Deep Brain Stimulation最新文献

Electrical stimulation and recording from non-cranial areas in freely moving rodents often require tethered devices for monitoring from a distant location. Inspired by our experience in electrode implantation for deep brain stimulation (DBS), we developed an implantation approach, which allows for performing electrical modulation of the urinary bladder. In order to prevent the wires from being damaged by rats in freely moving conditions and compromising animal welfare, we guided the wires subcutaneously toward the nape to reach a plug, which was mounted on the skull. No complications such as infection, gastrointestinal tract injury, or inflammation occurred during or after surgery. The device allowed easy plugging and unplugging throughout the bladder stimulation and behavioral testing sessions undertaken in freely moving animals. This method enables modulation of peripheral organs in combination with DBS in freely moving rodents and can encompass many procedures such as electrical stimulation and recording, drug delivery, or electromyography.

Background

Preoperative Magnetic Resonance Imaging (MRI) and Computed Tomography (CT) coregistration is often applied to perform deep brain stimulation (DBS) surgeries. Thin sliced (high dose) CT is used and recommended because of the high reported accuracy but there are no comparative studies. Thin sliced CT could lead to a higher radiation exposure for the patient in contrast to thicker sliced CT (low dose) due to a longer scanning time. In this study we investigated if the preoperative CT slice thickness had an effect on the registration accuracy in a preoperative simulated DBS setting.

Material and methods

An implanted phantom, a Citrullus lanatus (watermelon), was used to acquire an MRI data set (2 millimeter (mm) T2) with a fixed reference point. Two observers targeted the reference point independently and they recorded and compared the coordinates, ring, and arc angles from all coregistered series with different CT slice thicknesses of 0.5 mm, 1 mm, 1.5 mm, 2 mm, 3 mm, 4 mm, and 5 mm. Separately, both MRI and CT were used as reference series for coregistration and analysis. Lastly, inter-observer reliability was calculated with Kendall’s coefficient of concordance (W). With W> 0.9 defined as very good.

Results

Our results show no relevant effect on the preoperative registration accuracies for the different CT’s with all absolute differences in mm for the stereotactic coordinates< 0.5 and angles in degrees< 0.4. Additionally, the inter-observer reliability was high (W 0.991).

Conclusion

We found no relevant effect of increased slice thickness of preoperative CT on the preoperative registration accuracy in a simulated DBS setting.

Background

Peri-lead edema (PLE) following deep brain stimulation surgery is apparently a common, self-limiting condition. PLE generally occurs within days to weeks, rarely occurring before postoperative day one. Majority of patients are asymptomatic, although a wide range of sings/symptoms may be present.

Case description

A 62-year-old female patient with Parkinson’s Disease underwent DBS of the subthalamic nucleus in November 2018. Asymptomatic, the patient presented bilateral PLE in the immediate post-operative CT. After two weeks, she developed a frontal lobe dysfunction and persistence of PLE in MRI. She underwent a three-week course of dexamethasone, with mild improvement. However, she subsequently fell at home in January 2019, sustaining an injury to the scalp over the connection site surgical incision. Due to persisting PLE, this was managed with a new course of Dexamethasone, and she was followed-up with CT scans. Two months later (March 2019) the patient presented with urinary tract infection and a lateral scalp erosion over the lead’s connection site. Debridement and primary closure of the skin were performed, followed by a four-week vancomycin course. A MRI at the stage showed marked improvement of the edema. The most recent MRI (May 2019) and CT scan (July 2019) showed resolution of the edema.

Conclusions

We reported an atypical case of ultra early and persistent PLE presentation following DBS surgery, which improved with courses of steroids. It is unknown whether steroids have a role in the management of PLE.

Background

Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been widely performed for medically refractory Parkinson's disease (PD). Recent new technology of the multiple independent current control (MICC) with the directional lead provides both vertical and horizontal current steering on purposes. Consequently, MICC directional lead allows fine stimulation adjustment tailoring the condition of the individual patient. It is also expected to avoid stimulation induced adverse effects.

Methods

We retrospectively investigated the situation of current steering and the reason for doing so 3-month and 1-year after surgery in 80 patients who underwent bilateral STN-DBS for PD using MICC directional lead.

Results

In 160 leads of 80 patients, current steering was used in 39 leads (24%) 3-month after surgery, but in 80 leads (50%) 1-year after surgery. As for the reason, vertical steering was used in 7 leads (4%) and horizontal steering was used in 28 leads (18%) to explore better stimulation effect for cardinal symptoms of PD. In addition, vertical steering was used for improving dyskinesia in 40 leads (25%) and alleviating tremor in 5 leads (3%). Horizontal steering was also used for avoiding adverse effects in 15 leads (9%), most of which were used to alleviate the symptoms of excessive stimulation of pyramidal tract.

Conclusions

Current steering with the MICC directional lead was actually utilized in STN-DBS to explore more precise control of motor symptoms and also useful to avoid stimulation-induced adverse effect. Current steering is especially used in the later period after introduction of DBS.

Deep brain stimulation (DBS) is an important clinical therapeutic tool to control motor symptoms of Parkinson’s disease (PD) for many patients whose symptoms are not well controlled by medication alone (Malek, 2019 [1]). DBS therapy involves the delivery of an electrical current through an electrode that is surgically placed in the brain, traditionally in the subthalamic nucleus (STN) or globus pallidus internus (GPi). Recent technology has allowed these devices to not only deliver an electrical current, but also measure local field potentials (LFPs). LFPs are electrical potentials, produced by the activation of neurons, that act as markers for the frequency and severity of specific motor symptoms in PD (Neumann et al., 2017 [2], Swann et al., 2016 [3]). These markers can give insight into the efficacy of a given treatment regiment, by providing data to use as clinical benchmarks for the treatment team. The utility of LFPs in the treatment of PD is illustrated in this case series of three patients with complex motor fluctuations such as dyskinesias, Levodopa wearing-off and muscle rigidity. Here we demonstrate how we used LFP sensing through Timeline, Streaming and Event Capture to gain insight to the patients’ symptoms and offer data driven therapy optimization. The first case is a 72-year-old y/o female patient with PD, who presented with severe dyskinesias and motor fluctuations. By monitoring real-time LFPs, the treatment team was able to identify significant dyskinesias and optimize medication and stimulation frequency, which led to more personalized and efficacious treatment. The second case is a 66 y/o male patient with PD, hoping to achieve more on time without troublesome dyskinesias. Using chronic LFP data the treatment team was able to adjust therapy amplitude and pulse width to better manage the patient’s symptoms. In addition, the LFP data was used to educate the patient on when the patient programmer could be used situationally for changing programming groups. The third case is a 65 y/o male patient with a ten-year history of PD, experiencing abrupt and unpredictable medication wearing off times and severe dyskinesias, which compromised gait and activities of daily living. Real time and chronic LFP sensing supported the optimization of his stimulation amplitude and pulse width and medication regimen, ultimately decreasing his fluctuations and greatly improving his gait and quality of life.

Background

Women with Parkinson’s Disease (PD) receive Deep Brain Stimulation (DBS) less often than men.

Objective

To determine gender differences in the use of DBS for PD and essential tremor (ET) in the United States and at a single academic center.

Methods

The Nationwide Readmissions Database (NRD) was used to identify patients with PD and ET who underwent DBS from 2016 to 2017. The primary outcome was a comparison of the proportions of women and men who underwent DBS using chi-square tests. Locally, we identified patients with PD and ET referred for DBS from 2011 to 2020. The primary outcomes included a comparison of the proportions of women and men who were referred, completed the evaluation, were approved for surgery, and underwent DBS using Fisher’s exact tests.

Results

From 2016–2017, 6952 patients with PD (30.5% women) and 3000 patients with ET (42.6% women) underwent DBS in the United States. At a single academic center, 428 patients with PD (30.6% women) and 126 patients with ET (34% women) were referred for DBS, which was significantly different than the proportion of women with PD and ET in the neurology clinic population (p = 0.001 and p < 0.001, respectively). In both groups, women and men were equally likely to complete the evaluation and be approved for surgery; however, women with ET were more likely to decline surgery (35% vs 13%, p = 0.05).

Conclusion

Women with PD and ET were less likely to be referred for DBS evaluation, and women with ET were more likely to decline surgery once approved.

Background

Huntington's disease (HD) is a hereditary neurodegenerative disease leading to cognitive and motor impairment. HD depends on basal ganglia dysfunctions, but the role of subthalamic nucleus (STN) neurons is not completely known. Drug-resistant motor symptoms of HD can be alleviated by neuromodulation of the basal ganglia through Deep Brain Stimulation (DBS) of STN. DBS target selection is supported by intra-operative microelectrode recordings (MER). MER have been previously used to characterize neural dynamics of STN in several movement disorders and can provide information on firing patterns underlying HD.

Methods

We analyzed MER data acquired during bilateral DBS of STN in a juvenile HD female patient with hypokinetic motor symptoms (generalized dystonia, stiffness, and severe gait impairment). Firing patterns of STN in HD were characterized by isolating single neuron activities (n = 23) and measuring their regularity, bursting, and oscillatory behavior. Multi-unit activity recordings spectrum was used to estimate the presence of network oscillations.

Results

STN neurons displayed irregular dynamics and intense and sparse bursting. Only 3/23 neurons presented oscillatory activity. However, network oscillations were detected, in particular in the beta (12–30 Hz) band. After bilateral STN-DBS surgery, the Unified Huntington's Disease Rating Scale decreased from 60 to 54.

Conclusions

The most salient difference between HD and other movement disorders in STN activity is the presence of a weakly synchronized oscillatory mode, in which oscillations are evident at the network level but not at the single neuron level.