1
|
Stanslaski SR, Case MA, Giftakis JE, Raike RS, Stypulkowski PH. Long Term Performance of a Bi-Directional Neural Interface for Deep Brain Stimulation and Recording. Front Hum Neurosci 2022; 16:916627. [PMID: 35754768 PMCID: PMC9218069 DOI: 10.3389/fnhum.2022.916627] [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: 04/09/2022] [Accepted: 05/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background: In prior reports, we described the design and initial performance of a fully implantable, bi-directional neural interface system for use in deep brain and other neurostimulation applications. Here we provide an update on the chronic, long-term neural sensing performance of the system using traditional 4-contact leads and extend those results to include directional 8-contact leads. Methods: Seven ovine subjects were implanted with deep brain stimulation (DBS) leads at different nodes within the Circuit of Papez: four with unilateral leads in the anterior nucleus of the thalamus and hippocampus; two with bilateral fornix leads, and one with bilateral hippocampal leads. The leads were connected to either an Activa PC+S® (Medtronic) or Percept PC°ledR (Medtronic) deep brain stimulation and recording device. Spontaneous local field potentials (LFPs), evoked potentials (EPs), LFP response to stimulation, and electrode impedances were monitored chronically for periods of up to five years in these subjects. Results: The morphology, amplitude, and latencies of chronic hippocampal EPs evoked by thalamic stimulation remained stable over the duration of the study. Similarly, LFPs showed consistent spectral peaks with expected variation in absolute magnitude dependent upon behavioral state and other factors, but no systematic degradation of signal quality over time. Electrode impedances remained within expected ranges with little variation following an initial stabilization period. Coupled neural activity between the two nodes within the Papez circuit could be observed in synchronized recordings up to 5 years post-implant. The magnitude of passive LFP power recorded from directional electrode segments was indicative of the contacts that produced the greatest stimulation-induced changes in LFP power within the Papez network. Conclusion: The implanted device performed as designed, providing the ability to chronically stimulate and record neural activity within this network for up to 5 years of follow-up.
Collapse
|
2
|
Koch J, Schuettler M, Pasluosta C, Stieglitz T. Electrical connectors for neural implants: design, state of the art and future challenges of an underestimated component. J Neural Eng 2019; 16:061002. [PMID: 31362277 DOI: 10.1088/1741-2552/ab36df] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Technological advances in electrically active implantable devices have increased the complexity of hardware design. In particular, the increasing number of stimulation and recording channels requires innovative approaches for connectors that interface electrodes with the implant circuitry. OBJECTIVE This work aims to provide a common theoretical ground for implantable connector development with a focus on neural applications. APPROACH Aspects and experiences from several disciplines are compiled from an engineering perspective to discuss the state of the art of connector solutions. Whenever available, we also present general design guidelines. MAIN RESULTS Degradation mechanisms, material stability and design rules in terms of biocompatibility and biostability are introduced. Considering contact physics, we address the design and characterization of the contact zone and review contaminants, wear and contact degradation. For high-channel counts and body-like environments, insulation can be even more crucial than the electrical connection itself. Therefore, we also introduce the requirements for electrical insulation to prevent signal loss and distortion and discuss its impact on the practical implementation. SIGNIFICANCE A final review is dedicated to the state of the art connector concepts, their mechanical setup, electrical performance and the interface to other implant components. We conclude with an outlook for possible approaches for the future generations of implants.
Collapse
Affiliation(s)
- Julia Koch
- Laboratory for Biomedical Microtechnology, Department of Microsystems Engineering, University of Freiburg, Freiburg, Germany
| | | | | | | |
Collapse
|
3
|
Towards unambiguous reporting of complications related to deep brain stimulation surgery: A retrospective single-center analysis and systematic review of the literature. PLoS One 2018; 13:e0198529. [PMID: 30071021 PMCID: PMC6071984 DOI: 10.1371/journal.pone.0198529] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 05/21/2018] [Indexed: 02/04/2023] Open
Abstract
Background and objective To determine rates of adverse events (AEs) related to deep brain stimulation (DBS) surgery or implanted devices from a large series from a single institution. Sound comparisons with the literature require the definition of unambiguous categories, since there is no consensus on the reporting of such AEs. Patients and methods 123 consecutive patients (median age 63 yrs; female 45.5%) treated with DBS in the subthalamic nucleus (78 patients), ventrolateral thalamus (24), internal pallidum (20), and centre médian-parafascicular nucleus (1) were analyzed retrospectively. Both mean and median follow-up time was 4.7 years (578 patient-years). AEs were assessed according to three unambiguous categories: (i) hemorrhages including other intracranial complications because these might lead to neurological deficits or death, (ii) infections and similar AEs necessitating the explantation of hardware components as this results in the interruption of DBS therapy, and (iii) lead revisions for various reasons since this involves an additional intracranial procedure. For a systematic review of the literature AE rates were calculated based on primary data presented in 103 publications. Heterogeneity between studies was assessed with the I2 statistic and analyzed further by a random effects meta-regression. Publication bias was analyzed with funnel plots. Results Surgery- or hardware-related AEs (23) affected 18 of 123 patients (14.6%) and resolved without permanent sequelae in all instances. In 2 patients (1.6%), small hemorrhages in the striatum were associated with transient neurological deficits. In 4 patients (3.3%; 0.7% per patient-year) impulse generators were removed due to infection. In 2 patients electrodes were revised (1.6%; 0.3% per patient-year). There was no lead migration or surgical revision because of lead misplacement. Age was not statistically significant different (p>0.05) between patients affected by AEs or not. AE rates did not decline over time and similar incidences were found among all patients (423) implanted with DBS systems at our institution until December 2016. A systematic literature review revealed that exact AE rates could not be determined from many studies, which could not be attributed to study designs. Average rates for intracranial complications were 3.8% among studies (per-study analysis) and 3.4% for pooled analysis of patients from different studies (per-patient analysis). Annual hardware removal rates were 3.6 and 2.4% for per-study and per-patient analysis, respectively, and lead revision rates were 4.1 and 2.6%, respectively. There was significant heterogeneity between studies (I2 ranged between 77% and 91% for the three categories; p< 0.0001). For hardware removal heterogeneity (I2 = 87.4%) was reduced by taking study size (p< 0.0001) and publication year (p< 0.01) into account, although a significant degree of heterogeneity remained (I2 = 80.0%; p< 0.0001). Based on comparisons with health care-related databases there appears to be publication bias with lower rates for hardware-related AEs in published patient cohorts. Conclusions The proposed categories are suited for an unequivocal assessment of AEs even in a retrospective manner and useful for benchmarking. AE rates in the present cohorts from our institution compare favorable with the literature.
Collapse
|
4
|
Yin S, Jin W, De Salles A. Occipital-device-related pain as a complication of deep brain stimulation. Br J Neurosurg 2015; 29:340-2. [PMID: 25659960 DOI: 10.3109/02688697.2014.1003031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Deep brain stimulation is an established treatment for movement disorders. We reported 4 patients (1.3%) of post-operative occipital headache related to the placement of the connection among 309 patients from 1998 to 2008. The patients were treated successfully by repositioning the connector into a groove created in the bone.
Collapse
Affiliation(s)
- Shaoya Yin
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California, and VA Greater Los Angeles Healthcare System , Los Angeles, California , USA
| | | | | |
Collapse
|
5
|
Yang HJ, Yun JY, Kim YE, Lim YH, Kim HJ, Paek SH, Jeon BS. Sudden loss of the deep brain stimulation effect with high impedance without macroscopic fracture: a case report and review of the published literature. Neuropsychiatr Dis Treat 2015; 11:1799-803. [PMID: 26229475 PMCID: PMC4516336 DOI: 10.2147/ndt.s86120] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The number of deep brain stimulation (DBS) hardware complications has increased during the past decade. In cases of abnormally high lead impedance with no evidence of a macroscopic fracture, optimal treatment options have not yet been established. Here, we present the case of a 49-year-old woman with a 12-year history of Parkinson's disease who received bilateral subthalamic nucleus DBS in March 2006. The patient showed good control of parkinsonism until December 24, 2010, when she awoke with abrupt worsening of parkinsonian symptoms. At telemetric testing, lead impedances were found at >2,000 Ω in all four leads on the left side. Fracture of a lead or an extension wire was suspected. However, radiological screening and palpation revealed no macroscopic fracture. In June 2011, the implantable pulse generator (IPG) was changed under local anesthesia without any complications. Postoperatively, her parkinsonism immediately improved to the previous level, and the lead impedance readings by telemetry were also normalized. The disconnection of the neurostimulator connector block and the hybrid circuit board of the IPG was confirmed by destructive analysis. The present report illustrates that a staged approach that starts with simple IPG replacement can be an option for some cases of acute DBS effect loss with high impedance, when radiological findings are normal, thereby sparing the intact electrodes and extension wires.
Collapse
Affiliation(s)
- Hui-Jun Yang
- Department of Neurology, Ulsan University Hospital, Ulsan, South Korea
| | - Ji Young Yun
- Department of Neurology, Ewha Womans University Mokdong Hospital, Seoul, South Korea
| | - Young Eun Kim
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Yong Hoon Lim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
| | - Han-Joon Kim
- Department of Neurology and Movement Disorder Center, Parkinson's Disease Study Group and Neuroscience Research Institute, Seoul National University Hospital, Seoul, South Korea
| | - Sun Ha Paek
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
| | - Beom S Jeon
- Department of Neurology and Movement Disorder Center, Parkinson's Disease Study Group and Neuroscience Research Institute, Seoul National University Hospital, Seoul, South Korea
| |
Collapse
|
6
|
Constantoyannis C, Berk C, Honey CR, Mendez I, Brownstone RM. Reducing Hardware-Related Complications of Deep Brain Stimulation. Can J Neurol Sci 2014; 32:194-200. [PMID: 16018154 DOI: 10.1017/s0317167100003966] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
ABSTRACT:Background:Deep brain stimulation (DBS) is used increasingly worldwide for the treatment of Parkinson's disease, dystonia, tremor and pain. As with any implanted system, however, DBS introduces a new series of problems related to its hardware. Infection, malfunction and lead migration or fracture may increase patient morbidity and should be considered when evaluating the risk/benefit ratio of this therapy. This work highlights several factors felt to increase DBS hardware complications.Methods:The authors undertook a prospective analysis of their patients receiving this therapy in two Canadian centres, over a four-year period.Results:One hundred and forty-four patients received 204 permanent electrode implants. The average follow-up duration was 24 months. Complications related to the DBS hardware were seen in 11 patients (7.6%). There were two lead fractures (1.4%) and nine infections (6.2%) including two erosions (1.4%). There was a significantly greater risk of infection in patients who underwent staged procedures with externalization. In patients with straight scalp incisions, the rate of infection was higher than that seen with curved incisions.Conclusion:Hardware complications were not common. A period of externalization of the electrodes for a stimulation trial was associated with an increased infection rate. It is also possible that a straight scalp incision instead of curvilinear incision may lead to an increase in the rate of infection. With a clear understanding of the accepted DBS device indications and their potential complications, patients may make a truly informed decision about DBS technology.
Collapse
|
7
|
Jiang C, Mo X, Dong Y, Meng F, Hao H, Zhang J, Feng X, Li L. An Experimental Study of Deep Brain Stimulation Lead Fracture: Possible Fatigue Mechanisms and Prevention Approach. Neuromodulation 2014; 18:243-8; discussion 248. [DOI: 10.1111/ner.12229] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 06/21/2014] [Accepted: 06/30/2014] [Indexed: 11/28/2022]
Affiliation(s)
- Changqing Jiang
- National Engineering Laboratory for Neuromodulation; School of Aerospace Engineering; Tsinghua University; Beijing China
| | - Xiaolong Mo
- National Engineering Laboratory for Neuromodulation; School of Aerospace Engineering; Tsinghua University; Beijing China
| | - Yantao Dong
- National Engineering Laboratory for Neuromodulation; School of Aerospace Engineering; Tsinghua University; Beijing China
| | - Fangang Meng
- Beijing Neurosurgical Institute; Capital Medical University; Beijing China
| | - Hongwei Hao
- National Engineering Laboratory for Neuromodulation; School of Aerospace Engineering; Tsinghua University; Beijing China
| | - Jianguo Zhang
- Department of Neurosurgery; Beijing Tiantan Hospital; Capital Medical University; Beijing China
| | - Xiqiao Feng
- Institute of Biomechanics and Medical Engineering; Department of Engineering Mechanics; Tsinghua University; Beijing China
| | - Luming Li
- National Engineering Laboratory for Neuromodulation; School of Aerospace Engineering; Tsinghua University; Beijing China
| |
Collapse
|
8
|
Schlesinger D, Benedict S, Diederich C, Gedroyc W, Klibanov A, Larner J. MR-guided focused ultrasound surgery, present and future. Med Phys 2014; 40:080901. [PMID: 23927296 DOI: 10.1118/1.4811136] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
MR-guided focused ultrasound surgery (MRgFUS) is a quickly developing technology with potential applications across a spectrum of indications traditionally within the domain of radiation oncology. Especially for applications where focal treatment is the preferred technique (for example, radiosurgery), MRgFUS has the potential to be a disruptive technology that could shift traditional patterns of care. While currently cleared in the United States for the noninvasive treatment of uterine fibroids and bone metastases, a wide range of clinical trials are currently underway, and the number of publications describing advances in MRgFUS is increasing. However, for MRgFUS to make the transition from a research curiosity to a clinical standard of care, a variety of challenges, technical, financial, clinical, and practical, must be overcome. This installment of the Vision 20∕20 series examines the current status of MRgFUS, focusing on the hurdles the technology faces before it can cross over from a research technique to a standard fixture in the clinic. It then reviews current and near-term technical developments which may overcome these hurdles and allow MRgFUS to break through into clinical practice.
Collapse
Affiliation(s)
- David Schlesinger
- Department of Radiation Oncology, University of Virginia, Charlottesville, Virginia 22908, USA.
| | | | | | | | | | | |
Collapse
|
9
|
Kocabicak E, Temel Y. Deep brain stimulation of the subthalamic nucleus in Parkinson's disease: Surgical technique, tips, tricks and complications. Clin Neurol Neurosurg 2013; 115:2318-23. [DOI: 10.1016/j.clineuro.2013.08.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 08/13/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
|
10
|
Falowski S, Ooi YC, Smith A, Verhargen Metman L, Bakay RAE. An evaluation of hardware and surgical complications with deep brain stimulation based on diagnosis and lead location. Stereotact Funct Neurosurg 2012; 90:173-80. [PMID: 22678355 DOI: 10.1159/000338254] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 03/16/2012] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Deep brain stimulation is the most frequently performed neurosurgical procedure for movement disorders. This procedure is well tolerated, but not free of complications. Analysis of hardware complications based on patient diagnosis and lead location could prove valuable in recognizing potential pitfalls and patients at higher risk. METHODS This review analyzes the most common surgery-related complications that may occur based on diagnosis and lead location. Patients were categorized based on diagnosis - Parkinson's disease (PD), dystonia, and essential tremor (ET) - as well as by lead location - subthalamic nucleus (STN), globus pallidus interna (GPi), and ventral intermediate nucleus of the thalamus (Vim). It is a retrospective review of 326 patients undergoing 949 procedures over a 10-year period by one surgeon. Fisher's exact test and χ(2) test were employed and multivariate logistic regression analysis was performed to identify the significant variables of correlation. RESULTS Overall lead revision was observed at 5.7%, but was observed at 11.9% of GPi lead placements, and 10.7% of dystonia patients with only 4.6% of STN lead placements. Total extension revision was at 2.5%, but observed at 5.3% for dystonia patients and at only 1.4% for ET patients. Overall infection rate was at 1.9% with the highest rate observed in dystonia and ET patients. Postoperative complications with hardware, erosion, infection, and delayed stimulation failure were observed more often with ET and dystonia than with PD. This difference was statistically significant between dystonia and PD (p < 0.03) but not between the other disease entities (p > 0.05). On multivariate analysis, age and gender had no correlation with these complications. PD had significantly fewer complications on forward selection regression analysis (p = 0.004). Asymptomatic intracerebral hemorrhage was at 2.5% with the majority in Vim and none observed in GPi placements. There was only one symptomatic hemorrhage with a permanent deficit. Infarcts were observed at 0.8%. There were no mortalities. CONCLUSION This large series of patients and long-term follow-up demonstrate that risks of complications are not universal among movement disorder patients. Diagnosis and lead location are important risk stratification factors in determining complications.
Collapse
Affiliation(s)
- Steven Falowski
- Department of Neurosurgery, Rush University, Chicago, IL 60612, USA.
| | | | | | | | | |
Collapse
|
11
|
Guridi J, Rodriguez-Oroz MC, Alegre M, Obeso JA. Hardware complications in deep brain stimulation: electrode impedance and loss of clinical benefit. Parkinsonism Relat Disord 2012; 18:765-9. [PMID: 22522071 DOI: 10.1016/j.parkreldis.2012.03.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 03/08/2012] [Accepted: 03/19/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) is an effective treatment in patients with movement disorders. Successful outcomes are correlated with patient selection, accurate placement of the electrodes in their surgical target and optimal programming of patients. The loss of clinical efficacy after successful treatment may be related to hardware complications. OBJECTIVES We studied the causes of loss of stimulation efficacy in patients with stable antiparkinsonian benefit after DBS. RESULTS Seven out of 110 (6.3%) patients surgically treated with DBS showed a loss of clinical efficacy, and were included in the study. Five cases had subacute clinical worsening and two sudden deterioration. All of them had an impedance increment (>4000 Ω) with the active contacts. Further reprogramming was attempted in all the cases using the undamaged contacts. However, five patients had incomplete clinical control and were reoperated with an electrode replacement. X-rays provided information in all cases except one showing the disruption or rupture of electrode. CONCLUSIONS It is important to identify this hardware problem in view of the growing number of patients receiving this therapy. A protocol for patients with loss of stimulation efficacy and electrode impedance increment needs to be created in clinical visits in order to detect the failed stimulation mechanism.
Collapse
Affiliation(s)
- Jorge Guridi
- Department of Neurosurgery, Clínica Universidad de Navarra, 31008 Pamplona, Spain.
| | | | | | | |
Collapse
|
12
|
Starr PA, Bejjani P, Lozano AM, Metman LV, Hariz MI. Stereotactic techniques and perioperative management of DBS in dystonia. Mov Disord 2011; 26 Suppl 1:S23-30. [PMID: 21692108 DOI: 10.1002/mds.23489] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
This article reviews the available literature related to the surgical technique for implantation of deep brain stimulation (DBS) hardware for the treatment of dystonia. Topics covered include stereotactic targeting, selection of specific hardware components, site of placement of the cable connectors and pulse generators, and postoperative documentation of electrode location. Techniques in stereotactic neurosurgery are rapidly evolving, and there is no Class I evidence to unequivocally validate any specific technique described. Nevertheless, the guidelines provided may assist surgical teams in tailoring a rational approach to DBS implantation in dystonia.
Collapse
Affiliation(s)
- Philip A Starr
- Department of Neurosurgery, UCSF, San Francisco, California, USA.
| | | | | | | | | |
Collapse
|
13
|
Park YS, Kim JP, Chang WS, Lee PH, Sohn YH, Chang JW. Assessment of the effects of unilateral electrode dysfunction in patients with Parkinson disease undergoing bilateral subthalamic nucleus deep brain stimulation. Neurosurgery 2011; 70:163-9; discussion 169. [PMID: 21768919 DOI: 10.1227/neu.0b013e31822d5d4c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Bilateral subthalamic nucleus deep brain stimulation (STN-DBS) is the gold standard surgical treatment for medically intractable Parkinson disease, and unilateral electrodes are reported to have beneficial effects. However, assessment of patients after electrode failure needs to be established. OBJECTIVE To assess the effects of the remaining unilateral electrode in Parkinson disease after bilateral STN-DBS. METHODS Between May 2000 and March 2009, 8 patients had unilateral STN-DBS after bilateral STN-DBS. We assessed clinical outcome by comparing the Unified Parkinson Disease Rating Scale (UPDRS) motor score, activities of daily living, levodopa-equivalent daily dosages, and quality of life according to the Short-Form 36 Health Survey between patients with unilateral and bilateral electrodes. RESULTS Although ipsilateral and axial UPDRS motor scores were compromised, UPDRS motor scores contralateral to the side of the implant remained unaltered after removal of 1 electrode. Although physical aspects of quality of life declined significantly with a unilateral electrode, pain and social functioning were not significantly affected. No significant changes in activities of daily living, Hoehn and Yahr stage, or levodopa-equivalent daily dosage were observed after removal of 1 electrode. CONCLUSION The UPDRS motor score with unilateral STN-DBS was compromised relative to bilateral STN-DBS for ipsilateral motor and axial symptoms. When 1 electrode is compromised, revision of that electrode will eventually be required, but not immediately in all patients. If a patient tolerates loss of 1 electrode according to motor score while maintaining activities of daily living and quality of life, it is possible to wait and observe the situation instead of immediately revising the electrode.
Collapse
Affiliation(s)
- Young Seok Park
- Department of Neurosurgery, Bundang CHA Hospital, CHA University School of Medicine, Seongnam, Korea
| | | | | | | | | | | |
Collapse
|
14
|
Baizabal Carvallo JF, Simpson R, Jankovic J. Diagnosis and treatment of complications related to deep brain stimulation hardware. Mov Disord 2011; 26:1398-406. [PMID: 21714001 DOI: 10.1002/mds.23800] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2011] [Revised: 04/09/2011] [Accepted: 04/18/2011] [Indexed: 11/08/2022] Open
Abstract
Deep brain stimulation is a therapeutic technique increasingly used in the treatment of a variety of neurological, psychiatric, and pain disorders. Although beneficial, it carries the immediate and long-term risks associated with implanted hardware in the brain parenchyma and subcutaneous tissue. The most common hardware complications include electrode migrations or misplacements, wire fractures, skin erosion, infections, and device malfunction. We systematically reviewed the literature on deep brain stimulation-related complications and propose a diagnostic and therapeutic algorithm. Our aim is to provide a guide for clinicians and medical staff involved in the treatment of patients with deep brain stimulation for rapid recognition and efficient management of these complications.
Collapse
Affiliation(s)
- José Fidel Baizabal Carvallo
- Parkinson's Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas, USA.
| | | | | |
Collapse
|
15
|
Park YS, Kang JH, Kim HY, Kang DW, Chang WS, Kim JP, Chang JW. A Combination Procedure with Double C-Shaped Skin Incision and Dual-Floor Burr Hole Method to Prevent Skin Erosion on the Scalp and Reduce Postoperative Skin Complications in Deep Brain Stimulation. Stereotact Funct Neurosurg 2011; 89:178-84. [DOI: 10.1159/000324903] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2010] [Accepted: 02/07/2011] [Indexed: 11/19/2022]
|
16
|
Boviatsis EJ, Stavrinou LC, Themistocleous M, Kouyialis AT, Sakas DE. Surgical and hardware complications of deep brain stimulation. A seven-year experience and review of the literature. Acta Neurochir (Wien) 2010; 152:2053-62. [PMID: 20658301 DOI: 10.1007/s00701-010-0749-8] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 07/12/2010] [Indexed: 11/29/2022]
Abstract
PURPOSE Deep brain stimulation (DBS) has been established as a safe and efficient method for the treatment of various movement disorders. As the emerging applications continue to expand and more centers become eligible for the procedure, complication rates and complication avoidance become increasingly important. Our aim was to report the DBS-related complication in our department over the last 7 years, compare our rates with those reported in the literature, and highlight those practices that will aid complications avoidance. PATIENTS AND METHODS Since 2003, 106 patients underwent DBS for various pathologies in our department. There were 38 (36%) females and 68 (64%) males with a mean age of 57 years. Preoperative diagnoses included Parkinson's disease (n = 88), dystonia (n = 12), tremor (n = 3), epilepsy (n = 1), obsessive-compulsive disorder (n = 1), and central pain syndrome (n = 1). Surgical and hardware-related complications, their treatment, and outcome were recorded and compared with those reported in the literature. RESULTS There were 12 procedure-related complications (11.3% of patients, 5.7% of the procedures). These included death (n = 1), aborted procedure (n = 1), postoperative respiratory distress (n = 3), intracranial hemorrhage (n = 2), epilepsy (n = 1), postoperative confusion or agitation (n = 3), and malignant neuroleptic syndrome (n = 1). Hardware-related complications presented in 4.3% of the procedures and included infection (five patients, 4.7%), electrode breakage (0.94%), lead migration or misplacement (0.94%), and stricture formation (two patients, 1.9%). CONCLUSIONS Complication rates after DBS surgery remain low, proving that DBS is not only effective but also safe. Certain strategies do exist in order to minimize complications.
Collapse
|
17
|
Blomstedt P, Hariz GM, Hariz MI, Koskinen LOD. Thalamic deep brain stimulation in the treatment of essential tremor: a long-term follow-up. Br J Neurosurg 2009; 21:504-9. [PMID: 17922323 DOI: 10.1080/02688690701552278] [Citation(s) in RCA: 137] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
18
|
Abstract
The advancement of electrical stimulation of the central nervous system has been a story of fits and bursts with numerous setbacks. In many ways, this history has paralleled the history of medicine and physics. We have moved from anecdotal observation to double-blinded, prospective randomized trials. We have moved from faradic stimulation to systems that lie completely under the skin and can deliver complex electrical currents to discrete areas of the brain while controlled through a device that is not much bigger than a PDA. This review will discuss how deep brain stimulation has developed into its current form, where we see the field going and the potential pitfalls along the way.
Collapse
Affiliation(s)
- Jason M Schwalb
- Department of Neurological Surgery, University of Rochester, Rochester, NY 14642, USA.
| | | |
Collapse
|
19
|
Blomstedt P, Jabre M, Bejjani BP, Koskinen LOD. Electromagnetic Environmental Influences on Implanted Deep Brain Stimulators. Neuromodulation 2006; 9:262-9. [DOI: 10.1111/j.1525-1403.2006.00068.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
20
|
Blomstedt P, Hariz MI. Are Complications Less Common in Deep Brain Stimulation than in Ablative Procedures for Movement Disorders? Stereotact Funct Neurosurg 2006; 84:72-81. [PMID: 16790989 DOI: 10.1159/000094035] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The side effects and complications of deep brain stimulation (DBS) and ablative lesions for tremor and Parkinson's disease were recorded in 256 procedures (129 DBS and 127 lesions). Perioperative complications (seizures, haemorrhage, confusion) were rare and did not differ between the two groups. The rate of hardware-related complications was 17.8%. In ventral intermediate (Vim) thalamotomies, the rate of side effects was 74.5%, in unilateral Vim-DBS 47.3%, while in 7 bilateral Vim-DBS 13 side effects occurred. Most of the side effects of Vim-DBS were reversible upon switching off, or altering, stimulation parameters. In unilateral pallidotomy, the frequency of side effects was 21.9%, while in bilateral staged pallidotomies it was 33.3%. Eight side effects occurred in 11 procedures with pallidal DBS. In 22 subthalamic nucleus DBS procedures, 23 side effects occurred, of which 8 were psychiatric or cognitive. Unilateral ablative surgery may not harbour more postoperative complications or side effects than DBS. Some of the side effects following lesioning are transient and most but not all DBS side effects are reversible. In the Vim DBS is safer than lesioning, while in the pallidum, unilateral lesions are well tolerated.
Collapse
Affiliation(s)
- Patric Blomstedt
- Department of Neurosurgery, University Hospital of Northern Sweden, Umeå, Sweden.
| | | |
Collapse
|
21
|
Rezai AR, Kopell BH, Gross RE, Vitek JL, Sharan AD, Limousin P, Benabid AL. Deep brain stimulation for Parkinson's disease: Surgical issues. Mov Disord 2006; 21 Suppl 14:S197-218. [PMID: 16810673 DOI: 10.1002/mds.20956] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Numerous factors need to be taken into account when implanting deep brain stimulation (DBS) systems into patients with Parkinson's disease. The surgical procedure itself can be divided into immediate preoperative, intraoperative, and immediate postoperative phases. Preoperative considerations include medication withdrawal issues, stereotactic equipment choices, imaging modalities, and targeting strategy. Intraoperative considerations focus on methods for physiological confirmation of a given target for DBS electrode deployment. Terms such as microelectrode recording, microstimulation, and macrostimulation will be defined to clarify inconsistencies in the literature. Advantages and disadvantages of each technique will be addressed. Furthermore, operative decisions such as staging, choice of electrode and implantable pulse generator, and methods of device fixation will be outlined. Postoperative issues include imaging considerations, including magnetic resonance safety, device-device interactions, and immediate surgical complications pertaining to the DBS procedure. This report outlines answers to a series of questions developed to address all aspects of the DBS surgical procedure and decision-making with a systematic overview of the literature (until mid-2004) and by the expert opinion of the authors. This is a report from the Consensus on Deep Brain Stimulation for Parkinson's Disease, a project commissioned by the Congress of Neurological Surgeons and the Movement Disorder Society. It outlines answers to a series of questions developed to address all surgical aspects of deep brain stimulation.
Collapse
Affiliation(s)
- Ali R Rezai
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
| | | | | | | | | | | | | |
Collapse
|
22
|
Deuschl G, Herzog J, Kleiner-Fisman G, Kubu C, Lozano AM, Lyons KE, Rodriguez-Oroz MC, Tamma F, Tröster AI, Vitek JL, Volkmann J, Voon V. Deep brain stimulation: Postoperative issues. Mov Disord 2006; 21 Suppl 14:S219-37. [PMID: 16810719 DOI: 10.1002/mds.20957] [Citation(s) in RCA: 199] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Numerous factors need to be taken into account when managing a patient with Parkinson's disease (PD) after deep brain stimulation (DBS). Questions such as when to begin programming, how to conduct a programming screen, how to assess the effects of programming, and how to titrate stimulation and medication for each of the targeted sites need to be addressed. Follow-up care should be determined, including patient adjustments of stimulation, timing of follow-up visits and telephone contact with the patient, and stimulation and medication conditions during the follow-up assessments. A management plan for problems that can arise after DBS such as weight gain, dyskinesia, axial symptoms, speech dysfunction, muscle contractions, paresthesia, eyelid, ocular and visual disturbances, and behavioral and cognitive problems should be developed. Long-term complications such as infection or erosion, loss of effect, intermittent stimulation, tolerance, and pain or discomfort can develop and need to be managed. Other factors that need consideration are social and job-related factors, development of dementia, general medical issues, and lifestyle changes. This report from the Consensus on Deep Brain Stimulation for Parkinson's Disease, a project commissioned by the Congress of Neurological Surgeons and the Movement Disorder Society, outlines answers to a series of questions developed to address all aspects of DBS postoperative management and decision-making with a systematic overview of the literature (until mid-2004) and by the expert opinion of the authors. The report has been endorsed by the Scientific Issues Committee of the Movement Disorder Society and the American Society of Stereotactic and Functional Neurosurgery.
Collapse
Affiliation(s)
- Günther Deuschl
- Department of Neurology, Christian-Albrechts-Universität Kiel, Kiel, Germany.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Blomstedt P, Hariz MI. Hardware-related complications of deep brain stimulation: a ten year experience. Acta Neurochir (Wien) 2005; 147:1061-4; discussion 1064. [PMID: 16041470 DOI: 10.1007/s00701-005-0576-5] [Citation(s) in RCA: 138] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2004] [Accepted: 05/26/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To analyse the occurrence of hardware-related complications in patients with deep brain stimulation (DBS), over a long period of time. METHOD All patients operated on with DBS at our institution between 1993 and 2002 were followed with respect to adverse events related to the implanted hardware. RESULTS One hundred and nineteen consecutive patients underwent 139 procedures with implantation of 161 electrodes. The minimum follow-up was 12 months. The follow-up time was 540 electrode-years. The rate of hardware-related complications per electrode-year was 4.3%. In total, 17 patients (15%) had 23 hardware-related complications. These included 8 electrode breakages, 4 electrode migrations, 2 stimulator migrations, 3 erosions, 2 erosions and infections, 2 infections and 2 cases of stimulator malfunction. The majority of these complications occurred during the first four years in our experience. CONCLUSIONS DBS is a life-long therapy that requires a life-long follow-up. Increased experience and adaptation of surgical technique are the main determinants for avoidance of hardware-related complications.
Collapse
Affiliation(s)
- P Blomstedt
- Department of Neurosurgery, University Hospital, Umeå, Sweden.
| | | |
Collapse
|
24
|
|
25
|
Alex Mohit A, Samii A, Slimp JC, Grady MS, Goodkin R. Mechanical failure of the electrode wire in deep brain stimulation. Parkinsonism Relat Disord 2004; 10:153-6. [PMID: 15036170 DOI: 10.1016/j.parkreldis.2003.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2003] [Revised: 11/03/2003] [Accepted: 11/03/2003] [Indexed: 10/26/2022]
Abstract
The feasibility and efficacy of deep brain stimulation (DBS) has offered new possibilities for treatment of movement disorders. Mechanical failure of the DBS system is a potential complication. Here we report five patients who presented with mechanical failure of the DBS system. Radiographs of the skull and cervical spine were analyzed for disruptions. Seven instances of lead breakage near the connection of the DBS electrode with the extension wire were identified. In one patient this was in the paramastoid area over the skull, while in all others were in the supraclavicular location. The patients consisted of three men and two women ranging in age from 24 to 78 (at the time of first operation), one person suffering three breakages. The length of spanned time from implantation to presentation ranged from 8 to 32 months. Palpation of the electrode lead wire in the neck for breakage proved unreliable. Radiography localized the site of breakage in all but one patient who required intraoperative exploration, which revealed that although the lead wire was disrupted, the two ends remained in contact. The fact that all breakages occurred near the connection wire suggests that to-and-fro motion of the DBS electrode with repeated head turning leads to fatigue and eventual disruption.
Collapse
Affiliation(s)
- A Alex Mohit
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA 98108, USA
| | | | | | | | | |
Collapse
|
26
|
Ai H, Meng H, Ichinose I, Jones SA, Mills DK, Lvov YM, Qiao X. Biocompatibility of layer-by-layer self-assembled nanofilm on silicone rubber for neurons. J Neurosci Methods 2003; 128:1-8. [PMID: 12948543 DOI: 10.1016/s0165-0270(03)00191-2] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Electrostatic layer-by-layer (LbL) self-assembly, a novel method for ultrathin film coating has been applied to silicone rubber to encourage nerve cell adhesion. The surfaces studied consisted of precursor layers, with alternating cationic poly(ethyleneimine) (PEI) and anionic sodium poly(styrenesulfonate) (PSS) followed by alternating laminin and poly-D-lysine (PDL) layers or fibronectin and PDL layers. Film growth increased linearly with the number of layers. Every fibronectin/PDL and laminin/PDL bilayer was 4.4 and 3.5 nm thick, respectively. All layers were more hydrophilic than the unmodified silicone rubber surface, as determined from contact angle measurements. Of the coatings studied, a PDL layer was the most hydrophilic. A multilayer film with composition [PSS/PEI]3+[fibronectin/PDL]4 or [PSS/PEI]3+[laminin/PDL]4 was highly favorable for neuron adhesion, in contrast to bare silicone rubber substrate. The film coated on silicone rubber is biocompatible for cerebellar neurons with active viability, as shown by lactate dehydrogenase (LDH) assay and fluorescence cellular metabolism observations. These results demonstrate that LbL self-assembly provides an effective approach to apply films with nanometer thickness to silicone rubber. Such only few nanometer thick films are biocompatible with neurons, and may be used to coat devises for long-term implant in the central nervous system.
Collapse
Affiliation(s)
- Hua Ai
- Department of Biomedical Engineering and Institute for Micromanufacturing, Louisiana Tech University, Ruston, LA 71272, USA
| | | | | | | | | | | | | |
Collapse
|