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Faingold CL, Feng HJ. A unified hypothesis of SUDEP: Seizure-induced respiratory depression induced by adenosine may lead to SUDEP but can be prevented by autoresuscitation and other restorative respiratory response mechanisms mediated by the action of serotonin on the periaqueductal gray. Epilepsia 2023; 64:779-796. [PMID: 36715572 PMCID: PMC10673689 DOI: 10.1111/epi.17521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/20/2023] [Accepted: 01/27/2023] [Indexed: 01/31/2023]
Abstract
Sudden unexpected death in epilepsy (SUDEP) is a major cause of death in people with epilepsy (PWE). Postictal apnea leading to cardiac arrest is the most common sequence of terminal events in witnessed cases of SUDEP, and postconvulsive central apnea has been proposed as a potential biomarker of SUDEP susceptibility. Research in SUDEP animal models has led to the serotonin and adenosine hypotheses of SUDEP. These neurotransmitters influence respiration, seizures, and lethality in animal models of SUDEP, and are implicated in human SUDEP cases. Adenosine released during seizures is proposed to be an important seizure termination mechanism. However, adenosine also depresses respiration, and this effect is mediated, in part, by inhibition of neuronal activity in subcortical structures that modulate respiration, including the periaqueductal gray (PAG). Drugs that enhance the action of adenosine increase postictal death in SUDEP models. Serotonin is also released during seizures, but enhances respiration in response to an elevated carbon dioxide level, which often occurs postictally. This effect of serotonin can potentially compensate, in part, for the adenosine-mediated respiratory depression, acting to facilitate autoresuscitation and other restorative respiratory response mechanisms. A number of drugs that enhance the action of serotonin prevent postictal death in several SUDEP models and reduce postictal respiratory depression in PWE. This effect of serotonergic drugs may be mediated, in part, by actions on brainstem sites that modulate respiration, including the PAG. Enhanced activity in the PAG increases respiration in response to hypoxia and other exigent conditions and can be activated by electrical stimulation. Thus, we propose the unifying hypothesis that seizure-induced adenosine release leads to respiratory depression. This can be reversed by serotonergic action on autoresuscitation and other restorative respiratory responses acting, in part, via the PAG. Therefore, we hypothesize that serotonergic or direct activation of this brainstem site may be a useful approach for SUDEP prevention.
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Affiliation(s)
- Carl L Faingold
- Department of Pharmacology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
- Department of Neurology, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Hua-Jun Feng
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
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2
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Elias GJB, Loh A, Gwun D, Pancholi A, Boutet A, Neudorfer C, Germann J, Namasivayam A, Gramer R, Paff M, Lozano AM. Deep brain stimulation of the brainstem. Brain 2021; 144:712-723. [PMID: 33313788 DOI: 10.1093/brain/awaa374] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 07/31/2020] [Accepted: 08/17/2020] [Indexed: 01/02/2023] Open
Abstract
Deep brain stimulation (DBS) of the subthalamic nucleus, pallidum, and thalamus is an established therapy for various movement disorders. Limbic targets have also been increasingly explored for their application to neuropsychiatric and cognitive disorders. The brainstem constitutes another DBS substrate, although the existing literature on the indications for and the effects of brainstem stimulation remains comparatively sparse. The objective of this review was to provide a comprehensive overview of the pertinent anatomy, indications, and reported stimulation-induced acute and long-term effects of existing white and grey matter brainstem DBS targets. We systematically searched the published literature, reviewing clinical trial articles pertaining to DBS brainstem targets. Overall, 164 studies describing brainstem DBS were identified. These studies encompassed 10 discrete structures: periaqueductal/periventricular grey (n = 63), pedunculopontine nucleus (n = 48), ventral tegmental area (n = 22), substantia nigra (n = 9), mesencephalic reticular formation (n = 7), medial forebrain bundle (n = 8), superior cerebellar peduncles (n = 3), red nucleus (n = 3), parabrachial complex (n = 2), and locus coeruleus (n = 1). Indications for brainstem DBS varied widely and included central neuropathic pain, axial symptoms of movement disorders, headache, depression, and vegetative state. The most promising results for brainstem DBS have come from targeting the pedunculopontine nucleus for relief of axial motor deficits, periaqueductal/periventricular grey for the management of central neuropathic pain, and ventral tegmental area for treatment of cluster headaches. Brainstem DBS has also acutely elicited numerous motor, limbic, and autonomic effects. Further work involving larger, controlled trials is necessary to better establish the therapeutic potential of DBS in this complex area.
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Affiliation(s)
- Gavin J B Elias
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Aaron Loh
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Dave Gwun
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Aditya Pancholi
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Alexandre Boutet
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada.,Joint Department of Medical Imaging, University of Toronto, Toronto, Canada
| | - Clemens Neudorfer
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Jürgen Germann
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Andrew Namasivayam
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Robert Gramer
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Michelle Paff
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
| | - Andres M Lozano
- Division of Neurosurgery, Department of Surgery, University Health Network and University of Toronto, Toronto, Canada
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3
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Dyspnea after subthalamic deep brain stimulation in Parkinson's disease: a case-control study. J Neurol 2020; 267:3054-3060. [PMID: 32524258 DOI: 10.1007/s00415-020-09976-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Dyspnea can be present as non-motor symptom in patients with Parkinson's disease (PD). Deep brain stimulation (DBS) of the subthalamic nucleus (STN) improves motor and non-motor symptoms in PD. However, new-onset dyspnea has been reported after DBS surgery. We have studied respiratory characteristics of PD patients with bilateral STN-DBS to assess the impact of DBS on pulmonary function. METHODS STN-DBS PD patients with dyspnea after surgery (cases) were matched with STN-DBS PD patients without dyspnea (controls). Motor and pulmonary function were assessed with stimulation and without medication (on stim/off med), and without stimulation and medication (off stim/off med). Pulmonary function was investigated with spirometry and dyspnea with the Medical Research Council Dyspnea Scale (MRCDS) and the Borg Scale (BS). RESULTS Seven cases (five men, 58.30 ± 6.70 years of age) and seven controls (six men, 61.10 ± 6.30 years of age) were enrolled. MRCDS and BS revealed the presence of dyspnea in both groups. No significant changes in pulmonary function were found in both cases and controls in on stim/off med vs. off stim/off med condition (p < 0.05), and in cases vs. controls in on stim/ off med condition (p < 0.05). CONCLUSIONS No impact of STN-DBS on pulmonary function was found in cases. Impaired perception of dyspnea and spread of stimulation surrounding the STN might account for new-onset dyspnea after DBS surgery. Dyspnea was detected also in controls using ad hoc questionnaires. Our findings suggest further investigation of this non-motor symptom in PD patients.
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Bellini G, Best LA, Brechany U, Mills R, Pavese N. Clinical Impact of Deep Brain Stimulation on the Autonomic System in Patients with Parkinson's Disease. Mov Disord Clin Pract 2020; 7:373-382. [PMID: 32373653 DOI: 10.1002/mdc3.12938] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 02/26/2020] [Accepted: 03/08/2020] [Indexed: 12/14/2022] Open
Abstract
Background The role of deep brain stimulation (DBS) in the management of motor symptoms in patients with Parkinson's disease is well defined. However, it is becoming increasingly clear that DBS can either improve or worsen a number of non-motor phenomena. Objectives We examined the published literature to better understand the effects on autonomic symptoms following DBS of the subthalamic nucleus and the globus pallidus interna. Methods We conducted a PubMed search of studies regarding the effects of DBS on the autonomic system published from January 2001. We searched for the following terms and their combinations: Parkinson's disease, deep brain stimulation, subthalamic nucleus, globus pallidus interna, autonomic dysfunction. Results Most studies reported in the literature focus on DBS targeting the subthalamic nucleus, with particular emphasis on favorable outcomes regarding gastrointestinal function and bladder control. However, the emergence or worsening of autonomic symptoms in subgroups of patients has also been documented. More controversial is the effect of stimulation on the cardiovascular, pulmonary, and thermo-regulatory systems as well as sexual functioning. Data regarding the influence of DBS on the autonomic system when the target is the globus pallidus interna is less forthcoming, with target selection varying according to centre and clinical indication. Conclusions DBS appears to affect the autonomic nervous system, with varying degrees of influence, which may or may not be clinically beneficial for the patient. A better understanding of these effects could help personalize stimulation for individual patients with autonomic disorders and/or avoid autonomic symptoms in susceptible patients.
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Affiliation(s)
- Gabriele Bellini
- Clinical Ageing Research Centre Newcastle University Newcastle Upon Tyne United Kingdom
| | - Laura A Best
- Clinical Ageing Research Centre Newcastle University Newcastle Upon Tyne United Kingdom
| | - Una Brechany
- Newcastle Upon Tyne Hospitals NHS Foundation Trust Newcastle Upon Tyne United Kingdom
| | - Russell Mills
- Newcastle Upon Tyne Hospitals NHS Foundation Trust Newcastle Upon Tyne United Kingdom
| | - Nicola Pavese
- Clinical Ageing Research Centre Newcastle University Newcastle Upon Tyne United Kingdom.,Department of Nuclear Medicine and PET Centre Aarhus University Hospital Aarhus Denmark
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Farrell SM, Green A, Aziz T. The Use of Neuromodulation for Symptom Management. Brain Sci 2019; 9:brainsci9090232. [PMID: 31547392 PMCID: PMC6769574 DOI: 10.3390/brainsci9090232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 09/07/2019] [Accepted: 09/09/2019] [Indexed: 01/23/2023] Open
Abstract
Pain and other symptoms of autonomic dysregulation such as hypertension, dyspnoea and bladder instability can lead to intractable suffering. Incorporation of neuromodulation into symptom management, including palliative care treatment protocols, is becoming a viable option scientifically, ethically, and economically in order to relieve suffering. It provides further opportunity for symptom control that cannot otherwise be provided by pharmacology and other conventional methods.
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Affiliation(s)
- Sarah Marie Farrell
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK.
| | - Alexander Green
- Nuffield department of clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK.
| | - Tipu Aziz
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK.
- Nuffield department of clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford OX3 9DU, UK.
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Hyam JA, Wang S, Roy H, Moosavi SH, Martin SC, Brittain JS, Coyne T, Silburn P, Aziz TZ, Green AL. The pedunculopontine region and breathing in Parkinson's disease. Ann Clin Transl Neurol 2019; 6:837-847. [PMID: 31139681 PMCID: PMC6529926 DOI: 10.1002/acn3.752] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 01/11/2019] [Indexed: 01/02/2023] Open
Abstract
Objective Respiratory abnormalities such as upper airway obstruction are common in Parkinson's disease (PD) and are an important cause of mortality and morbidity. We tested the effect of pedunculopontine region (PPNr) stimulation on respiratory maneuvers in human participants with PD, and separately recorded PPNr neural activity reflected in the local field potential (LFP) during these maneuvers. Methods Nine patients with deep brain stimulation electrodes in PPNr, and seven in globus pallidus interna (GPi) were studied during trials of maximal inspiration followed by forced expiration with stimulation OFF and ON. Local field potentials (LFPs) were recorded in the unstimulated condition. Results PEFR increased from 6.41 ± 0.63 L/sec in the OFF stimulation state to 7.5 L ± 0.65 L/sec in the ON stimulation state (z = −2.666, df = 8, P = 0.024). Percentage improvement in PEFR was strongly correlated with proximity of the stimulated electrode contact to the mesencephalic locomotor region in the rostral PPN (r = 0.814, n = 9, P = 0.008). Mean PPNr LFP power increased within the alpha band (7–11 Hz) during forced respiratory maneuvers (1.63 ± 0.16 μV2/Hz) compared to resting breathing (0.77 ± 0.16 μV2/Hz; z = −2.197, df = 6, P = 0.028). No changes in alpha activity or spirometric indices were seen with GPi recording or stimulation. Percentage improvement in PEFR was strongly positively correlated with increase in alpha power (r = 0.653, n = 14 (7 PPNr patients recorded bilaterally), P = 0.0096). Interpretation PPNr stimulation in PD improves indices of upper airway function. Increased alpha‐band activity is seen within the PPNr during forced respiratory maneuvers. Our findings suggest a link between the PPNr and respiratory performance in PD.
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Affiliation(s)
- Jonathan A Hyam
- Department of Physiology, Anatomy & Genetics University of Oxford Oxford UK.,Department of Neurosurgery John Radcliffe Hospital Oxford UK.,Nuffield Department of Surgical Sciences University of Oxford Oxford UK
| | - Shouyan Wang
- Department of Physiology, Anatomy & Genetics University of Oxford Oxford UK
| | - Holly Roy
- Nuffield Department of Surgical Sciences University of Oxford Oxford UK
| | - Shakeeb H Moosavi
- Department of Biological and Medical Sciences Oxford Brookes University Headington, Oxford UK
| | - Sean C Martin
- Nuffield Department of Surgical Sciences University of Oxford Oxford UK
| | | | - Terry Coyne
- St Andrews and Wesley Hospitals Brisbane Australia
| | - Peter Silburn
- St Andrews and Wesley Hospitals Brisbane Australia.,Queensland Brain Institute University of Queensland Brisbane Australia
| | - Tipu Z Aziz
- Department of Physiology, Anatomy & Genetics University of Oxford Oxford UK.,Department of Neurosurgery John Radcliffe Hospital Oxford UK.,Nuffield Department of Surgical Sciences University of Oxford Oxford UK
| | - Alexander L Green
- Department of Physiology, Anatomy & Genetics University of Oxford Oxford UK.,Department of Neurosurgery John Radcliffe Hospital Oxford UK.,Nuffield Department of Surgical Sciences University of Oxford Oxford UK
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7
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Faull OK, Subramanian HH, Ezra M, Pattinson KTS. The midbrain periaqueductal gray as an integrative and interoceptive neural structure for breathing. Neurosci Biobehav Rev 2019; 98:135-144. [PMID: 30611797 DOI: 10.1016/j.neubiorev.2018.12.020] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/08/2018] [Accepted: 12/18/2018] [Indexed: 01/25/2023]
Abstract
The periaqueductal gray (PAG) plays a critical role in autonomic function and behavioural responses to threatening stimuli. Recent evidence has revealed the PAG's potential involvement in the perception of breathlessness, a highly threatening respiratory symptom. In this review, we outline the current evidence in animals and humans on the role of the PAG in respiratory control and in the perception of breathlessness. While recent work has unveiled dissociable brain activity within the lateral PAG during perception of breathlessness and ventrolateral PAG during conditioned anticipation in healthy humans, this is yet to be translated into diseases dominated by breathlessness symptomology, such as chronic obstructive pulmonary disease. Understanding how the sub-structures of the PAG differentially interact with interoceptive brain networks involved in the perception of breathlessness will help towards understanding discordant symptomology, and may reveal treatment targets for those debilitated by chronic and pervasive breathlessness.
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Affiliation(s)
- Olivia K Faull
- Translational Neuromodeling Unit, University of Zürich and ETH Zürich, Zürich, Switzerland; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | | | - Martyn Ezra
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kyle T S Pattinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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8
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Roy HA, Green AL, Aziz TZ. State of the Art: Novel Applications for Deep Brain Stimulation. Neuromodulation 2017; 21:126-134. [DOI: 10.1111/ner.12604] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/19/2017] [Accepted: 03/11/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Holly A. Roy
- Nuffield Department of Surgical Sciences; Oxford University; Oxford UK
- Neurosurgery Department; Oxford University Hospitals; Oxford UK
| | - Alexander L. Green
- Nuffield Department of Surgical Sciences; Oxford University; Oxford UK
- Neurosurgery Department; Oxford University Hospitals; Oxford UK
| | - Tipu Z. Aziz
- Nuffield Department of Surgical Sciences; Oxford University; Oxford UK
- Neurosurgery Department; Oxford University Hospitals; Oxford UK
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9
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Hogg E, Wertheimer J, Graner S, Tagliati M. Deep Brain Stimulation and Nonmotor Symptoms. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 134:1045-1089. [DOI: 10.1016/bs.irn.2017.05.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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10
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Basiago A, Binder DK. Effects of Deep Brain Stimulation on Autonomic Function. Brain Sci 2016; 6:brainsci6030033. [PMID: 27537920 PMCID: PMC5039462 DOI: 10.3390/brainsci6030033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/10/2016] [Accepted: 08/10/2016] [Indexed: 12/22/2022] Open
Abstract
Over the course of the development of deep brain stimulation (DBS) into a well-established therapy for Parkinson's disease, essential tremor, and dystonia, its utility as a potential treatment for autonomic dysfunction has emerged. Dysfunction of autonomic processes is common in neurological diseases. Depending on the specific target in the brain, DBS has been shown to raise or lower blood pressure, normalize the baroreflex, to alter the caliber of bronchioles, and eliminate hyperhidrosis, all through modulation of the sympathetic nervous system. It has also been shown to improve cortical control of the bladder, directly induce or inhibit the micturition reflex, and to improve deglutition and gastric emptying. In this review, we will attempt to summarize the relevant available studies describing these effects of DBS on autonomic function, which vary greatly in character and magnitude with respect to stimulation target.
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Affiliation(s)
- Adam Basiago
- School of Medicine, University of California, Riverside, CA 92521, USA.
| | - Devin K Binder
- Division of Biomedical Sciences, School of Medicine, University of California, 1247 Webber Hall, Riverside, CA 92521, USA.
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11
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Subramanian HH, Holstege G. Stimulation of the midbrain periaqueductal gray modulates preinspiratory neurons in the ventrolateral medulla in the rat in vivo. J Comp Neurol 2014; 521:3083-98. [PMID: 23630049 PMCID: PMC3761193 DOI: 10.1002/cne.23334] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 03/06/2013] [Accepted: 03/13/2013] [Indexed: 12/11/2022]
Abstract
The midbrain periaqueductal gray (PAG) is involved in many basic survival behaviors that affect respiration. We hypothesized that the PAG promotes these behaviors by changing the firing of preinspiratory (pre-I) neurons in the pre-Bötzinger complex, a cell group thought to be important in generating respiratory rhythm. We tested this hypothesis by recording single unit activity of pre-Bötzinger pre-I neurons during stimulation in different parts of the PAG. Stimulation in the dorsal PAG increased the firing of pre-I neurons, resulting in tachypnea. Stimulation in the medial part of the lateral PAG converted the pre-I neurons into inspiratory phase-spanning cells, resulting in inspiratory apneusis. Stimulation in the lateral part of the lateral PAG generated an early onset of the pre-I neuronal discharge, which continued throughout the inspiratory phase, while at the same time attenuating diaphragm contraction. Stimulation in the ventral part of the lateral PAG induced tachypnea but inhibited pre-I cell firing, whereas stimulation in the ventrolateral PAG inhibited not only pre-I cells but also the diaphragm, leading to apnea. These findings show that PAG stimulation changes the activity of the pre-Bötzinger pre-I neurons. These changes are in line with the different behaviors generated by the PAG, such as the dorsal PAG generating avoidance behavior, the lateral PAG generating fight and flight, and the ventrolateral PAG generating freezing and immobility. J. Comp. Neurol. 521: 3083–3098, 2013. © 2013 Wiley Periodicals, Inc.
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Affiliation(s)
- Hari H Subramanian
- The University of Queensland Centre for Clinical Research, Herston, Queensland, 4029, Australia
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12
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Chalif JI, Sitsapesan HA, Pattinson KTS, Herigstad M, Aziz TZ, Green AL. Dyspnea as a side effect of subthalamic nucleus deep brain stimulation for Parkinson's disease. Respir Physiol Neurobiol 2014; 192:128-33. [PMID: 24373841 DOI: 10.1016/j.resp.2013.12.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 11/18/2013] [Accepted: 12/17/2013] [Indexed: 01/10/2023]
Abstract
Bilateral subthalamic nucleus deep brain stimulation for Parkinson's disease improves limb function. Unpublished observations from our clinic noted that some subthalamic nucleus deep brain stimulation patients complain of post-operative dyspnea. Therefore, we designed a prospective, longitudinal study to characterize this in greater depth. We used specific questionnaires to assess dyspnea in patients with electrodes in the subthalamic nucleus (n=13) or ventral intermediate thalamus (n=7). St. George's Hospital Respiratory Questionnaire symptom subscale scores were greater in subthalamic nucleus patients (median=18.60, interquartile range=40.80) than ventral intermediate thalamus patients (median = 0.00, interquartile range=15.38) at greater than 6 months post-operatively (p<0.05). Several of the subthalamic nucleus patients exhibited functional impairments as judged by the St. George's Hospital Respiratory Questionnaire impact subscale, the Medical Research Council Dyspnoea Scale, and the Dyspnoea-12 Questionnaire. There was no correlation between limb function ratings, stimulation parameters, or precise electrode position and dyspnea severity. We have shown, for the first time, that dyspnea can be a side effect of subthalamic nucleus deep brain stimulation, and that this dyspnea may be highly disabling.
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Affiliation(s)
- Joshua I Chalif
- Nuffield Department of Surgical Sciences and Department of Neurosurgery University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK; MD-PhD Program, College of Physicians & Surgeons, Columbia University, 630 West 168th Street, P&S 11-511, New York, NY 10032, USA.
| | - Holly A Sitsapesan
- Nuffield Department of Surgical Sciences and Department of Neurosurgery University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
| | - Kyle T S Pattinson
- Nuffield Department of Clinical Neurosciences and FMRIB Centre University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
| | - Mari Herigstad
- Nuffield Department of Clinical Neurosciences and FMRIB Centre University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
| | - Tipu Z Aziz
- Nuffield Department of Surgical Sciences and Department of Neurosurgery University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
| | - Alexander L Green
- Nuffield Department of Surgical Sciences and Department of Neurosurgery University of Oxford, Level 3, West Wing, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, UK.
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13
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The midbrain periaqueductal gray changes the eupneic respiratory rhythm into a breathing pattern necessary for survival of the individual and of the species. PROGRESS IN BRAIN RESEARCH 2014; 212:351-84. [PMID: 25194206 DOI: 10.1016/b978-0-444-63488-7.00017-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Modulation of respiration is a prerequisite for survival of the individual and of the species. For example, respiration has to be adjusted in case of speech, strenuous exercise, laughing, crying, or sudden escape from danger. Respiratory centers in pons and medulla generate the basic respiratory rhythm or eupnea, but they cannot modulate breathing in the context of emotional challenges, for which they need input from higher brain centers. In simple terms, the prefrontal cortex integrates visual, auditory, olfactory, and somatosensory information and informs subcortical structures such as amygdala, hypothalamus, and finally the midbrain periaqueductal gray (PAG) about the results. The PAG, in turn, generates the final motor output for basic survival, such as setting the level of all cells in the brain and spinal cord. Best known in this framework is determining the level of pain perception. The PAG also controls heart rate, blood pressure, micturition, sexual behavior, vocalization, and many other basic motor output systems. Within this context, the PAG also changes the eupneic respiratory rhythm into a breathing pattern necessary for basic survival. This review examines the latest developments regarding of how the PAG controls respiration.
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14
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Hyam JA, Aziz TZ, Green AL. Control of the lungs via the human brain using neurosurgery. PROGRESS IN BRAIN RESEARCH 2014; 209:341-66. [PMID: 24746057 DOI: 10.1016/b978-0-444-63274-6.00018-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neurosurgery can alter cardiorespiratory performance via central networks and includes deep brain stimulation (DBS), a routinely employed therapy for movement disorders and chronic pain syndromes. We review the established cardiovascular effects of DBS and the presumed mechanism by which they are produced via the central autonomic network. We then review the respiratory effects of DBS, including modulation of respiratory rate and lung function indices, and the mechanisms via which these may occur. We conclude by highlighting the potential future therapeutic applications of DBS for intractable airway diseases.
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Affiliation(s)
- Jonathan A Hyam
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK; Department of Physiology, Anatomy & Genetics, University of Oxford, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK.
| | - Tipu Z Aziz
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK; Department of Physiology, Anatomy & Genetics, University of Oxford, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Alexander L Green
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK; Department of Physiology, Anatomy & Genetics, University of Oxford, Oxford, UK; Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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15
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Affiliation(s)
- Thelma Lovick
- Physiology and Pharmacology; University of Bristol; Bristol BS8 1TD UK
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Sitsapesan H, Green AL, Aziz TZ, Pereira EAC. The periaqueductal grey area and control of blood pressure in neurodegeneration. Clin Auton Res 2013; 23:215-9. [PMID: 23812562 DOI: 10.1007/s10286-013-0206-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 06/14/2013] [Indexed: 11/29/2022]
Abstract
The periaqueductal/periventricular grey area (PAG/PVG) is a midbrain nucleus with an important role in pain signalling and autonomic control. We present the case of an initially hypertensive man who developed a presumed neurodegenerative disorder over a decade, characterised by progressive right-sided chronic pain, extra-pyramidal symptoms and autonomic dysfunction including postural hypotension, sleep apnoea, and bladder instability. He underwent a variety of treatments for his symptoms, including deep brain stimulation (DBS) of the PAG/PVG. 24-h blood pressure monitoring was carried out 1 and 5 years after implantation. Although the DBS initially produced a significant reduction in blood pressure, the effect was significantly reversed when the same tests were repeated 5 years after surgery. This may imply a functional involvement of the PAG/PVG in the neurodegenerative process.
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Affiliation(s)
- Holly Sitsapesan
- Nuffield Department of Surgical Science, University of Oxford, Level 3, West Wing, Oxford, OX3 9DU, UK.
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Pereira EAC, Wang S, Owen SLF, Aziz TZ, Green AL. Human periventricular grey somatosensory evoked potentials suggest rostrocaudally inverted somatotopy. Stereotact Funct Neurosurg 2013; 91:290-7. [PMID: 23797328 DOI: 10.1159/000348324] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 01/20/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Somatosensory homunculi have been demonstrated in primary somatosensory cortex and ventral posterior thalamus but not periaqueductal and periventricular grey matter (PAVG), a therapeutic target for deep brain stimulation (DBS) in chronic pain. AIMS The study is an investigation of somatotopic representation in PAVG and assessment for a somatosensory homunculus. METHODS Five human subjects were investigated using electrical somatosensory stimulation and deep brain macroelectrode recording. DBS were implanted in the contralateral PAVG. Cutaneous arm, leg and face regions were stimulated while event-related potentials were recorded from deep brain electrodes. Electrode contact positions were mapped using MRI and brain atlas information. RESULTS Monopolar P1 somatosensory evoked potential amplitudes were highest and onset latencies shortest in contralateral caudal PAVG with facial stimulation and rostral with leg stimulation, in agreement with reported subjective sensation during intra-operative electrode advancement. CONCLUSIONS A rostrocaudally inverted somatosensory homunculus exists in the human PAVG region. Objective human evidence of PAVG somatotopy increases understanding of a brainstem region important to pain and autonomic control that is a clinical target for both pharmacological and neurosurgical therapies. Such knowledge may assist DBS target localisation for neuropathic pain syndromes related to particular body regions like brachial plexopathies, anaesthesia dolorosa and phantom limb pain.
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Affiliation(s)
- Erlick A C Pereira
- Oxford Functional Neurosurgery and Experimental Neurology Group, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Ewing SG, Winter C. The ventral portion of the CA1 region of the hippocampus and the prefrontal cortex as candidate regions for neuromodulation in schizophrenia. Med Hypotheses 2013; 80:827-32. [PMID: 23583328 DOI: 10.1016/j.mehy.2013.03.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Accepted: 03/17/2013] [Indexed: 02/08/2023]
Abstract
Existing antipsychotic drugs are most effective in the treatment of the positive symptoms of schizophrenia. However, they are associated with considerable side effects and have relatively low efficacy. Diminished inhibitory control in the hippocampus has been suggested to lead to hyperactivation of the dopamine system thus underpinning the dopamine-dependent psychosis associated with schizophrenia. Similarly, diminished inhibitory control is thought to underpin the cortical disruption associated with the cognitive dysfunctions. Impairment of a specific class of parvalbumin-positive inhibitory interneuron has been consistently identified in the prefrontal cortex and hippocampus of schizophrenics. Thus, this impairment common to both regions, may subserve these distinct symptom domains. Deep brain stimulation has been suggested to act, at least in part, through the modulation of interneuron function and here we propose the prefrontal cortex and hippocampus as potential targets for neuromodulatory intervention in the treatment of schizophrenia. Further, we specifically consider whether multiple targets and multiple neuromodulatory approaches may be necessary in the treatment of this multi-faceted disease. Finally we propose that deep brain stimulation of the ventral protion of the CA1 region of the hippocampus may be the most promising single target for neuromodulation in schizophrenia.
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Affiliation(s)
- Samuel G Ewing
- Bereich Experimentelle Psychiatrie, Universitätsklinik Carl Gustav Carus an der Technischen Universität Dresden, Fetscherstrasse 74, D-01307 Dresden, Germany.
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Abstract
The palliative care population is generally vulnerable to experiencing medication-induced adverse effects and drug–drug interactions. Neuromodulation may offer particular advantages over systemic medications in this population. Spinal cord stimulation and peripheral nerve stimulation have long been utilized in efforts to provide analgesia for various painful conditions. More recently, deep brain stimulation/motor cortex stimulation has anecdotally been utilized for certain intractable pain states. Although brain electrical stimulation has not been adequately trialed or in some cases even tried at all for management of a variety of symptoms, it is conceivable that in the future it may be a potential therapeutic option in efforts to palliate various severe refractory symptoms (eg, intractable pain, nausea, dyspnea, delirium).
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Affiliation(s)
- Howard S. Smith
- Department of Anesthesiology, Albany Medical College, Albany, NY, USA
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Pereira EA, Wang S, Peachey T, Lu G, Shlugman D, Stein JF, Aziz TZ, Green AL. Elevated gamma band power in humans receiving naloxone suggests dorsal periaqueductal and periventricular gray deep brain stimulation produced analgesia is opioid mediated. Exp Neurol 2013; 239:248-55. [DOI: 10.1016/j.expneurol.2012.10.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2012] [Revised: 10/03/2012] [Accepted: 10/24/2012] [Indexed: 11/29/2022]
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Ritz T. Airway responsiveness to psychological processes in asthma and health. Front Physiol 2012; 3:343. [PMID: 22973233 PMCID: PMC3433706 DOI: 10.3389/fphys.2012.00343] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 08/08/2012] [Indexed: 12/16/2022] Open
Abstract
Psychosocial factors have been found to impact airway pathophysiology in respiratory disease with considerable consistency. Influences on airway mechanics have been studied particularly well. The goal of this article is to review the literature on airway responses to psychological stimulation, discuss potential pathways of influence, and present a well-established emotion-induction paradigm to study airway obstruction elicited by unpleasant stimuli. Observational studies have found systematic associations between lung function and daily mood changes. The laboratory-based paradigm of bronchoconstrictive suggestion has been used successfully to elicit airway obstruction in a substantial proportion of asthmatic individuals. Other studies have demonstrated modulation of airway responses to standard airway challenges with exercise, allergens, or pharmacological agents by psychological factors. Standardized emotion-induction techniques have consistently shown airway constriction during unpleasant stimulation, with surgery, blood, and injury stimuli being particularly powerful. Findings with various forms of stress induction have been more mixed. A number of methodological factors may account for variability across studies, such as choice of measurement technique, temporal association between stimulation and measurement, and the specific quality and intensity of the stimulus material, in particular the extent of implied action-orientation. Research has also begun to elucidate physiological processes associated with psychologically induced airway responses, with vagal excitation and ventilatory influences being the most likely candidate pathways, whereas the role of specific central nervous system pathways and inflammatory processes has been less studied. The technique of emotion-induction using films has the potential to become a standardized challenge paradigm for the further exploration of airway hyperresponsiveness mediated by central nervous system processes.
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Affiliation(s)
- Thomas Ritz
- Southern Methodist University Dallas, TX, USA
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Hyam JA, Kringelbach ML, Silburn PA, Aziz TZ, Green AL. The autonomic effects of deep brain stimulation--a therapeutic opportunity. Nat Rev Neurol 2012; 8:391-400. [PMID: 22688783 DOI: 10.1038/nrneurol.2012.100] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Deep brain stimulation (DBS) is an expanding field in neurosurgery and has already provided important insights into the fundamental mechanisms underlying brain function. One of the most exciting emerging applications of DBS is modulation of blood pressure, respiration and micturition through its effects on the autonomic nervous system. DBS stimulation at various sites in the central autonomic network produces rapid changes in the functioning of specific organs and physiological systems that are distinct from its therapeutic effects on central nervous motor and sensory systems. For example, DBS modulates several parameters of cardiovascular function, including heart rate, blood pressure, heart rate variability, baroreceptor sensitivity and blood pressure variability. The beneficial effects of DBS also extend to improvements in lung function. This article includes an overview of the anatomy of the central autonomic network, which consists of autonomic nervous system components in the cortex, diencephalon and brainstem that project to the spinal cord or cranial nerves. The effects of DBS on physiological functioning (particularly of the cardiovascular and respiratory systems) are discussed, and the potential for these findings to be translated into therapies for patients with autonomic diseases is examined.
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Affiliation(s)
- Jonathan A Hyam
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Department of Psychiatry, University of Oxford, Headley Way, Headington, Oxford OX3 9DU, UK.
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