brain stimulation (VIM DBS) and bilateral DBS with Magnetic Resonance-guided Focused Ultrasound (MRgFUS) thalamotomy, which comprises focused acoustic energy generating ablation under real-time MRI guidance. Discussion includes their impact on tremor reduction and their potential complications. Finally, the authors provide their expert opinion. EXPERT OPINION DBS is adjustable, potentially reversible and allows bilateral treatments; however, it is invasive requires hardware implantation, and has higher surgical risks. Instead, MRgFUS is less invasive, less expensive, and requires no hardware maintenance. Beyond these technical differences, the decision should also involve the patient, family, and caregivers.
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Affiliation(s)
- Yuri Ferreira Felloni Borges
- Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, University of Toronto, Toronto, ON, Canada
| | - Cletus Cheyuo
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
| | - Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Division of Neurology, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, University of Toronto, Toronto, ON, Canada
- Krembil Brain Institute, Toronto, ON, Canada
- Center for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, ON, Canada
- Department of Parkinson's Disease & Movement Disorders Rehabilitation, Moriggia-Pelascini Hospital, Gravedona Ed Uniti, Como, Italy
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Hariz M. Pros and Cons of Ablation for Functional Neurosurgery in the Neurostimulation Age. Neurosurg Clin N Am 2023; 34:291-299. [PMID: 36906335 DOI: 10.1016/j.nec.2022.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Should one recommend stereotactic ablation for Parkinson disease, tremor, dystonia, and obsessive compulsive disorder, in this era of DBS? The answer depends on several variables such as the symptoms to treat, the patient's preferences and expectations, the surgeons' competence and preference, the availability of financial means (by government health care, by private insurance), the geographical issues, and not least the current and dominating fashion at that particular time. Both ablation and stimulation can be either used alone or even combined (provided expertise in both of them) to treat various symptoms of movement and mind disorders.
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Affiliation(s)
- Marwan Hariz
- Department of Clinical Neuroscience, University Hospital, Umeå 90185, Sweden.
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Abstract
Parkinson's disease (PD) is a progressive neurodegenerative illness with both motor and nonmotor symptoms. Deep brain stimulation (DBS) is an established safe neurosurgical symptomatic therapy for eligible patients with advanced disease in whom medical treatment fails to provide adequate symptom control and good quality of life, or in whom dopaminergic medications induce severe side effects such as dyskinesias. DBS can be tailored to the patient's symptoms and targeted to various nodes along the basal ganglia-thalamus circuitry, which mediates the various symptoms of the illness; DBS in the thalamus is most efficient for tremors, and DBS in the pallidum most efficient for rigidity and dyskinesias, whereas DBS in the subthalamic nucleus (STN) can treat both tremors, akinesia, rigidity and dyskinesias, and allows for decrease in doses of medications even in patients with advanced stages of the disease, which makes it the preferred target for DBS. However, DBS in the STN assumes that the patient is not too old, with no cognitive decline or relevant depression, and does not exhibit severe and medically resistant axial symptoms such as balance and gait disturbances, and falls. Dysarthria is the most common side effect of DBS, regardless of the brain target. DBS has a long-lasting effect on appendicular symptoms, but with progression of disease, nondopaminergic axial features become less responsive to DBS. DBS for PD is highly specialised; to enable adequate selection and follow-up of patients, DBS requires dedicated multidisciplinary teams of movement disorder neurologists, functional neurosurgeons, specialised DBS nurses and neuropsychologists.
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Affiliation(s)
- Marwan Hariz
- Department of Clinical Neuroscience, University Hospital of Umeå, Umeå, Sweden.,UCL-Queen Square Institute of Neurology, London, UK
| | - Patric Blomstedt
- Department of Clinical Neuroscience, University Hospital of Umeå, Umeå, Sweden
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Sajonz BE, Frommer ML, Walz ID, Reisert M, Maurer C, Rijntjes M, Piroth T, Schröter N, Jenkner C, Reinacher PC, Brumberg J, Meyer PT, Blazhenets G, Coenen VA. Unravelling delayed therapy escape after thalamic deep brain stimulation for essential tremor? - Additional clinical and neuroimaging evidence. Neuroimage Clin 2022; 36:103150. [PMID: 35988341 PMCID: PMC9402391 DOI: 10.1016/j.nicl.2022.103150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 07/15/2022] [Accepted: 08/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Delayed therapy escape after thalamic deep brain stimulation (DBS) for essential tremor is a serious yet frequent condition. It is often difficult to detect this process at onset due to its gradual evolution. OBJECTIVE Here we aim to identify clinical and neuroimaging hallmarks of delayed therapy escape. METHODS We retrospectively studied operationalized and quantitative analyses of tremor and gait, as well as [18F]fluorodeoxyglucose (FDG) PET of 12 patients affected by therapy escape. All examinations were carried out with activated DBS (ON) and 72 h after deactivation (OFF72h); gait and tremor were also analyzed directly after deactivation (OFF0h). Changes of normalized glucose metabolism between stimulation conditions were assessed using within-subject analysis of variance and statistical parametric mapping. Additionally, a comparison to the [18F]FDG PET of an age-matched control group was performed. Exploratory correlation analyses were conducted with operationalized and parametric clinical data. RESULTS Of the immediately accessible parametric tremor data (i.e. ON or OFF0h) only the rebound (i.e. OFF0h) frequency of postural tremor showed possible correlations with signs of ataxia at ON. Regional glucose metabolism was significantly increased bilaterally in the thalamus and dentate nucleus in ON compared to OFF72h. No differences in regional glucose metabolism were found in patients in ON and OFF72h compared with the healthy controls. CONCLUSIONS Rebound frequency of postural tremor seems to be a good diagnostic marker for delayed therapy escape. Regional glucose metabolism suggests that this phenomenon may be associated with increased metabolic activity in the thalamus and dentate nucleus possibly due to antidromic stimulation effects. We see reasons to interpret the delayed therapy escape phenomenon as being related to long term and chronic DBS.
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Affiliation(s)
- Bastian E.A. Sajonz
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Corresponding author at: Department of Stereotactic and Functional Neurosurgery, Freiburg University Medical Center, Breisacher Strasse 64 – 79106 Freiburg, i.Br., Germany.
| | - Marvin L. Frommer
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Isabelle D. Walz
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Department of Sport and Sport Science, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marco Reisert
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christoph Maurer
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Michel Rijntjes
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Tobias Piroth
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Nils Schröter
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Carolin Jenkner
- Clinical Trials Unit, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Peter C. Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Fraunhofer Institute for Laser Technology (ILT), Aachen, Germany
| | - Joachim Brumberg
- Department of Nuclear Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Philipp T. Meyer
- Department of Nuclear Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Ganna Blazhenets
- Department of Nuclear Medicine, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Volker A. Coenen
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Center for Deep Brain Stimulation, University of Freiburg, Germany,Center for Basics in Neuromodulation (Neuromod Basics), Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
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Yuen J, Kouzani AZ, Berk M, Tye SJ, Rusheen AE, Blaha CD, Bennet KE, Lee KH, Shin H, Kim JH, Oh Y. Deep Brain Stimulation for Addictive Disorders-Where Are We Now? Neurotherapeutics 2022; 19:1193-1215. [PMID: 35411483 PMCID: PMC9587163 DOI: 10.1007/s13311-022-01229-4] [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] [Accepted: 03/18/2022] [Indexed: 10/18/2022] Open
Abstract
In the face of a global epidemic of drug addiction, neglecting to develop new effective therapies will perpetuate the staggering human and economic costs of substance use. This review aims to summarize and evaluate the preclinical and clinical studies of deep brain stimulation (DBS) as a novel therapy for refractory addiction, in hopes to engage and inform future research in this promising novel treatment avenue. An electronic database search (MEDLINE, EMBASE, Cochrane library) was performed using keywords and predefined inclusion criteria between 1974 and 6/18/2021 (registered on Open Science Registry). Selected articles were reviewed in full text and key details were summarized and analyzed to understand DBS' therapeutic potential and possible mechanisms of action. The search yielded 25 animal and 22 human studies. Animal studies showed that DBS of targets such as nucleus accumbens (NAc), insula, and subthalamic nucleus reduces drug use and seeking. All human studies were case series/reports (level 4/5 evidence), mostly targeting the NAc with generally positive outcomes. From the limited evidence in the literature, DBS, particularly of the NAc, appears to be a reasonable last resort option for refractory addictive disorders. We propose that future research in objective electrophysiological (e.g., local field potentials) and neurochemical (e.g., extracellular dopamine levels) biomarkers would assist monitoring the progress of treatment and developing a closed-loop DBS system. Preclinical literature also highlighted the prefrontal cortex as a promising DBS target, which should be explored in human research.
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Affiliation(s)
- Jason Yuen
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong VIC 3216, Australia
| | - Abbas Z Kouzani
- School of Engineering, Deakin University, Geelong VIC 3216, Australia
| | - Michael Berk
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong VIC 3216, Australia
| | - Susannah J Tye
- Queensland Brain Institute, The University of Queensland, St Lucia, QLD, 4072, Australia
- Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN, 55905, USA
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, 55455, USA
- Department of Psychiatry, Emory University, Atlanta, GA, 30322, USA
| | - Aaron E Rusheen
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Charles D Blaha
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kevin E Bennet
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
- Division of Engineering, Mayo Clinic, Rochester, MN, 55905, USA
| | - Kendall H Lee
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
- Department of Biomedical Engineering, Mayo Clinic, Rochester, MN, 55905, USA
| | - Hojin Shin
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Jee Hyun Kim
- Deakin University, IMPACT, The Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Geelong VIC 3216, Australia.
| | - Yoonbae Oh
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA.
- Department of Biomedical Engineering, Mayo Clinic, Rochester, MN, 55905, USA.
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Overnight unilateral withdrawal of thalamic deep brain stimulation to identify reversibility of gait disturbances. Exp Neurol 2022; 355:114135. [DOI: 10.1016/j.expneurol.2022.114135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 05/11/2022] [Accepted: 05/30/2022] [Indexed: 11/20/2022]
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Kondapavulur S, Silva AB, Wang DD. Ventral Intermediate Nucleus of the Thalamus versus Posterior Subthalamic Area: Network Meta-Analysis of DBS Target Site Efficacy for Essential Tremor. Stereotact Funct Neurosurg 2022; 100:224-235. [PMID: 35350022 DOI: 10.1159/000522573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 02/03/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Deep brain stimulation (DBS) targeting the ventral intermediate nucleus (Vim) of the thalamus or the posterior subthalamic area (PSA) are effective treatments for essential tremor (ET). However, their relative efficacy is unknown. OBJECTIVE Here, we present the first systematic review and network meta-analysis, examining the efficacy of Vim versus PSA DBS for treating medically refractory ET. METHODS We included all primary studies that reported validated Fahn-Tolosa-Marin Tremor Rating Scale (FTM-TRS) scores pre-/postimplantation or on-/off-stimulation postimplantation, for patients receiving either Vim or PSA DBS. The primary outcome was FTM-TRS score reduction; the secondary outcome was percent reduction in score. We categorized all outcomes as short-term (≤12 months) or long-term (>12 months). RESULTS For pre-/postimplantation comparisons, 19 and 11 studies met inclusion criteria for short- and long-term follow-ups, respectively. For on-/off-stimulation tremor score comparisons, 8 studies met inclusion criteria for short-term follow-up. Network meta-analysis of pre-/postimplantation tremor scores showed greater tremor reduction with PSA implantation short-term (absolute tremor reduction: PSA: -30.94 [95% confidence interval (CI): -34.93, -26.95]; Vim: -26.26 [95% CI: -33.39, -19.12]; relative tremor reduction: PSA: 63.3% [95% CI: 61.8%-64.8%]; Vim: 57.8% [95% CI: 56.5%-59.0%]). However, there was no difference in efficacy between PSA and Vim DBS when comparing tremor on-versus off-stimulation at short-term follow-up or pre- versus postimplantation tremor reduction long-term. CONCLUSION Our systematic review highlighted both heterogeneity in scoring systems used and lack of transparency in reporting total scores, limiting direct comparison across studies. We found a modestly superior efficacy with PSA stimulation in the short term, but no difference in tremor reduction long-term.
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Affiliation(s)
- Sravani Kondapavulur
- Department of Neurological Surgery, UCSF, San Francisco, California, USA.,Medical Scientist Training Program, UCSF, San Francisco, California, USA
| | - Alexander B Silva
- Department of Neurological Surgery, UCSF, San Francisco, California, USA.,Medical Scientist Training Program, UCSF, San Francisco, California, USA
| | - Doris D Wang
- Department of Neurological Surgery, UCSF, San Francisco, California, USA
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Gilmour GS, Martino D, Hunka K, Lawrence P, Kiss ZHT, Bruno V. Response to Thalamic Ventralis Intermedius Nucleus Deep Brain Stimulation in Essential Tremor vs. Essential Tremor-Plus. Front Neurol 2021; 12:790027. [PMID: 34912292 PMCID: PMC8666686 DOI: 10.3389/fneur.2021.790027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Essential tremor (ET) is a tremor syndrome characterized by bilateral, upper limb action tremor. Essential tremor-plus (ET-plus) describes ET patients with additional neurologic signs. It is unknown whether there is a difference in response to treatment with ventralis intermedius nucleus deep brain stimulation (VIM DBS) in patients with ET and ET-plus. Due to potential variability in underlying etiology in ET-plus, there is a concern that ET-plus patients may have worse outcomes. The aim of this study was to identify whether patients with ET-plus have worse tremor outcomes after VIM DBS than patients with ET. Methods: This is a retrospective chart and video review evaluating VIM DBS outcomes by comparing changes from baseline in the Fahn-Tolosa-Marin Tremor Rating Scale Part B (FTM-B) for the treated limb between patients with ET and ET-plus at follow-up examinations. Patients were re-classified as having ET or ET-plus using pre-operative examination videos by two independent movement disorders neurologists blinded to patient characteristics. As a secondary outcome, we evaluated for correlations and potential predictors of treatment response. Results: Twenty-six patients were included: 13 with ET, 13 with ET-plus. There were no significant differences in the change in FTM-B scores between the ET and ET-plus patients at each follow-up examination. None of the included patients developed new symptoms compatible with dystonia, parkinsonism or gait disturbances. Conclusions: Patients with ET-plus had tremor improvement from VIM DBS, with no differences when compared to those with ET, without emergence of postoperative neurological issues. Patients with ET-plus should still be considered good candidates for VIM DBS for treatment of tremor.
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Affiliation(s)
- Gabriela S Gilmour
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Davide Martino
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Karen Hunka
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Pia Lawrence
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Zelma H T Kiss
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Veronica Bruno
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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Bai Y, Yin Z, Diao Y, Hu T, Yang A, Meng F, Zhang J. Loss of long-term benefit from VIM-DBS in essential tremor: A secondary analysis of repeated measurements. CNS Neurosci Ther 2021; 28:279-288. [PMID: 34866345 PMCID: PMC8739044 DOI: 10.1111/cns.13770] [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: 02/25/2021] [Revised: 10/18/2021] [Accepted: 11/16/2021] [Indexed: 11/26/2022] Open
Abstract
AIMS Deep brain stimulation (DBS) in the ventral intermediate nucleus (Vim-DBS) is the preferred surgical therapy for essential tremor (ET). Tolerance and disease progression are considered to be the two main reasons underlying the loss of long-term efficacy of Vim-DBS. This study aimed to explore whether Vim-DBS shows long-term loss of efficacy and to evaluate the reasons for this diminished efficacy from different aspects. METHODS In a repeated-measures meta-analysis of 533 patients from 18 studies, Vim-DBS efficacy was evaluated at ≤6 months, 7-12 months, 1-3 years, and ≥4 years. The primary outcomes were the score changes in different components of the Fahn-Tolosa-Marin Tremor Rating Scale (TRS; total score, motor score, hand-function score, and activities of daily living [ADL] score). Secondary outcomes were the long-term predictive factors. RESULTS The TRS total, motor, and ADL scores showed significant deterioration with disease progression (p = 0.002, p = 0.047, and p < 0.001, respectively), while the TRS total (p < 0.001), hand-function (p = 0.036), and ADL (p = 0.004) scores indicated a significant long-term reduction in DBS efficacy, although the motor subscore indicated no loss of efficacy. Hand-function (p < 0.001) and ADL (p = 0.028) scores indicated DBS tolerance, while the TRS total and motor scores did not. Stimulation frequency and preoperative score were predictive factors for long-term results. CONCLUSION This study provides level 3a evidence that long-term Vim-DBS is effective in controlling motor symptoms without waning benefits. The efficacy reduction for hand function was caused by DBS tolerance, while that for ADL was caused by DBS tolerance and disease progression. More attention should be given to actual functional recovery rather than changes in motor scores in patients with ET.
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Affiliation(s)
- Yutong Bai
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Zixiao Yin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Yu Diao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Tianqi Hu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Anchao Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Fangang Meng
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
| | - Jianguo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Neurostimulation, Beijing, China
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Wang Y, Guo R, Hu W, Jiang J, Kainz W, Chen J. MR Conditionality of Abandoned Leads from Active Implantable Medical Devices at 1.5T. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021; 2021:7412-7415. [PMID: 34892810 DOI: 10.1109/embc46164.2021.9630892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
During Magnetic Resonance (MR) scans, abandoned leads from active implantable medical devices (AIMDs) can experience excessive heating near the lead-tip, depending on the types of termination applied to the proximal end. The influence of different proximal treatments, i.e., (i) freely exposed in the tissue, (ii) capped with metallic material, and (iii) capped with plastic material on the RF-induced heating are studied. Abandoned leads from a sacral neuromodulation (SNM) system were investigated in this study. The device models, i.e., the transfer functions, for different proximal treatments were developed. These models are then used to assess the in-vivo lead-tip heating inside four virtual human models (FATS, Duke, Ella, and Billie). The RF-induced heating from these abandoned leads with different proximal end treatments are compared with the lead-tip heating of the original AIMD system. The maximum lead-tip heating for abandoned leads using metal cap at the proximal end is lower than that from the original intact AIMD system. Abandoned leads with plastic cap treatment at the proximal end will lead to an average in-vivo temperature that is 3.5 times higher than that from the original intact AIMD system. Therefore, from this study and in terms of the RF-induced heating, the abandoned leads with metallic cap treatment at the proximal end can maintain the MR conditionality of the original AIMD system.Clinical Relevance- The different treatments of proximal end of the abandoned leads from AIMD are studied to ensure that MR Conditional AIMD leads remain MR Conditional when the leads are abandoned in the patients.
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Phokaewvarangkul O, Vateekul P, Wichakam I, Anan C, Bhidayasiri R. Using Machine Learning for Predicting the Best Outcomes With Electrical Muscle Stimulation for Tremors in Parkinson's Disease. Front Aging Neurosci 2021; 13:727654. [PMID: 34566628 PMCID: PMC8461308 DOI: 10.3389/fnagi.2021.727654] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022] Open
Abstract
Recent studies have identified that peripheral stimulation in Parkinson’s disease (PD) is effective in tremor reduction, indicating that a peripheral feedback loop plays an important role in the tremor reset mechanism. This was an open-label, quasi-experimental, pre- and post-test design, single-blind, single-group study involving 20 tremor-dominant PD patients. The objective of this study is to explore the effect of electrical muscle stimulation (EMS) as an adjunctive treatment for resting tremor during “on” period and to identify the best machine learning model to predict the suitable stimulation level that will yield the longest period of tremor reduction or tremor reset time. In this study, we used a Parkinson’s glove to evaluate, stimulate, and quantify the tremors of PD patients. This adjustable glove incorporates a 3-axis gyroscope to measure tremor signals and an EMS to provide an on-demand muscle stimulation to suppress tremors. Machine learning models were applied to identify the suitable pulse amplitude (stimulation level) in five classes that led to the longest tremor reset time. The study was registered at the www.clinicaltrials.gov under the name “The Study of Rest Tremor Suppression by Using Electrical Muscle Stimulation” (NCT02370108). Twenty tremor-dominant PD patients were recruited. After applying an average pulse amplitude of 6.25 (SD 2.84) mA and stimulation period of 440.7 (SD 560.82) seconds, the total time of tremor reduction, or tremor reset time, was 329.90 (SD 340.91) seconds. A significant reduction in tremor parameters during stimulation was demonstrated by a reduction of Unified Parkinson’s Disease Rating Scale (UPDRS) scores, and objectively, with a reduction of gyroscopic data (p < 0.05, each). None of the subjects reported any serious adverse events. We also compared gyroscopic data with five machine learning techniques: Logistic Regression, Random Forest, Support Vector Machine (SVM), Neural Network (NN), and Long-Short-Term-Memory (LSTM). The machine learning model that gave the highest accuracy was LSTM, which obtained: accuracy = 0.865 and macro-F1 = 0.736. This study confirms the efficacy of EMS in the reduction of resting tremors in PD. LSTM was identified as the most effective model for predicting pulse amplitude that would elicit the longest tremor reset time. Our study provides further insight on the tremor reset mechanism in PD.
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Affiliation(s)
- Onanong Phokaewvarangkul
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Peerapon Vateekul
- Department of Computer Engineering, Faculty of Engineering, Chulalongkorn University, Bangkok, Thailand
| | - Itsara Wichakam
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Chanawat Anan
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Roongroj Bhidayasiri
- Department of Medicine, Faculty of Medicine, Chulalongkorn Centre of Excellence for Parkinson's Disease and Related Disorders, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,The Academy of Science, The Royal Society of Thailand, Bangkok, Thailand
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15
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Wearable sensor-driven responsive deep brain stimulation for essential tremor. Brain Stimul 2021; 14:1434-1443. [PMID: 34547503 DOI: 10.1016/j.brs.2021.09.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/28/2021] [Accepted: 09/11/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Deep brain stimulation (DBS) is an effective surgical therapy for individuals with essential tremor (ET). However, DBS operates continuously, resulting in adverse effects such as postural instability or dysarthria. Continuous DBS (cDBS) also presents important practical issues including limited battery life of the implantable neurostimulator (INS). Collectively, these shortcomings impact optimal therapeutic benefit in ET. OBJECTIVE The goal of the study was to establish a physiology-driven responsive DBS (rDBS) system to provide targeted and personalized therapy based on electromyography (EMG) signals. METHODS Ten participants with ET underwent rDBS using Nexus-D, a Medtronic telemetry wand that acts as a direct conduit to the INS by modulating stimulation voltage. Two different rDBS paradigms were tested: one driven by one EMG (single-sensor) and another driven by two or more EMGs (multi-sensor). The feature(s) used in the rDBS algorithms was the pow2er in the participant's tremor frequency band derived from the sensors controlling stimulation. Both algorithms were trained on kinetic and postural data collected during DBS off and cDBS states. RESULTS Using established clinical scales and objective measurements of tremor severity, we confirm that both rDBS paradigms deliver equivalent clinical benefit as cDBS. Moreover, both EMG-driven rDBS paradigms delivered less total electrical energy translating to an increase in the battery life of the INS. CONCLUSIONS The results of this study verify that EMG-driven rDBS provides clinically equivalent tremor suppression compared to cDBS, while delivering less total electrical energy. Controlling stimulation using a dynamic rDBS paradigm can mitigate limitations of traditional cDBS systems.
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Peters J, Tisch S. Habituation After Deep Brain Stimulation in Tremor Syndromes: Prevalence, Risk Factors and Long-Term Outcomes. Front Neurol 2021; 12:696950. [PMID: 34413826 PMCID: PMC8368435 DOI: 10.3389/fneur.2021.696950] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/02/2021] [Indexed: 12/12/2022] Open
Abstract
Deep brain stimulation (DBS) of the thalamus is an effective treatment for medically refractory essential, dystonic and Parkinson's tremor. It may also provide benefit in less common tremor syndromes including, post-traumatic, cerebellar, Holmes, neuropathic and orthostatic tremor. The long-term benefit of DBS in essential and dystonic tremor (ET/DT) often wanes over time, a phenomena referred to as stimulation “tolerance” or “habituation”. While habituation is generally accepted to exist, it remains controversial. Attempts to quantify habituation have revealed conflicting reports. Placebo effects, loss of micro-lesional effect, disease related progression, suboptimal stimulation and stimulation related side-effects may all contribute to the loss of sustained long-term therapeutic effect. Habituation often presents as substantial loss of initial DBS benefit occurring as early as a few months after initial stimulation; a complex and feared issue when faced in the setting of optimal electrode placement. Simply increasing stimulation current tends only to propagate tremor severity and induce stimulation related side effects. The report by Paschen and colleagues of worsening tremor scores in the “On” vs. “Off” stimulation state over time, even after accounting for “rebound” tremor, supports the concept of habituation. However, these findings have not been consistent across all studies. Chronic high intensity stimulation has been hypothesized to induce detrimental plastic effects on tremor networks, with some lines of evidence that DT and ET may be more susceptible than Parkinson's tremor to habituation. However, Tsuboi and colleague's recent longitudinal follow-up in dystonic and “pure” essential tremor suggests otherwise. Alternatively, post-mortem findings support a biological adaption to stimulation. The prevalence and etiology of habituation is still not fully understood and management remains difficult. A recent study reported that alternating thalamic stimulation parameters at weekly intervals provided improved stability of tremor control consistent with reduced habituation. In this article the available evidence for habituation after DBS for tremor syndromes is reviewed; including its prevalence, time-course, possible mechanisms; along with expected long-term outcomes for tremor and factors that may assist in predicting, preventing and managing habituation.
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Affiliation(s)
- James Peters
- Department of Neurology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Stephen Tisch
- Department of Neurology, St Vincent's Hospital, Sydney, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, NSW, Australia
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17
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Wang Y, Guo R, Hu W, Zheng J, Wang Q, Jiang J, Kurpad KKN, Kaula N, Long S, Chen J, Kainz W. Magnetic resonance conditionality of abandoned leads from active implantable medical devices at 1.5 T. Magn Reson Med 2021; 87:394-408. [PMID: 34378816 DOI: 10.1002/mrm.28967] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/26/2021] [Accepted: 07/26/2021] [Indexed: 11/07/2022]
Abstract
PURPOSE During MR scans, abandoned leads from active implantable medical devices (AIMDs) can experience excessive heating at the lead tip, depending on the type of termination applied to the proximal contacts (proximal end treatment). The influence of different proximal end treatments (ie, [1] freely exposed in the tissue, [2] terminated with metal in contact with the tissue, or [3] capped with plastic, and thereby fully insulated, on the RF-induced lead-tip heating) are studied. A technique to ensure that MR Conditional AIMD leads remain MR Conditional even when abandoned is recommended. METHODS Abandoned leads from three MR Conditional AIMDs ([1] a sacral neuromodulation system, [2] a cardiac rhythm management pacemaker system, and [3] a deep brain stimulator system) were investigated in this study. The computational lead models (ie, the transfer functions) for different proximal end treatments were measured and used to assess the in vivo lead-tip heating for four virtual human models (FATS, Duke, Ella, and Billie) and compared with the lead-tip heating of the complete MR Conditional AIMD system. RESULT The average and maximum lead-tip heating for abandoned leads proximally capped with metal is always lower than that from the complete AIMD system. Abandoned leads proximally insulated could lead to an average in vivo temperature rise up to 3.5 times higher than that from the complete AIMD system. CONCLUSION For the three investigated AIMDs under 1.5T MR scanning, our results indicate that RF-induced lead-tip heating of abandoned leads strongly depends on the proximal lead termination. A metallic cap applied to the proximal termination of the tested leads could significantly reduce the RF-induced lead-tip heating.
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Affiliation(s)
- Yu Wang
- Department of Electrical and Computer Engineering, University of Houston, Houston, Texas, USA
| | - Ran Guo
- Department of Electrical and Computer Engineering, University of Houston, Houston, Texas, USA
| | - Wei Hu
- Department of Electrical and Computer Engineering, University of Houston, Houston, Texas, USA
| | - Jianfeng Zheng
- Department of Electrical and Computer Engineering, University of Houston, Houston, Texas, USA
| | - Qingyan Wang
- Department of Electrical and Computer Engineering, University of Houston, Houston, Texas, USA
| | - Jay Jiang
- Axonics Modulation Technologies, Irvine, California, USA
| | | | | | - Stuart Long
- Department of Electrical and Computer Engineering, University of Houston, Houston, Texas, USA
| | - Ji Chen
- Department of Electrical and Computer Engineering, University of Houston, Houston, Texas, USA
| | - Wolfgang Kainz
- Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland, USA
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18
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Kremer NI, Pauwels RWJ, Pozzi NG, Lange F, Roothans J, Volkmann J, Reich MM. Deep Brain Stimulation for Tremor: Update on Long-Term Outcomes, Target Considerations and Future Directions. J Clin Med 2021; 10:3468. [PMID: 34441763 PMCID: PMC8397098 DOI: 10.3390/jcm10163468] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 07/29/2021] [Accepted: 08/03/2021] [Indexed: 01/11/2023] Open
Abstract
Deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus is one of the main advanced neurosurgical treatments for drug-resistant tremor. However, not every patient may be eligible for this procedure. Nowadays, various other functional neurosurgical procedures are available. In particular cases, radiofrequency thalamotomy, focused ultrasound and radiosurgery are proven alternatives to DBS. Besides, other DBS targets, such as the posterior subthalamic area (PSA) or the dentato-rubro-thalamic tract (DRT), may be appraised as well. In this review, the clinical characteristics and pathophysiology of tremor syndromes, as well as long-term outcomes of DBS in different targets, will be summarized. The effectiveness and safety of lesioning procedures will be discussed, and an evidence-based clinical treatment approach for patients with drug-resistant tremor will be presented. Lastly, the future directions in the treatment of severe tremor syndromes will be elaborated.
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Affiliation(s)
- Naomi I. Kremer
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (N.I.K.); (R.W.J.P.)
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Rik W. J. Pauwels
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands; (N.I.K.); (R.W.J.P.)
| | - Nicolò G. Pozzi
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Florian Lange
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Jonas Roothans
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Jens Volkmann
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
| | - Martin M. Reich
- Department of Neurology, University Hospital and Julius-Maximilian-University, 97080 Wuerzburg, Germany; (N.G.P.); (F.L.); (J.R.); (J.V.)
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Steffen JK, Jergas H, Petry-Schmelzer JN, Dembek TA, Thies T, Jost ST, Dafsari HS, Kessler J, Wirths J, Fink GR, Visser-Vandewalle V, Barbe MT. Thalamic Deep Brain Stimulation in Essential Tremor Plus Is as Effective as in Essential Tremor. Brain Sci 2020; 10:brainsci10120970. [PMID: 33322350 PMCID: PMC7763605 DOI: 10.3390/brainsci10120970] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 12/03/2022] Open
Abstract
The new essential tremor (ET) classification defined ET-plus (ET-p) as an ET subgroup with additional neurological signs besides action tremor. While deep brain stimulation (DBS) is effective in ET, there are no studies specifically addressing DBS effects in ET-p. 44 patients with medication-refractory ET and thalamic/subthalamic DBS implanted at our center were postoperatively classified into ET and ET-p according to preoperative documentation. Tremor suppression with DBS (stimulation ON vs. preoperative baseline and vs. stimulation OFF), measured via the Fahn–Tolosa–Marin tremor rating scale (TRS), stimulation parameters, and the location of active contacts were compared between patients classified as ET and ET-p. TRS scores at baseline were higher in ET-p. ET-p patients showed comparable tremor reduction as patients with ET, albeit higher stimulation parameters were needed in ET-p. Active electrode contacts were located more dorsally in ET-p of uncertain reason. Our data show that DBS is similarly effective in ET-p compared to ET. TRS scores were higher in ET-p preoperatively, and higher stimulation parameters were needed for tremor reduction compared to ET. The latter may be related to a more dorsal location of active electrode contacts in the ET-p group of this cohort. Prospective studies are warranted to investigate DBS in ET-p further.
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Affiliation(s)
- Julia K. Steffen
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (H.J.); (J.N.P.-S.); (T.A.D.); (T.T.); (S.T.J.); (H.S.D.); (J.K.); (G.R.F.); (M.T.B.)
- Correspondence: ; Tel.: +49-221-478-4013
| | - Hannah Jergas
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (H.J.); (J.N.P.-S.); (T.A.D.); (T.T.); (S.T.J.); (H.S.D.); (J.K.); (G.R.F.); (M.T.B.)
| | - Jan N. Petry-Schmelzer
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (H.J.); (J.N.P.-S.); (T.A.D.); (T.T.); (S.T.J.); (H.S.D.); (J.K.); (G.R.F.); (M.T.B.)
| | - Till A. Dembek
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (H.J.); (J.N.P.-S.); (T.A.D.); (T.T.); (S.T.J.); (H.S.D.); (J.K.); (G.R.F.); (M.T.B.)
| | - Tabea Thies
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (H.J.); (J.N.P.-S.); (T.A.D.); (T.T.); (S.T.J.); (H.S.D.); (J.K.); (G.R.F.); (M.T.B.)
| | - Stefanie T. Jost
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (H.J.); (J.N.P.-S.); (T.A.D.); (T.T.); (S.T.J.); (H.S.D.); (J.K.); (G.R.F.); (M.T.B.)
| | - Haidar S. Dafsari
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (H.J.); (J.N.P.-S.); (T.A.D.); (T.T.); (S.T.J.); (H.S.D.); (J.K.); (G.R.F.); (M.T.B.)
| | - Josef Kessler
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (H.J.); (J.N.P.-S.); (T.A.D.); (T.T.); (S.T.J.); (H.S.D.); (J.K.); (G.R.F.); (M.T.B.)
| | - Jochen Wirths
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (J.W.); (V.V.-V.)
| | - Gereon R. Fink
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (H.J.); (J.N.P.-S.); (T.A.D.); (T.T.); (S.T.J.); (H.S.D.); (J.K.); (G.R.F.); (M.T.B.)
- Cognitive Neuroscience, Research Center Jülich, Institute of Neuroscience and Medicine (INM-3), 52428 Jülich, Germany
| | - Veerle Visser-Vandewalle
- Department of Stereotactic and Functional Neurosurgery, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (J.W.); (V.V.-V.)
| | - Michael T. Barbe
- Department of Neurology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany; (H.J.); (J.N.P.-S.); (T.A.D.); (T.T.); (S.T.J.); (H.S.D.); (J.K.); (G.R.F.); (M.T.B.)
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Giordano M, Caccavella VM, Zaed I, Foglia Manzillo L, Montano N, Olivi A, Polli FM. Comparison between deep brain stimulation and magnetic resonance-guided focused ultrasound in the treatment of essential tremor: a systematic review and pooled analysis of functional outcomes. J Neurol Neurosurg Psychiatry 2020; 91:1270-1278. [PMID: 33055140 DOI: 10.1136/jnnp-2020-323216] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 08/22/2020] [Accepted: 09/09/2020] [Indexed: 01/01/2023]
Abstract
The current gold standard surgical treatment for medication-resistant essential tremor (ET) is deep brain stimulation (DBS). However, recent advances in technologies have led to the development of incisionless techniques, such as magnetic resonance-guided focused ultrasound (MRgFUS) thalamotomy. The authors perform a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to compare unilateral MRgFUS thalamotomy to unilateral and bilateral DBS in the treatment of ET in terms of tremor severity and quality of life improvement. PubMed, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and SCOPUS databases were searched. 45 eligible articles, published between 1990 and 2019, were retrieved. 1202 patients were treated with DBS and 477 were treated with MRgFUS thalamotomy. Postoperative tremor improvement was greater following DBS than MRgFUS thalamotomy (p<0.001). A subgroup analysis was carried out stratifying by treatment laterality: bilateral DBS was significantly superior to both MRgFUS and unilateral DBS (p<0.001), but no significant difference was recorded between MRgFUS and unilateral DBS (p<0.198). Postoperative quality of life improvement was significantly greater following MRgFUS thalamotomy than DBS (p<0.001). Complications were differently distributed among the two groups (p<0.001). Persistent complications were significantly more common in the MRgFUS group (p=0.042). While bilateral DBS proves superior to unilateral MRgFUS thalamotomy in the treatment of ET, a subgroup analysis suggests that treatment laterality is the most significant determinant of tremor improvement, thus highlighting the importance of future investigations on bilateral staged MRgFUS thalamotomy.
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Affiliation(s)
- Martina Giordano
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | | | - Ismail Zaed
- Department of Neurosurgery, Humanitas Clinical and Research Center, Rozzano, Italy
| | | | - Nicola Montano
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | - Alessandro Olivi
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
| | - Filippo Maria Polli
- Department of Neurosurgery, University Hospital Agostino Gemelli, Roma, Italy
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Cooper SS, Ferleger BI, Ko AL, Herron JA, Chizeck HJ. Rebound effect in deep brain stimulation for essential tremor and symptom severity estimation from neural data. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2020; 2020:3621-3624. [PMID: 33018786 DOI: 10.1109/embc44109.2020.9175908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Deep brain stimulation (DBS) is a safe and established treatment for essential tremor (ET). However, there remains considerable room for improvement due to concerns associated with the initial implant surgery, semi-regular revision surgeries for battery replacements, and side effects including paresthesia, gait ataxia, and emotional disinhibition that have been associated with continuous, or conventional, DBS (cDBS) treatment. Adaptive DBS (aDBS) seeks to ameliorate some of these concerns by using feedback from either an external wearable or implanted sensor to modulate stimulation parameters as needed. aDBS has been demonstrated to be as or more effective than cDBS, but the purely binary control system most commonly deployed by aDBS systems likely still provides sub-optimal treatment and may introduce new issues. One example of these issues is rebound effect, in which the tremor symptoms of an ET patient receiving DBS therapy temporarily worsen after cessation of stimulation before leveling out to a steady state. Here is presented a quantitative analysis of rebound effect in 3 patients receiving DBS for ET. Rebound was evident in all 3 patients by both clinical assessment and inertial measurement unit data, peaking by the latter at Tp = 6.65 minutes after cessation of stimulation. Using features extracted from neural data, linear regression was applied to predict tremor severity, with $R_{avg{\text{ }}}^2 = 0.82$. These results strongly suggest that rebound effect and the additional information made available by rebound effect should be considered and exploited when designing novel aDBS systems.
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22
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Enatsu R, Kitagawa M, Morishita T, Sasagawa A, Kuribara T, Hirano T, Arihara M, Mikami T, Mikuni N. Effect of Cycling Thalamosubthalamic Stimulation on Tremor Habituation and Rebound in Parkinson Disease. World Neurosurg 2020; 144:64-67. [PMID: 32841798 DOI: 10.1016/j.wneu.2020.08.141] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Deep brain stimulation is an effective treatment for severe tremor in essential tremor and Parkinson disease (PD). However, progressive loss of the beneficial effects of deep brain stimulation may occur due to several factors. CASE DESCRIPTION We assessed the effects of different temporal patterns of cycling stimulation in the posterior subthalamic area, subthalamic nucleus, and the ventral intermediate nucleus of the thalamus in 3 PD patients with early decline of tremor suppression associated with severe tremor rebound. CONCLUSIONS Certain temporal patterns of cycling (10 seconds on/1 second off or 30 seconds on/5 seconds off, soft start off) were useful for treating tremor habituation and rebound and showed long-term tremor suppression. Cycling stimulation may prevent tremor habituation in PD patients with severe tremor rebound.
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Affiliation(s)
- Rei Enatsu
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
| | - Mayumi Kitagawa
- Department of Neurology, Sapporo Teishinkai Hospital, Sapporo, Japan
| | - Takashi Morishita
- Department of Neurosurgery, Fukuoka University Faculty of Medicine, Sapporo, Japan
| | - Ayaka Sasagawa
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tomoyoshi Kuribara
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Tsukasa Hirano
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masayasu Arihara
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takeshi Mikami
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Nobuhiro Mikuni
- Department of Neurosurgery, Sapporo Medical University School of Medicine, Sapporo, Japan
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23
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Park SE, Connolly MJ, Exarchos I, Fernandez A, Ghetiya M, Gutekunst CA, Gross RE. Optimizing neuromodulation based on surrogate neural states for seizure suppression in a rat temporal lobe epilepsy model. J Neural Eng 2020; 17:046009. [PMID: 32492658 DOI: 10.1088/1741-2552/ab9909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Developing a new neuromodulation method for epilepsy treatment requires a large amount of time and resources to find effective stimulation parameters and often fails due to inter-subject variability in stimulation effect. As an alternative, we present a novel data-driven surrogate approach which can optimize the neuromodulation efficiently by investigating the stimulation effect on surrogate neural states. APPROACH Medial septum (MS) optogenetic stimulation was applied for modulating electrophysiological activities of the hippocampus in a rat temporal lobe epilepsy model. For the new approach, we implemented machine learning techniques to describe the pathological neural states and to optimize the stimulation parameters. Specifically, first, we found neural state surrogates to estimate a seizure susceptibility based on hippocampal local field potentials. Second, we modulated the neural state surrogates in a desired way with the subject-specific optimal stimulation parameters found by in vivo Bayesian optimization. Finally, we tested whether modulating the neural state surrogates affected seizure frequency. MAIN RESULTS We found two neural state surrogates: The first was hippocampal theta power by considering its well-known relationship with epilepsy, and the second was the output of pre-ictal state model (PriSM) which was built by characterizing the hippocampal activity during the pre-ictal period. The optimal stimulation parameters found by Bayesian optimization outperformed the other parameters in terms of modulating the surrogates toward anti-seizure neural state. When treatment efficacy was tested, the subject-specific optimal parameters for increasing theta power were more effective to suppress seizures than fixed stimulation parameter (7 Hz). However, modulation of the other neural state surrogate, PriSM, did not suppress seizures. SIGNIFICANCE The surrogate approach can save enormous time and resources to find subject-specific optimal stimulation parameters which can effectively modulate neural states and further improve therapeutic effectiveness. This approach can also be used for improving neuromodulation treatment of other neurological or psychiatric diseases.
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Affiliation(s)
- Sang-Eon Park
- Department of Electrical and Computer Engineering, Georgia Institute of Technology, Atlanta, GA 30332, United States of America
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24
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Bruno S, Nikolov P, Hartmann CJ, Trenado C, Slotty PJ, Vesper J, Schnitzler A, Groiss SJ. Directional Deep Brain Stimulation of the Thalamic Ventral Intermediate Area for Essential Tremor Increases Therapeutic Window. Neuromodulation 2020; 24:343-352. [PMID: 32666569 DOI: 10.1111/ner.13234] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/16/2020] [Accepted: 06/15/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Deep brain stimulation (DBS) of the posterior subthalamic area (PSA) and the ventral intermediate thalamic nucleus (VIM) is a well-established therapy for essential tremor (ET), but it is frequently associated with side effects like dysarthria or gait ataxia. Directional DBS (dDBS) may be a way to activate fiber tracts more selectively. Is dDBS for ET superior to omnidirectional DBS (oDBS) regarding therapeutic window and clinically as effective as oDBS? MATERIALS AND METHODS Ten patients with ET treated with PSA/VIM-DBS were recruited. Therapeutic window served as primary outcome parameter; clinical efficacy, volume of neuronal activation, and total electrical energy delivered (TEED) served as secondary outcome parameters. Therapeutic window was calculated for all three dDBS directions and for oDBS by determining therapeutic thresholds and side effect thresholds. Clinical efficacy was assessed by comparing the effect of best dDBS and oDBS on tremor and ataxia rating scales, and accelerometry. Volume of neural activation and TEED were also calculated for both paradigms. RESULTS For best dDBS, therapeutic window was wider and therapeutic threshold was lower compared to oDBS. While side effect threshold did not differ, volume of neural activation was larger for dDBS. In terms of clinical efficacy, dDBS was as effective as oDBS. CONCLUSIONS dDBS for ET widens therapeutic window due to reduction of therapeutic threshold. Larger volume of neural activation for dDBS at side effect threshold supports the notion of persistent directionality even at higher intensities. dDBS may compensate for slightly misplaced leads and should be considered first line for PSA/VIM-DBS.
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Affiliation(s)
- Sabine Bruno
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Petyo Nikolov
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christian J Hartmann
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Carlos Trenado
- Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Philipp J Slotty
- Department of Functional Neurosurgery and Stereotaxy, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Vesper
- Department of Functional Neurosurgery and Stereotaxy, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Alfons Schnitzler
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefan J Groiss
- Department of Neurology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Institute of Clinical Neuroscience and Medical Psychology, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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25
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Nowacki A, Debove I, Rossi F, Schlaeppi JA, Petermann K, Wiest R, Schüpbach M, Pollo C. Targeting the posterior subthalamic area for essential tremor: proposal for MRI-based anatomical landmarks. J Neurosurg 2019; 131:820-827. [PMID: 30497206 DOI: 10.3171/2018.4.jns18373] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/12/2018] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Deep brain stimulation (DBS) of the posterior subthalamic area (PSA) is an alternative to thalamic DBS for the treatment of essential tremor (ET). The dentato-rubro-thalamic tract (DRTT) has recently been proposed as the anatomical substrate underlying effective stimulation. For clinical purposes, depiction of the DRTT mainly depends on diffusion tensor imaging (DTI)-based tractography, which has some drawbacks. The objective of this study was to present an accurate targeting strategy for DBS of the PSA based on anatomical landmarks visible on MRI and to evaluate clinical effectiveness. METHODS The authors performed a retrospective cohort study of a prospective series of 11 ET patients undergoing bilateral DBS of the PSA. The subthalamic nucleus and red nucleus served as anatomical landmarks to define the target point within the adjacent PSA on 3-T T2-weighted MRI. Stimulating contact (SC) positions with reference to the midcommissural point were analyzed and projected onto the stereotactic atlas of Morel. Postoperative outcome assessment after 6 and 12 months was based on change in Tremor Rating Scale (TRS) scores. RESULTS Actual target position corresponded to the intended target based on anatomical landmarks depicted on MRI. The total TRS score was reduced (improved) from 47.2 ± 15.7 to 21.3 ± 10.7 (p < 0.001). No severe complication occurred. The mean SC position projected onto the PSA at the margin of the cerebellothalamic fascicle and the zona incerta. CONCLUSIONS Targeting of the PSA based on anatomical landmarks representable on MRI is reliable and leads to accurate lead placement as well as good long-term clinical outcome.
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Affiliation(s)
| | | | | | | | | | - Roland Wiest
- 3Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, and University of Bern, Bern, Switzerland
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Fernandez-Garcia C, Alonso-Frech F, Monje MHG, Matias-Guiu J. Role of deep brain stimulation therapy in the magnetic resonance-guided high-frequency focused ultrasound era: current situation and future prospects. Expert Rev Neurother 2019; 20:7-21. [PMID: 31623494 DOI: 10.1080/14737175.2020.1677465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Deep brain stimulation (DBS) is a well-established treatment of movement disorders; but recently there has been an increasing trend toward the ablative procedure magnetic resonance-guided focused ultrasound (MRgFU). DBS is an efficient neuromodulatory technique but associated with surgical complications. MRIgFUS is an incision-free method that allows thermal lesioning, with fewer surgical complications but irreversible effects.Areas covered: We look at current and prospective aspects of both techniques. In DBS, appropriate patient selection, improvement in surgical expertise, target accuracy (preoperative and intraoperative imaging), neurophysiological recordings, and novel segmented leads need to be considered. However, increased number of older patients with higher comorbidities and risk of DBS complications (mainly intracranial hemorrhage, but also infections, hardware complications) make them not eligible for surgery. With MRgFUS, hemorrhage risks are virtually nonexistent, infection or hardware malfunction are eliminated, while irreversible side effects can appear.Expert commentary: Comparison of the efficacy and risks associated with these techniques, in combination with a growing aged population in developed countries with higher comorbidities and a preference for less invasive treatments, necessitates a review of the indications for movement disorders and the most appropriate treatment modalities.
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Affiliation(s)
- C Fernandez-Garcia
- Department of Neurosurgery, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Madrid, Spain.,Medicine Department, Universidad Complutense, Madrid, Spain
| | - F Alonso-Frech
- Department of Neurology, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Universidad Complutense, Madrid, Spain.,HM CINAC, Hospital Universitario HM Puerta del Sur, Universidad CEU-San Pablo, Móstoles, Madrid, Spain
| | - M H G Monje
- HM CINAC, Hospital Universitario HM Puerta del Sur, Universidad CEU-San Pablo, Móstoles, Madrid, Spain
| | - J Matias-Guiu
- Medicine Department, Universidad Complutense, Madrid, Spain.,Department of Neurology, Hospital Clínico San Carlos, San Carlos Research Health Institute (IdISSC), Universidad Complutense, Madrid, Spain
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27
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Sharma S, Pandey S. Treatment of essential tremor: current status. Postgrad Med J 2019; 96:84-93. [DOI: 10.1136/postgradmedj-2019-136647] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 08/14/2019] [Accepted: 09/13/2019] [Indexed: 12/18/2022]
Abstract
Essential tremor is the most common cause of tremor involving upper limbs, head and voice. The first line of treatment for limb tremor is pharmacotherapy with propranolol or primidone. However, these two drugs reduce the tremor severity by only half. In medication refractory and functionally disabling tremor, alternative forms of therapy need to be considered. Botulinum toxin injections are likely efficacious for limb, voice and head tremor but are associated with side effects. Surgical interventions include deep brain stimulation; magnetic resonance-guided focused ultrasound and thalamotomy for unilateral and deep brain stimulation for bilateral procedures. Recent consensus classification for essential tremor has included a new subgroup, ‘Essential tremor plus’, who have associated subtle neurological ‘soft signs’, such as dystonic posturing of limbs and may require a different treatment approach. In this review, we have addressed the current management of essential tremor with regard to different anatomical locations of tremor as well as different modalities of treatment.
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28
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Nowacki A, Bogdanovic M, Sarangmat N, Fitzgerald J, Green A, Aziz TZ. Revisiting the rules for anatomical targeting of ventralis intermediate nucleus. J Clin Neurosci 2019; 68:97-100. [DOI: 10.1016/j.jocn.2019.07.027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 05/23/2019] [Accepted: 07/06/2019] [Indexed: 10/26/2022]
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Fasano A, Helmich RC. Tremor habituation to deep brain stimulation: Underlying mechanisms and solutions. Mov Disord 2019; 34:1761-1773. [PMID: 31433906 DOI: 10.1002/mds.27821] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 07/01/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022] Open
Abstract
DBS of the ventral intermediate nucleus is an extremely effective treatment for essential tremor, although a waning benefit is observed after a variable time in a variable proportion of patients (ranging from 0% to 73%), a concept historically defined as "tolerance." Tolerance is currently an established concept in the medical community, although there is debate on its real existence. In fact, very few publications have actually addressed the problem, thus making tolerance a typical example of science based on "eminence rather than evidence." The underpinnings of the phenomena associated with the progressive loss of DBS benefit are not fully elucidated, although the interplay of different-not mutually exclusive-factors has been advocated. In this viewpoint, we gathered the evidence explaining the progressive loss of benefit observed after DBS. We grouped these factors in three categories: disease-related factors (tremor etiology and progression); surgery-related factors (electrode location, microlesional effect and placebo); and stimulation-related factors (not optimized stimulation, stimulation-induced side effects, habituation, and tremor rebound). We also propose possible pathophysiological explanations for the phenomenon and define a nomenclature of the associated features: early versus late DBS failure; tremor rebound versus habituation (to be preferred over tolerance). Finally, we provide a practical approach for preventing and treating this loss of DBS benefit, and we draft a possible roadmap for the research to come. © 2019 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Alfonso Fasano
- Edmond J. Safra Program in Parkinson's Disease, Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, UHN, Toronto, Ontario, Canada; Division of Neurology, University of Toronto, Toronto, Ontario, Canada.,Krembil Brain Institute, Toronto, Ontario, Canada.,CenteR for Advancing Neurotechnological Innovation to Application (CRANIA), Toronto, Ontario, Canada
| | - Rick C Helmich
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Department of Neurology, Nijmegen, The Netherlands
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Paschen S, Forstenpointner J, Becktepe J, Heinzel S, Hellriegel H, Witt K, Helmers AK, Deuschl G. Long-term efficacy of deep brain stimulation for essential tremor: An observer-blinded study. Neurology 2019; 92:e1378-e1386. [PMID: 30787161 DOI: 10.1212/wnl.0000000000007134] [Citation(s) in RCA: 65] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 11/13/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Deep brain stimulation (DBS) of the ventral intermediate thalamic nucleus (Vim) is established for medically refractory severe essential tremor (ET), but long-term efficacy is controversial. METHODS Twenty patients with ET with DBS had standardized video-documented examinations at baseline, in the stimulation-on condition at short term (13.1 ± 1.9 months since surgery, mean ± SEM), and in the stimulator switched on and off (stim-ON/OFF) at long term; all assessments were done between 32 and 120 months (71.9 ± 6.9 months) after implantation. The primary outcome was the Tremor Rating Scale (TRS) blindly assessed by 2 trained movement disorder neurologists. Secondary outcomes were TRS subscores A, B, and C; Archimedes spiral score; and activities of daily living score. At long-term follow-up, tremor was additionally recorded with accelerometry. The rebound effect after switching the stimulator off was assessed for 1 hour in a subgroup. RESULTS Tremor severity worsened considerably over time in both in the nonstimulated and stimulated conditions. Vim-DBS improved the TRS in the short term and long term significantly. The spiral score and functional measures showed similar improvements. All changes were highly significant. However, the stimulation effect was negatively correlated with time since surgery (ρ = -0.78, p < 0.001). This was also true for the secondary outcomes. Only one-third of the patients had a rebound effect terminated 60 minutes after the stimulator was switched off. Long-term worsening of the TRS was more profound during stim-ON than in the stim-OFF condition, indicating habituation to stimulation. CONCLUSION Vim-DBS loses efficacy over the long term. Efforts are needed to improve the long-term efficacy of Vim-DBS. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that for patients with medically refractory severe ET, the efficacy of Vim-DBS severely decreases over 10 years.
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Affiliation(s)
- Steffen Paschen
- From the Departments of Neurology (S.P., J.F., J.B., S.H., H.H., K.W., G.D.) and Neurosurgery (A.-K.H.), Christian-Albrechts-University; Division of Neurological Pain Research and Therapy (J.F.), Department of Neurology, University Hospital Schleswig-Holstein, Kiel; and Department of Neurology (K.W.), School of Medicine and Health Sciences-European Medical School, University Oldenburg and Research Center Neurosensory Science, Carl von Ossietzky University, Oldenburg, Germany
| | - Julia Forstenpointner
- From the Departments of Neurology (S.P., J.F., J.B., S.H., H.H., K.W., G.D.) and Neurosurgery (A.-K.H.), Christian-Albrechts-University; Division of Neurological Pain Research and Therapy (J.F.), Department of Neurology, University Hospital Schleswig-Holstein, Kiel; and Department of Neurology (K.W.), School of Medicine and Health Sciences-European Medical School, University Oldenburg and Research Center Neurosensory Science, Carl von Ossietzky University, Oldenburg, Germany
| | - Jos Becktepe
- From the Departments of Neurology (S.P., J.F., J.B., S.H., H.H., K.W., G.D.) and Neurosurgery (A.-K.H.), Christian-Albrechts-University; Division of Neurological Pain Research and Therapy (J.F.), Department of Neurology, University Hospital Schleswig-Holstein, Kiel; and Department of Neurology (K.W.), School of Medicine and Health Sciences-European Medical School, University Oldenburg and Research Center Neurosensory Science, Carl von Ossietzky University, Oldenburg, Germany
| | - Sebastian Heinzel
- From the Departments of Neurology (S.P., J.F., J.B., S.H., H.H., K.W., G.D.) and Neurosurgery (A.-K.H.), Christian-Albrechts-University; Division of Neurological Pain Research and Therapy (J.F.), Department of Neurology, University Hospital Schleswig-Holstein, Kiel; and Department of Neurology (K.W.), School of Medicine and Health Sciences-European Medical School, University Oldenburg and Research Center Neurosensory Science, Carl von Ossietzky University, Oldenburg, Germany
| | - Helge Hellriegel
- From the Departments of Neurology (S.P., J.F., J.B., S.H., H.H., K.W., G.D.) and Neurosurgery (A.-K.H.), Christian-Albrechts-University; Division of Neurological Pain Research and Therapy (J.F.), Department of Neurology, University Hospital Schleswig-Holstein, Kiel; and Department of Neurology (K.W.), School of Medicine and Health Sciences-European Medical School, University Oldenburg and Research Center Neurosensory Science, Carl von Ossietzky University, Oldenburg, Germany
| | - Karsten Witt
- From the Departments of Neurology (S.P., J.F., J.B., S.H., H.H., K.W., G.D.) and Neurosurgery (A.-K.H.), Christian-Albrechts-University; Division of Neurological Pain Research and Therapy (J.F.), Department of Neurology, University Hospital Schleswig-Holstein, Kiel; and Department of Neurology (K.W.), School of Medicine and Health Sciences-European Medical School, University Oldenburg and Research Center Neurosensory Science, Carl von Ossietzky University, Oldenburg, Germany
| | - Ann-Kristin Helmers
- From the Departments of Neurology (S.P., J.F., J.B., S.H., H.H., K.W., G.D.) and Neurosurgery (A.-K.H.), Christian-Albrechts-University; Division of Neurological Pain Research and Therapy (J.F.), Department of Neurology, University Hospital Schleswig-Holstein, Kiel; and Department of Neurology (K.W.), School of Medicine and Health Sciences-European Medical School, University Oldenburg and Research Center Neurosensory Science, Carl von Ossietzky University, Oldenburg, Germany
| | - Günther Deuschl
- From the Departments of Neurology (S.P., J.F., J.B., S.H., H.H., K.W., G.D.) and Neurosurgery (A.-K.H.), Christian-Albrechts-University; Division of Neurological Pain Research and Therapy (J.F.), Department of Neurology, University Hospital Schleswig-Holstein, Kiel; and Department of Neurology (K.W.), School of Medicine and Health Sciences-European Medical School, University Oldenburg and Research Center Neurosensory Science, Carl von Ossietzky University, Oldenburg, Germany.
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Degeneffe A, Kuijf ML, Ackermans L, Temel Y, Kubben PL. Comparing deep brain stimulation in the ventral intermediate nucleus versus the posterior subthalamic area in essential tremor patients. Surg Neurol Int 2018; 9:244. [PMID: 30603229 PMCID: PMC6293600 DOI: 10.4103/sni.sni_234_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/27/2018] [Indexed: 11/12/2022] Open
Abstract
Background: The ventral intermediate nucleus (VIM) is the most commonly used target for deep brain stimulation (DBS) in patients with essential tremor (ET). Recent evidence suggests that the posterior subthalamic area (PSA) might be a better target for tremor reduction. We compared the outcome of VIM DBS with PSA DBS in our cohort of patients. Methods: Overall, 19 ET patients with bilateral DBS were included in this retrospective study, with a total of 38 electrodes (12 located in the VIM, 12 in the PSA, and 14 in an intermediate area). The outcome was measured using the essential tremor rating scale (ETRS), the glass scale and the quality of life in essential tremor questionnaire (QUEST). Results: Unilateral tremor-scores with items 5–6 (tremor of the upper extremity), 8–9 (tremor of the lower extremity), and 11-14 (hand function) from the ETRS showed a 63% tremor reduction in the VIM group, 47% tremor reduction in the PSA group, and 67% tremor reduction in the intermediate group after a mean follow-up of 1.6 years. After a mean follow-up of 5.8 years, there was a tremor reduction of 50%, 34%, and 45%, respectively. In our series, side effects such as dysarthria (75%), ataxia and disequilibrium (40%), and paraesthesia (15%) were assessed. Conclusions: All aforementioned anatomical target areas are effective in reducing tremor, although no superior reduction was found with PSA stimulation. Because of intraindividual differences between left and right hemisphere regarding the stimulated anatomical target, no conclusions can be drawn regarding differences in side effects.
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Affiliation(s)
- Aurélie Degeneffe
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mark L Kuijf
- Department of Neurology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Linda Ackermans
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Pieter L Kubben
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, The Netherlands
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32
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Benefits and risks of unilateral and bilateral ventral intermediate nucleus deep brain stimulation for axial essential tremor symptoms. Parkinsonism Relat Disord 2018; 60:126-132. [PMID: 30220556 DOI: 10.1016/j.parkreldis.2018.09.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/09/2018] [Accepted: 09/04/2018] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Many experts assume bilateral deep brain stimulation (DBS) is necessary to improve axial tremor in essential tremor (ET). In the largest clinical trial of DBS for ET to date evaluating a non-directional, constant current device, we studied the effects of unilateral and staged bilateral DBS on axial tremor. METHODS We included all participants from the original trial with unilateral ventral intermediate nucleus (VIM) DBS and 90-day follow up at minimum. Primary outcomes were changes in pooled axial subscores in the Clinical Rating Scale for Tremor (CRST) at 90 and 180 days after activation of unilateral VIM DBS compared to pre-operative baseline (n=119). Additionally, we performed within-subject analyses for unilateral versus bilateral DBS at 180 days in the cohort who underwent staged surgery to bilateral DBS (n=39). RESULTS Unilateral VIM DBS improved midline tremor by 58% at 90 days (median[IQR]) (3[3] to 1[2], p<0.001) and 65% at 180 days (3[3] to 1[2], p<0.001) versus pre-op baseline. In the staged to bilateral DBS cohort, midline tremor scores further improved after bilateral DBS at 180 days by 63% versus unilateral DBS (3[3] to 1[3], p=0.007). There were, however, 35 additional DBS and surgery-related adverse events, 14 related to incoordination, gait impairment, or speech impairment, versus 6 after unilateral DBS. CONCLUSION Unilateral VIM DBS for ET significantly improved associated axial tremor. Staged bilateral DBS was associated with additional axial tremor improvement but also additional adverse events. Unilateral VIM DBS may be sufficient to achieve a goal of contralateral limb and axial tremor attenuation.
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Blomstedt P, Stenmark Persson R, Hariz GM, Linder J, Fredricks A, Häggström B, Philipsson J, Forsgren L, Hariz M. Deep brain stimulation in the caudal zona incerta versus best medical treatment in patients with Parkinson's disease: a randomised blinded evaluation. J Neurol Neurosurg Psychiatry 2018; 89:710-716. [PMID: 29386253 PMCID: PMC6031280 DOI: 10.1136/jnnp-2017-317219] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 11/29/2017] [Accepted: 01/09/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Several open-label studies have shown good effect of deep brain stimulation (DBS) in the caudal zona incerta (cZi) on tremor, including parkinsonian tremor, and in some cases also a benefit on akinesia and axial symptoms. The aim of this study was to evaluate objectively the effect of cZi DBS in patients with Parkinson's disease (PD). METHOD 25 patients with PD were randomised to either cZi DBS or best medical treatment. The primary outcomes were differences between the groups in the motor scores of the Unified Parkinson's Disease Rating Scale (UPDRS-III) rated single-blindly at 6 months and differences in the Parkinson's Disease Questionnaire 39 items (PDQ-39). 19 patients, 10 in the medical arm and 9 in the DBS arm, fulfilled the study. RESULTS The DBS group had 41% better UPDRS-III scores off-medication on-stimulation compared with baseline, whereas the scores of the non-surgical patients off-medication were unchanged. In the on-medication condition, there were no differences between the groups, neither at baseline nor at 6 months. Subitems of the UPDRS-III showed a robust effect of cZi DBS on tremor. The PDQ-39 domains 'stigma' and 'ADL' improved only in the DBS group. The PDQ-39 summary index improved in both groups. CONCLUSION This is the first randomised blinded evaluation of cZi DBS showing its efficacy on PD symptoms. The most striking effect was on tremor; however, the doses of dopaminergic medications could not be decreased. cZi DBS in PD may be an addition to existing established targets, enabling tailoring the surgery to the needs of the individual patient.
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Affiliation(s)
- Patric Blomstedt
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | | | - Gun-Marie Hariz
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.,Unit of Occupational Therapy, Department of Community Medicine and Rehabilitation, Umeå University, Umeå, Sweden
| | - Jan Linder
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Anna Fredricks
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Björn Häggström
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Johanna Philipsson
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Lars Forsgren
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Marwan Hariz
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.,Unit of Functional Neurosurgery, UCL Institute of Neurology, London, UK
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Objective predictors of 'early tolerance' to ventral intermediate nucleus of thalamus deep brain stimulation in essential tremor patients. Clin Neurophysiol 2018; 129:1628-1633. [PMID: 29908405 DOI: 10.1016/j.clinph.2018.05.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 04/24/2018] [Accepted: 05/04/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To identify pre-operative clinical and computerized spiral analysis characteristics that may help ascertain which patients with Essential Tremor (ET) will exhibit 'early tolerance' to ventral intermediate nucleus of thalamus (Vim) deep brain stimulation (DBS). METHODS Identification of comparative characteristics of defined cases of 'early tolerance' versus patients with sustained satisfactory response treated with Vim DBS surgery for medically-refractory ET, based on retrospective chart review by a clinician blinded to the findings of computerized spiral analysis. RESULTS Statistically significant differences in two spiral analysis indices, SWVI and DoS, were found in the dominant upper limbs of patients who developed 'early tolerance', whereas the clinical characteristics were not significantly different. CONCLUSION Objective measurements of upper limb kinematics using graphonomic tests like spiral analysis should be considered in the pre-operative evaluation for DBS, especially in the setting of moderate-severe predominantly action and proximal postural tremors. SIGNIFICANCE Ours is the first investigation looking into the pre-operative clinical and objective physiologic characteristics of the patients who develop 'early tolerance' to Vim DBS for the treatment of essential tremor. The study has significant implications for pre-operative evaluation and potential surgical target selection for the treatment of tremors.
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Abstract
INTRODUCTION Essential tremor is the most common form of pathologic tremor. Surgical therapies disrupt tremorogenic oscillation in the cerebellothalamocortical pathway and are capable of abolishing severe tremor that is refractory to available pharmacotherapies. Surgical methods are raspidly improving and are the subject of this review. Areas covered: A PubMed search on 18 January 2018 using the query essential tremor AND surgery produced 839 abstracts. 379 papers were selected for review of the methods, efficacy, safety and expense of stereotactic deep brain stimulation (DBS), stereotactic radiosurgery (SRS), focused ultrasound (FUS) ablation, and radiofrequency ablation of the cerebellothalamocortical pathway. Expert commentary: DBS and SRS, FUS and radiofrequency ablations are capable of reducing upper extremity tremor by more than 80% and are far more effective than any available drug. The main research questions at this time are: 1) the relative safety, efficacy, and expense of DBS, SRS, and FUS performed unilaterally and bilaterally; 2) the relative safety and efficacy of thalamic versus subthalamic targeting; 3) the relative safety and efficacy of atlas-based versus direct imaging tractography-based anatomical targeting; and 4) the need for intraoperative microelectrode recordings and macroelectrode stimulation in awake patients to identify the optimum anatomical target. Randomized controlled trials are needed.
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Affiliation(s)
- Rodger J Elble
- a Neuroscience Institute , Southern Illinois University School of Medicine , Springfield , Illinois , USA
| | - Ludy Shih
- b Department of Neurology , Beth Israel Deaconess Medical Center, Harvard Medical School , Boston , Massachusetts USA
| | - Jeffrey W Cozzens
- a Neuroscience Institute , Southern Illinois University School of Medicine , Springfield , Illinois , USA
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Wang TR, Dallapiazza RF, Moosa S, Huss D, Shah BB, Elias WJ. Thalamic Deep Brain Stimulation Salvages Failed Focused Ultrasound Thalamotomy for Essential Tremor: A Case Report. Stereotact Funct Neurosurg 2018; 96:60-64. [PMID: 29433124 DOI: 10.1159/000486646] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 01/08/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND A recent randomized controlled trial investigating unilateral MRI-guided focused ultrasound (FUS) for essential tremor demonstrated efficacy. The long-term durability of this thalamotomy, however, is unknown. Furthermore, the feasibility of stimulating a previously lesioned target such as the thalamic nucleus ventralis intermedius (Vim) is poorly understood. We report a case of tremor recurrence, following an initially successful FUS thalamotomy, in which Vim-DBS was subsequently utilized to regain tremor control. METHODS An 81-year-old right-handed female with medically refractory essential tremor (a Clinical Rating Scale for Tremor [CRST] value of 73) underwent left-sided FUS thalamotomy with initial abolition of right-upper extremity tremor. By the 6-month follow-up, there was complete recurrence of tremor (a CRST value of 76). The patient subsequently underwent left-sided Vim-DBS. RESULTS Vim-DBS provided clinical improvement with a CRST value of 42 at the 3-month follow-up; the patient continues to do clinically well at the 6-month follow-up. This result mirrors previous reported cases of stimulation following radiofrequency and gamma-knife lesioning. Our literature review highlights several reasons for the waning of clinical benefit seen with lesional procedures. CONCLUSION This case demonstrates that thalamic DBS can salvage a failed FUS thalamotomy and also the feasibility of stimulating a previously lesioned target.
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Affiliation(s)
- Tony R Wang
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Robert F Dallapiazza
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Shayan Moosa
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Diane Huss
- Department of Physical Therapy, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Binit B Shah
- Department of Neurology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - W Jeffrey Elias
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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Holslag JA, Neef N, Beudel M, Drost G, Oterdoom DLM, Kremer NI, van Laar T, van Dijk JMC. Deep Brain Stimulation for Essential Tremor: A Comparison of Targets. World Neurosurg 2018; 110:e580-e584. [DOI: 10.1016/j.wneu.2017.11.064] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/08/2017] [Accepted: 11/11/2017] [Indexed: 10/18/2022]
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Alomar S, King NKK, Tam J, Bari AA, Hamani C, Lozano AM. Speech and language adverse effects after thalamotomy and deep brain stimulation in patients with movement disorders: A meta-analysis. Mov Disord 2018; 32:53-63. [PMID: 28124434 DOI: 10.1002/mds.26924] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 12/22/2016] [Accepted: 12/23/2016] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The thalamus has been a surgical target for the treatment of various movement disorders. Commonly used therapeutic modalities include ablative and nonablative procedures. A major clinical side effect of thalamic surgery is the appearance of speech problems. OBJECTIVE This review summarizes the data on the development of speech problems after thalamic surgery. METHODS A systematic review and meta-analysis was performed using nine databases, including Medline, Web of Science, and Cochrane Library. We also checked for articles by searching citing and cited articles. We retrieved studies between 1960 and September 2014. RESULTS Of a total of 2,320 patients, 19.8% (confidence interval: 14.8-25.9) had speech difficulty after thalamotomy. Speech difficulty occurred in 15% (confidence interval: 9.8-22.2) of those treated with a unilaterally and 40.6% (confidence interval: 29.5-52.8) of those treated bilaterally. Speech impairment was noticed 2- to 3-fold more commonly after left-sided procedures (40.7% vs. 15.2%). Of the 572 patients that underwent DBS, 19.4% (confidence interval: 13.1-27.8) experienced speech difficulty. Subgroup analysis revealed that this complication occurs in 10.2% (confidence interval: 7.4-13.9) of patients treated unilaterally and 34.6% (confidence interval: 21.6-50.4) treated bilaterally. After thalamotomy, the risk was higher in Parkinson's patients compared to patients with essential tremor: 19.8% versus 4.5% in the unilateral group and 42.5% versus 13.9% in the bilateral group. After DBS, this rate was higher in essential tremor patients. CONCLUSION Both lesioning and stimulation thalamic surgery produce adverse effects on speech. Left-sided and bilateral procedures are approximately 3-fold more likely to cause speech difficulty. This effect was higher after thalamotomy compared to DBS. In the thalamotomy group, the risk was higher in Parkinson's patients, whereas in the DBS group it was higher in patients with essential tremor. Understanding the pathophysiology of speech disturbance after thalamic procedures is a priority. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Soha Alomar
- King Abdulaziz University, Department of Surgery, Division of Neurosurgery, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.,University of Toronto, Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Nicolas K K King
- University of Toronto, Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada.,Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Joseph Tam
- University of Toronto, Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Ausaf A Bari
- University of California Los Angeles, Department of Neurosurgery, Los Angeles, California, USA
| | - Clement Hamani
- University of Toronto, Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andres M Lozano
- University of Toronto, Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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Predictors of deep brain stimulation outcome in tremor patients. Brain Stimul 2018; 11:592-599. [PMID: 29330020 DOI: 10.1016/j.brs.2017.12.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/27/2017] [Accepted: 12/28/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Deep brain stimulation of the ventro-intermedius nucleus of the thalamus is an established treatment for tremor of differing etiologies but factors that may predict the short- and especially long-term outcome of surgery are still largely unknown. METHODS We retrospectively investigated the clinical, pharmacological, electrophysiological and anatomical features that might predict the initial response and preservation of benefit in all patients who underwent deep brain stimulation for tremor. Data were collected at the following time points: baseline (preoperative), one-year post-surgery, and most recent visit. Tremor severity was recorded using the Fahn-Tolosa-Marin Tremor Rating Scale and/or the Unified Parkinson's Disease Rating Scale. RESULTS A total of 52 patients were included in the final analysis: 31 with essential tremor, 15 with cerebellar tremor of different etiologies, and 6 with Parkinson's disease. Long-term success (mean follow-up duration 34.7 months, range 1.7-121.1 months) was reported in 63.5%. Predictors of long-term benefit were: underlying tremor etiology (best outcome in Parkinson's disease, worst outcome in cerebellar tremor); age at surgery (the older the better); baseline tremor severity (the greater the better); lack of response to benzodiazepines; a more anterior electrode placement and single-unit beta power (the greater the better). CONCLUSIONS Specific patients' features (including single unit beta activity) and electrode locations may predict the short- and long-term benefit of thalamic stimulation for tremor. Future prospective studies enrolling a much larger sample of patients are needed to substantiate the associations detected by this retrospective study.
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Raju SS, Niranjan A, Monaco III EA, Flickinger JC, Lunsford LD. Stereotactic Radiosurgery for Intractable Tremor-Dominant Parkinson Disease: A Retrospective Analysis. Stereotact Funct Neurosurg 2017; 95:291-297. [DOI: 10.1159/000479236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 07/06/2017] [Indexed: 11/19/2022]
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Cury RG, Fraix V, Castrioto A, Pérez Fernández MA, Krack P, Chabardes S, Seigneuret E, Alho EJL, Benabid AL, Moro E. Thalamic deep brain stimulation for tremor in Parkinson disease, essential tremor, and dystonia. Neurology 2017; 89:1416-1423. [PMID: 28768840 DOI: 10.1212/wnl.0000000000004295] [Citation(s) in RCA: 153] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/05/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To report on the long-term outcomes of deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (VIM) in Parkinson disease (PD), essential tremor (ET), and dystonic tremor. METHODS One hundred fifty-nine patients with PD, ET, and dystonia underwent VIM DBS due to refractory tremor at the Grenoble University Hospital. The primary outcome was a change in the tremor scores at 1 year after surgery and at the latest follow-up (21 years). Secondary outcomes included the relationship between tremor score reduction over time and the active contact position. Tremor scores (Unified Parkinson's Disease Rating Scale-III, items 20 and 21; Fahn, Tolosa, Marin Tremor Rating Scale) and the coordinates of the active contacts were recorded. RESULTS Ninety-eight patients were included. Patients with PD and ET had sustained improvement in tremor with VIM stimulation (mean improvement, 70% and 66% at 1 year; 63% and 48% beyond 10 years, respectively; p < 0.05). There was no significant loss of stimulation benefit over time (p > 0.05). Patients with dystonia exhibited a moderate response at 1-year follow-up (41% tremor improvement, p = 0.027), which was not sustained after 5 years (30% improvement, p = 0.109). The more dorsal active contacts' coordinates in the right lead were related to a better outcome 1 year after surgery (p = 0.029). During the whole follow-up, forty-eight patients (49%) experienced minor side effects, whereas 2 (2.0%) had serious events (brain hemorrhage and infection). CONCLUSIONS VIM DBS is an effective long-term (beyond 10 years) treatment for tremor in PD and ET. Effects on dystonic tremor were modest and transient. CLASSIFICATION OF EVIDENCE This provides Class IV evidence. It is an observational study.
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Affiliation(s)
- Rubens Gisbert Cury
- From the Service de Neurologie (R.G.C., V.F., A.C., M.A.P.F., E.M.), Service de Neurochirurgie (M.A.P.F., E.S.), Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U1216, Grenoble, France; Department of Neurology (R.G.C., M.A.P.F., E.J.L.A.), School of Medicine, University of São Paulo, São Paulo, Brazil; Hospital Dr. Dario Contreras (M.A.P.F.), Santo Domingo, Republica Dominicana; Service de Neurologie (P.K., S.C.), CHU de Genève, Switzerland; and Clinatec (A.-L.B.), Centre Hospitalier Universitaire de Grenoble, France
| | - Valerie Fraix
- From the Service de Neurologie (R.G.C., V.F., A.C., M.A.P.F., E.M.), Service de Neurochirurgie (M.A.P.F., E.S.), Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U1216, Grenoble, France; Department of Neurology (R.G.C., M.A.P.F., E.J.L.A.), School of Medicine, University of São Paulo, São Paulo, Brazil; Hospital Dr. Dario Contreras (M.A.P.F.), Santo Domingo, Republica Dominicana; Service de Neurologie (P.K., S.C.), CHU de Genève, Switzerland; and Clinatec (A.-L.B.), Centre Hospitalier Universitaire de Grenoble, France
| | - Anna Castrioto
- From the Service de Neurologie (R.G.C., V.F., A.C., M.A.P.F., E.M.), Service de Neurochirurgie (M.A.P.F., E.S.), Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U1216, Grenoble, France; Department of Neurology (R.G.C., M.A.P.F., E.J.L.A.), School of Medicine, University of São Paulo, São Paulo, Brazil; Hospital Dr. Dario Contreras (M.A.P.F.), Santo Domingo, Republica Dominicana; Service de Neurologie (P.K., S.C.), CHU de Genève, Switzerland; and Clinatec (A.-L.B.), Centre Hospitalier Universitaire de Grenoble, France
| | - Maricely Ambar Pérez Fernández
- From the Service de Neurologie (R.G.C., V.F., A.C., M.A.P.F., E.M.), Service de Neurochirurgie (M.A.P.F., E.S.), Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U1216, Grenoble, France; Department of Neurology (R.G.C., M.A.P.F., E.J.L.A.), School of Medicine, University of São Paulo, São Paulo, Brazil; Hospital Dr. Dario Contreras (M.A.P.F.), Santo Domingo, Republica Dominicana; Service de Neurologie (P.K., S.C.), CHU de Genève, Switzerland; and Clinatec (A.-L.B.), Centre Hospitalier Universitaire de Grenoble, France
| | - Paul Krack
- From the Service de Neurologie (R.G.C., V.F., A.C., M.A.P.F., E.M.), Service de Neurochirurgie (M.A.P.F., E.S.), Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U1216, Grenoble, France; Department of Neurology (R.G.C., M.A.P.F., E.J.L.A.), School of Medicine, University of São Paulo, São Paulo, Brazil; Hospital Dr. Dario Contreras (M.A.P.F.), Santo Domingo, Republica Dominicana; Service de Neurologie (P.K., S.C.), CHU de Genève, Switzerland; and Clinatec (A.-L.B.), Centre Hospitalier Universitaire de Grenoble, France
| | - Stephan Chabardes
- From the Service de Neurologie (R.G.C., V.F., A.C., M.A.P.F., E.M.), Service de Neurochirurgie (M.A.P.F., E.S.), Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U1216, Grenoble, France; Department of Neurology (R.G.C., M.A.P.F., E.J.L.A.), School of Medicine, University of São Paulo, São Paulo, Brazil; Hospital Dr. Dario Contreras (M.A.P.F.), Santo Domingo, Republica Dominicana; Service de Neurologie (P.K., S.C.), CHU de Genève, Switzerland; and Clinatec (A.-L.B.), Centre Hospitalier Universitaire de Grenoble, France
| | - Eric Seigneuret
- From the Service de Neurologie (R.G.C., V.F., A.C., M.A.P.F., E.M.), Service de Neurochirurgie (M.A.P.F., E.S.), Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U1216, Grenoble, France; Department of Neurology (R.G.C., M.A.P.F., E.J.L.A.), School of Medicine, University of São Paulo, São Paulo, Brazil; Hospital Dr. Dario Contreras (M.A.P.F.), Santo Domingo, Republica Dominicana; Service de Neurologie (P.K., S.C.), CHU de Genève, Switzerland; and Clinatec (A.-L.B.), Centre Hospitalier Universitaire de Grenoble, France
| | - Eduardo Joaquim Lopes Alho
- From the Service de Neurologie (R.G.C., V.F., A.C., M.A.P.F., E.M.), Service de Neurochirurgie (M.A.P.F., E.S.), Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U1216, Grenoble, France; Department of Neurology (R.G.C., M.A.P.F., E.J.L.A.), School of Medicine, University of São Paulo, São Paulo, Brazil; Hospital Dr. Dario Contreras (M.A.P.F.), Santo Domingo, Republica Dominicana; Service de Neurologie (P.K., S.C.), CHU de Genève, Switzerland; and Clinatec (A.-L.B.), Centre Hospitalier Universitaire de Grenoble, France
| | - Alim-Louis Benabid
- From the Service de Neurologie (R.G.C., V.F., A.C., M.A.P.F., E.M.), Service de Neurochirurgie (M.A.P.F., E.S.), Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U1216, Grenoble, France; Department of Neurology (R.G.C., M.A.P.F., E.J.L.A.), School of Medicine, University of São Paulo, São Paulo, Brazil; Hospital Dr. Dario Contreras (M.A.P.F.), Santo Domingo, Republica Dominicana; Service de Neurologie (P.K., S.C.), CHU de Genève, Switzerland; and Clinatec (A.-L.B.), Centre Hospitalier Universitaire de Grenoble, France
| | - Elena Moro
- From the Service de Neurologie (R.G.C., V.F., A.C., M.A.P.F., E.M.), Service de Neurochirurgie (M.A.P.F., E.S.), Centre Hospitalier Universitaire de Grenoble, Université Grenoble Alpes, INSERM U1216, Grenoble, France; Department of Neurology (R.G.C., M.A.P.F., E.J.L.A.), School of Medicine, University of São Paulo, São Paulo, Brazil; Hospital Dr. Dario Contreras (M.A.P.F.), Santo Domingo, Republica Dominicana; Service de Neurologie (P.K., S.C.), CHU de Genève, Switzerland; and Clinatec (A.-L.B.), Centre Hospitalier Universitaire de Grenoble, France.
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Buhmann C, Huckhagel T, Engel K, Gulberti A, Hidding U, Poetter-Nerger M, Goerendt I, Ludewig P, Braass H, Choe CU, Krajewski K, Oehlwein C, Mittmann K, Engel AK, Gerloff C, Westphal M, Köppen JA, Moll CKE, Hamel W. Adverse events in deep brain stimulation: A retrospective long-term analysis of neurological, psychiatric and other occurrences. PLoS One 2017; 12:e0178984. [PMID: 28678830 PMCID: PMC5497949 DOI: 10.1371/journal.pone.0178984] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 05/22/2017] [Indexed: 11/18/2022] Open
Abstract
Background and objective The extent to which deep brain stimulation (DBS) can improve quality of life may be perceived as a permanent trade-off between neurological improvements and complications of therapy, comorbidities, and disease progression. Patients and methods We retrospectively investigated 123 consecutive and non-preselected patients. Indications for DBS surgery were Parkinson's disease (82), dystonia (18), tremor of different etiology (21), Huntington's disease (1) and Gilles de la Tourette syndrome (1). AEs were defined as any untoward clinical occurrence, sign or patient complaint or unintended disease if related or unrelated to the surgical procedures, implanted devices or ongoing DBS therapy. Results Over a mean/median follow-up period of 4.7 years (578 patient-years) 433 AEs were recorded in 106 of 123 patients (86.2%). There was no mortality or persistent morbidity from the surgical procedure. All serious adverse events (SAEs) that occurred within 4 weeks of surgery were reversible. Neurological AEs (193 in 85 patients) and psychiatric AEs (78 in 48 patients) were documented most frequently. AEs in 4 patients (suicide under GPI stimulation, weight gain >20 kg, impairment of gait and speech, cognitive decline >2 years following surgery) were severe or worse, at least possibly related to DBS and non reversible. In PD 23.1% of the STN-stimulated patients experienced non-reversible (or unknown reversibility) AEs that were at least possibly related to DBS in the form of impaired speech or gait, depression, weight gain, cognitive disturbances or urinary incontinence (severity was mild or moderate in 15 of 18 patients). Age and Hoehn&Yahr stage of STN-simulated PD patients, but not preoperative motor impairment or response to levodopa, showed a weak correlation (r = 0.24 and 0.22, respectively) with the number of AEs. Conclusions DBS-related AEs that were severe or worse and non-reversible were only observed in PD (4 of 82 patients; 4.9%), but not in other diseases. PD patients exhibited a significant risk for non-severe AEs most of which also represented preexisting and progressive axial and non-motor symptoms of PD. Mild gait and/or speech disturbances were rather frequent complaints under VIM stimulation. GPI stimulation for dystonia could be applied with negligible DBS-related side effects.
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Affiliation(s)
- Carsten Buhmann
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Torge Huckhagel
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Katja Engel
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Alessandro Gulberti
- Institut für Neurophysiologie und Pathophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Ute Hidding
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Ines Goerendt
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Ludewig
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Hanna Braass
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Chi-un Choe
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Kara Krajewski
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | | | - Andreas K. Engel
- Institut für Neurophysiologie und Pathophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Klinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Manfred Westphal
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes A. Köppen
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Christian K. E. Moll
- Institut für Neurophysiologie und Pathophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Wolfgang Hamel
- Klinik für Neurochirurgie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
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Cossu G, Sensi M. Deep Brain Stimulation Emergencies: How the New Technologies Could Modify the Current Scenario. Curr Neurol Neurosci Rep 2017; 17:51. [PMID: 28497305 DOI: 10.1007/s11910-017-0761-y] [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] [Indexed: 12/22/2022]
Abstract
After 25 years of deep brain stimulation (DBS) for the treatment of Parkinson's disease, it has become increasingly recognized that a range of postoperative urgent situations and emergencies may occur. In this review we describe the possible scenarios of DBS-related emergencies: perioperative (intraoperative and early postoperative) and postoperative settings and issues from suboptimal control of motor and nonmotor symptoms in the early programming phase and during long-term follow-up. We also outline potential advantages in the management of these emergencies offered by the newest devices, emerging technologies, and new possibilities in programming.
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Affiliation(s)
- Giovanni Cossu
- Movement Disorders Unit, Department of Neurology, Brotzu General Hospital, Piazzale Ricchi 1, 09134, Cagliari, Italy.
| | - Mariachiara Sensi
- Department of Neurology, Azienda Ospedaliera Universitaria Arcispedale Sant'Anna, Ferrara, Italy
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Niranjan A, Raju SS, Kooshkabadi A, Monaco E, Flickinger JC, Lunsford LD. Stereotactic radiosurgery for essential tremor: Retrospective analysis of a 19-year experience. Mov Disord 2017; 32:769-777. [PMID: 28319282 DOI: 10.1002/mds.26925] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 11/29/2016] [Accepted: 12/23/2016] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Essential Tremor (ET) is a common movement disorder that can be disabling. Initial treatment is in the form of medical therapies. Patients with medically refractory ET seek surgical intervention which include radiofrequency thalamotomy, deep brain stimulation, and radiosurgical thalamotomy. Radiosurgical thalamotomy is a minimally invasive surgical option which is especially valuable for elderly and high surgical risk patients. OBJECTIVE The purpose of this study was to retrospectively analyze the outcomes of stereotactic radiosurgery for patients suffering from medically refractory essential tremor. METHODS During a 19-year period (1996-2015), 73 patients underwent gamma knife thalamotomy for intractable essential tremor. A median central dose of 140 Gy (range, 130-150) was delivered to the nucleus ventralis intermedius through a single 4-mm isocenter. We used the Fahn-Tolosa-Marin clinical tremor rating scale to score tremor, handwriting, drawing, and ability to drink fluids. The median time to last follow-up was 28 months (range, 6-152). RESULTS After gamma knife thalamotomy, 93.2% improved in tremor. Forty-four patients (60.3%) experienced tremor arrest or barely perceptible tremor. Eighteen patients (24.7%) noted tremor arrest and complete restoration of motor function. Tremor improvement was sustained at last follow-up in 96% of patients who experience tremor relief. Mean tremor score improved from 3.19 before to 1.27 after gamma knife thalamotomy (P < 0.0001). Mean handwriting score improved from 2.97 to 1.25 (P < 0.0001). Mean drawing score improved from 3.16 to 1.26 (P < 0.0001). Mean drinking score improved from 3.14 to 1.56 (P < 0.0001). Imaging follow-up showed three types of lesions: enhancing lesion, streaking along internal capsule on fluid-attenuated inversion recovery, and significant reactive changes. Three patients (4%) experienced temporary adverse radiation effects. CONCLUSION Radiosurgery is a safe and valuable treatment option for medically refractory essential tremor, especially for the elderly or those with high surgical risk for DBS or radiofrequency thalamotomy. © 2017 International Parkinson and Movement Disorder Society.
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Affiliation(s)
- Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sudesh S Raju
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ali Kooshkabadi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Edward Monaco
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John C Flickinger
- Department of Radiation Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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45
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Zrinzo L. Thalamotomy using MRI-guided focused ultrasound significantly improves contralateral symptoms and quality of life in essential tremor. EVIDENCE-BASED MEDICINE 2017; 22:64. [PMID: 28242608 DOI: 10.1136/ebmed-2016-110589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
The year 2017 marks the 30th anniversary of the birth of modern deep brain stimulation (DBS), which was introduced by Benabid, Pollak et al. in 1987, initially targeting the motor thalamus to treat tremor, and subsequently targeting the subthalamic nucleus (STN) for treatment of symptoms of advanced Parkinson's disease (PD). STN DBS is undoubtedly "the most important discovery since levodopa", as stated by David Marsden in 1994. In 2014, The Lasker- DeBakey Clinical Medical Research Award to "honor two scientists who developed deep brain stimulation of the subthalamic nucleus", was bestowed upon Benabid and DeLong. STN DBS remains today the main surgical procedure for PD, due to its effectiveness in ameliorating PD symptoms and because it is the only surgical procedure for PD that allows a radical decrease in medication. Future improvements of DBS include the possibility to deliver a "closed-loop", "on demand" stimulation, as highly preliminary studies suggest that it may improve both axial and appendicular symptoms and reduce side effects such as dysarthria. Even though DBS of the subthalamic nucleus is the main surgical procedure used today for patients with PD, all patients are not suitable for STN DBS; as a functional neurosurgeon performing since more than 25 years various surgical procedures the aim of which is not to save life but to improve the patient's quality of life, I consider that the surgery should be tailored to the patient's individual symptoms and needs, and that its safety is paramount.
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Affiliation(s)
- Marwan Hariz
- Simon Sainsbury Chair of Functional Neurosurgery, Unit of Functional Neurosurgery, UCL-Institute of Neurology, Queen Square, London, UK
- Department of Clinical Neuroscience, Stereotactic Surgery, Umeå University, Umeå, Sweden
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47
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Establishing a Standard of Care for Deep Brain Stimulation Centers in Canada. Can J Neurol Sci 2016; 44:132-138. [PMID: 27873569 DOI: 10.1017/cjn.2016.409] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractDuring the “DBS Canada Day” symposium held in Toronto July 4-5, 2014, the scientific committee invited experts to share their knowledge regarding deep brain stimulation (DBS) management of movement disorders in three domains: (1) the programming algorithms, (2) the necessary team to run a neurosurgery program, and (3) the appropriate scales to better define in a more comprehensive fashion the effect of the brain surgery. Each presentation was followed by an open discussion, and this article reports on the conclusions of this meeting on these three questions. Concerning programming, the role of the pulse width and the switching off of the stimulation at night for thalamic stimulation for the control of tremor have been discussed. The algorithms proposed in the literature for programming in Parkinson’s disease (PD) need validation. In dystonia, the use of monopolar vs bipolar parameters, the use of low vs high frequencies and the use of smaller versus larger pulse widths all need to be examined properly. Concerning the necessary team to run a neurosurgical program, recommendations will follow the suggestions for standardized outcome measures. Regarding the outcome measures for DBS in PD, investigations need to focus on the non-motor aspects of PD. Identifying which nonmotor symptoms respond to DBS would allow a better screening before and satisfaction postoperatively. There is an important need for more data to determine the optimal programming protocol and the standard measures that should be performed routinely by all centers.
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48
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Picillo M, Lozano AM, Kou N, Munhoz RP, Fasano A. Programming Deep Brain Stimulation for Tremor and Dystonia: The Toronto Western Hospital Algorithms. Brain Stimul 2016; 9:438-452. [DOI: 10.1016/j.brs.2016.02.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 01/02/2016] [Accepted: 02/03/2016] [Indexed: 10/22/2022] Open
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49
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Chandran AS, Joshi S, Thorburn M, Stell R, Lind CRP. Dystonic tics induced by deep brain stimulation of the posterior subthalamic area for essential tremor. J Neurosurg 2016; 126:386-390. [PMID: 27128590 DOI: 10.3171/2015.12.jns15915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The posterior subthalamic area (PSA) is a promising target of deep brain stimulation (DBS) for medication-refractory essential tremor (ET). This case series describes a novel adverse effect manifesting as dystonic tics in patients with ET undergoing DBS of the PSA. METHODS Six patients with ET received electrode implants for DBS of the dorsal and caudal zona incerta subregions of the PSA. RESULTS Five of the 6 patients developed dystonic tics soon after clinical programming. These tics were of varying severity and required reduction of the electrical stimulation amplitude. This reduction resolved tic occurrence without significantly affecting ET control. Dystonic tics were not observed in 39 additional patients who underwent DBS of the same brain regions for controlling non-ET movement disorders. CONCLUSIONS The pathophysiology of tic disorders is poorly understood and may involve the basal ganglia and related cortico-striato-thalamo-cortical circuits. This series is the first report of DBS-induced tics after stimulation of any brain target. Although the PSA has not previously been implicated in tic pathophysiology, it may be a candidate region for future studies.
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Affiliation(s)
| | - Stuti Joshi
- Department of Neurology, Sir Charles Gairdner Hospital
| | - Megan Thorburn
- Neurosurgical Service of Western Australia and.,Department of Neurology, Sir Charles Gairdner Hospital
| | - Rick Stell
- Department of Neurology, Sir Charles Gairdner Hospital.,Western Australian Neuroscience Research Institute; and
| | - Christopher R P Lind
- Neurosurgical Service of Western Australia and.,School of Surgery, University of Western Australia, Perth, Australia
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50
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Rodríguez Cruz PM, Vargas A, Fernández-Carballal C, Garbizu J, De La Casa-Fages B, Grandas F. Long-term Thalamic Deep Brain Stimulation for Essential Tremor: Clinical Outcome and Stimulation Parameters. Mov Disord Clin Pract 2016; 3:567-572. [PMID: 30363558 DOI: 10.1002/mdc3.12337] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/25/2015] [Accepted: 01/04/2016] [Indexed: 11/09/2022] Open
Abstract
Background The reasons underlying the loss of efficacy of deep brain stimulation (DBS) of the thalamic nucleus ventralis intermedius (VIM-DBS) over time in patients with essential tremor are not well understood. Methods Long-term clinical outcome and stimulation parameters were evaluated in 14 patients with essential tremor who underwent VIM-DBS. The mean ± standard deviation postoperative follow-up was 7.7 ± 3.8 years. At each visit (every 3-6 months), tremor was assessed using the Fahn-Tolosa-Marin tremor rating scale (FTM-TRS) and stimulation parameters were recorded (contacts, voltage, frequency, pulse width, and total electrical energy delivered by the internal generator [TEED 1sec]). Results The mean reduction in FTM-TRS score was 73.4% at 6 months after VIM-DBS surgery (P < 0.001) and 50.1% at the last visit (P < 0.001). The gradual worsening of FTM-TRS scores over time fit a linear regression model (coefficient of determination [R2] = 0.887; P < 0.001). Stimulation adjustments to optimize tremor control required a statistically significant increase in voltage (P = 0.01), pulse width (P = 0.01), frequency (P = 0.02), and TEED 1sec (P = 0.008). TEED 1sec fit a third-order polynomial curve model throughout the follow-up period (R2 = 0.966; P < 0.001). The initial exponential increase (first 4 years of VIM-DBS) was followed by a plateau and a further increase from the seventh year onward. Conclusions The current findings suggest that the waning effect of VIM-DBS over time in patients with essential tremor may be the consequence of a combination of factors. Superimposed on the progression of the disease, tolerance can occur during the early years of stimulation.
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Affiliation(s)
- Pedro M Rodríguez Cruz
- Movement Disorders Deep Brain Stimulation Group Hospital General Universitario Gregorio Marañón Madrid Spain
| | - Antonio Vargas
- Movement Disorders Deep Brain Stimulation Group Hospital General Universitario Gregorio Marañón Madrid Spain
| | - Carlos Fernández-Carballal
- Movement Disorders Deep Brain Stimulation Group Hospital General Universitario Gregorio Marañón Madrid Spain
| | - Jose Garbizu
- Movement Disorders Deep Brain Stimulation Group Hospital General Universitario Gregorio Marañón Madrid Spain
| | - Beatriz De La Casa-Fages
- Movement Disorders Deep Brain Stimulation Group Hospital General Universitario Gregorio Marañón Madrid Spain
| | - Francisco Grandas
- Movement Disorders Deep Brain Stimulation Group Hospital General Universitario Gregorio Marañón Madrid Spain
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