Deep Brain Stimulation最新文献

Deep brain stimulation (DBS) is a widely accepted and safe treatment for selected patients with movement disorders. Many medical centres prefer to perform DBS lead positioning using local anesthesia to enable microelectrode recordings (MER) and assess the therapeutic and side effects of stimulation. These steps allow for the precise identification of the borders and subdomains of the target nuclei using the electrophysiological properties. Additionally, they facilitate the evaluation of the therapeutic window and thereby improve the accuracy of final DBS lead placement. However, in some patients awake surgery can be challenging and, as a result, sedation or general anesthesia may be needed. Unfortunately, if not used properly this approach can lead to alterations in the electrophysiological signature and interfere with clinical testing, potentially affecting surgical outcomes. Consequently, the type and dose of anesthesia needs to be chosen carefully.

Deep brain stimulation (DBS) is a surgical treatment critical for alleviating symptoms of Parkinson's disease (PD), especially when medication fails to manage motor dysfunctions effectively. The accuracy of electrode placement in the subthalamic nucleus (STN) is critical for the procedure's success. The long-standing debate between electrophysiological recording (MER) and imaging-based targeting remains at the forefront of neurosurgical discussions. MER has traditionally been used to enhance the precision of DBS targeting, indicated by changes in local field potentials (LFPs), which correlate with Parkinsonian motor symptoms such as rigidity, bradykinesia, and tremor. However, the necessity of MER has been questioned due to advances in imaging techniques and the potential risks associated with the practice, including hemorrhage and cognitive decline post-surgery. A critical appraisal of the literature reveals mixed opinions, with recent meta-analyses showing no significant increase in hemorrhage risks with MER but demonstrating a modest increase in adverse cognitive outcomes using multiple electrodes. Despite improved imaging modalities enabling more accurate radiological targeting, MER remains a favored technique among surgeons for its direct feedback on electrode placement. Additionally, the aspect of conducting surgery under awake conditions versus general anesthesia is reviewed, considering the anxiety and discomfort associated with awake surgery against the limitations of performing electrophysiological recordings under general anesthesia. The current consensus underscores the importance of accurate electrode placement, achievable through a combination of MER, test stimulation, and intraoperative imaging, while also acknowledging the growing confidence in image-guided procedures performed under general anesthesia. This review highlights the need for individualized approaches considering patient-specific risks and the evolving landscape of DBS surgery.

Background

Deep brain stimulation (DBS) is an effective intervention for refractory obsessive-compulsive disorder (OCD). Although treatment success is measured by a decrease in the severity of core symptoms, this procedure can have broader psychological and physical effects. The field regrettably still lacks knowledge and tools allowing an adequate understanding and assessment of the full range of experiences that accompany DBS treatment. We aimed to describe possible side effects of DBS treatment as experienced by patients, beyond specific changes in OCD core symptoms.

Methods

We interviewed 16 patients and 7 of their relatives from two independent cohorts, receiving stimulation in different anatomical locations. We conducted semi-structured interviews, then transcribed at verbatim. Inductive content analysis was performed to code and group common themes.

Results

We categorized a variety of psychological and physical experiences. Patients frequently reported long-lasting changes often manifesting as improved mood and calmer behavior, but also as impaired memory, concentration, and sleep problems. Further, a wide range of individual experiences were described, suggesting that patients can feel and behave significantly different towards themselves and others, feeling more sensitive, more or less emotional, more impulsive, more irritable, more talkative.

Conclusions

We stress the importance of accumulating knowledge of the full range of DBS-related experiences, to improve shared decision making between patients and treating clinicians, and to facilitate comprehensive monitoring throughout the course of treatment.

Deep Brain Stimulation (DBS) has become widely accepted for treatment of many neurological disorders. Its success depends on several factors, of which imaging plays a crucial role for exact targeting of the deep nuclei. T2 weighted Magnetic Resonance Imaging (MRI) had still been used in routine practice for a long time. However, there are some new MRI sequences and techniques available which enhances direct targeting in planning of DBS surgeries. In this mini review, those recent developments were discussed briefly.

Deep brain stimulation is an established treatment option for various neurological and psychiatric disorders. Throughout its journey as a confirmed long-term efficacious therapeutic option for movement disorders such as Parkinson’ s disease, essential tremor and dystonia over the last three decades, programming strategies continuously improved to due to the development of DBS technologies. The aim of this review is to take a glance into current programming strategies in the era of movement disorders particularly with an updated review of the literature for current and emerging DBS technologies.

Modern electric-based deep brain stimulation (DBS) surgery has been a groundbreaking treatment modality since its first successful application in 1987. There have been many developments in electrical-based DBS technology over the years. We can divide these into titles as implants, stimulation parameters and developments in programming. Apart from that, the technique is in a constant state of evolution in parallel with the developments in many fields such as stereotactic localization, electrophysiology, radiological imaging, data processing and artificial intelligence. In the coming years, many developments are expected that will affect both the implant components, the stimulation parameters and the follow-up and programming processes of the patients.

O-arm® assisted navigation for placement of deep brain stimulation (DBS) electrodes using the Nexframe® device is a relatively new method that has been in use at many centers in the United States. However, no reports have described this operative technique in detail. In this technical report we describe the surgical nuances of this method in a stepwise approach. We also review and discuss the accuracy of this method in comparison to other methods of placing DBS electrodes.

Deep brain stimulation (DBS) is a significant neuromodulation method for treating neurological and psychiatric disorders. Despite its efficacy, complications, particularly infections, are a concern. This article reviews the prevalence, risk factors, pathogens, infection locations, timing, surgical approaches, prevention strategies, and treatment methods associated with infections following DBS procedures. DBS surgeries have gained popularity due to their adjustability, but infections pose challenges. Surgical site infections (SSIs) are common (0% to 24% cases) and extensively studied regarding patient groups, locations, timing, and pathogens. Expanding patient groups, including conditions like Tourette syndrome and epilepsy, have varying infection risks. Infections occur at burr-hole, extension, and implantable pulse generator (IPG) sites. Staphylococcus aureus is a primary pathogen, yet bacterial DNA on IPGs and colonization complicate understanding. Surgical approaches, staged or non-staged, show comparable infection rates. The influence of repetitive pulse generator replacements on infection rates is debated. Lead externalization, topical vancomycin powder, and other factors impact infection risk. Treating DBS-related infections often requires hardware extraction and antibiotic treatment. Innovations like ethylene oxide sterilization and hydrogen peroxide show potential. Algorithms suggest partial explantation for localized infections. Cost analyses favor starting with antibiotics. Infections persist despite progress; understanding risks, pathogens, and strategies is vital for optimal outcomes in DBS.

Despite extensive research efforts, the pathophysiology of obsessive-compulsive disorder (OCD) is still largely unknown. The dorsal anterior cingulate cortex (dACC) plays an important role in cognitive control and is therefore hypothesized to contribute to the pathogenesis of OCD. In this review, we aim to gain a wider understanding of the specific functions of the dACC and its role in the pathophysiology of OCD. The dACC is part of the cortico-basal ganglia-thalamo-cortical loop, where it forms connections between sensory input streams, cognitive and affective processing regions, and structures that regulate behaviour. This position facilitates a broad function for the dACC in multiple domains, which center on goal-directed behaviour and reward-based learning. When presented with a certain threatening stimulus, the dACC instructs downstream structures to select actions to respond to this particular stimulus, based on previous experiences We hypothesize that hyperactivity of the dACC may impair goal-directed behaviour in OCD patients which in turn may lead to obsessive-compulsive symptoms by creating an over-reliance on threatening stimuli and inadequate selection of neutralizing actions. The working mechanisms of cognitive behavioural therapy, serotonergic medication, repetitive transcranial magnetic stimulation and deep brain stimulation in OCD may be in part explained by the normalization of the activity of the dACC within the cortico-basal ganglia-thalamo-cortical (CBGTC) loop.

Background

Closed-loop deep brain stimulation (DBS) uses feedback to infer a clinical state and adjust stimulation accordingly. This novel mechanism has several potential advantages over conventional DBS including reducing stimulation-induced side effects, improving battery longevity, and alleviating symptoms not optimally treated with standard protocols. However, several ethical challenges may arise with the implementation of this technology, particularly with respect to clinical decision making.

Objective

To discuss potential ethical and clinical dilemmas encountered in using closed-loop DBS for neurological and psychiatric disorders.

Methods

The relevant literature is reviewed and supplemented with discussion of ethically challenging clinical scenarios. We outline an ethical framework for addressing these issues and provide practical recommendations for clinicians and researchers.

Results

Ethical considerations in closed-loop DBS revolve around five key principles: 1) risk/benefit analysis; 2) inclusion and exclusion criteria; 3) respect for patient autonomy; 4) quality of life and patient benefit; and 5) concerns associated with recording neural activity.

Conclusion(s)

Developing and implementing a pragmatic framework for ethical considerations in closed-loop DBS will be critical as this technology is utilized in patients with both neurologic and psychiatric indications.