Deep Brain Stimulation of the Lateral Habenular Complex in Treatment-Resistant Depression: Traps and Pitfalls of Trajectory Choice

2012 ◽  
Vol 72 (2) ◽  
pp. ons184-ons193 ◽  
Author(s):  
Till M. Schneider ◽  
Christopher Beynon ◽  
Alexander Sartorius ◽  
Andreas W. Unterberg ◽  
Karl L. Kiening
Keyword(s):  
Deep Brain Stimulation ◽  
Brain Stimulation ◽  
Anterior Commissure ◽  
Data Sets ◽  
Bilateral Stimulation ◽  
Imaging Data ◽  
Posterior Commissure ◽  
Trajectory Angle ◽  
Deep Brain ◽  
Stimulation Of

Abstract BACKGROUND: Deep brain stimulation (DBS) has recently been discussed as a promising treatment option for severe cases of major depression. Experimental data have suggested that the lateral habenular complex (LHb-c) is a central region of depression-related neuronal circuits. Because of its location close to the midline, stereotactic targeting of the LHb-c presents surgeons with distinct challenges. OBJECTIVE: To define the obstacles of DBS surgery for stimulation of the LHb-c and thus to establish safe trajectories. METHODS: Stereotactic magnetic resonance imaging data sets of 54 hemispheres originating from 27 DBS patients were taken for analysis on a stereotactic planning workstation. After alignment of images according to the anterior commissure-posterior commissure definition, analyses focused on vessels and enlarged ventricles interfering with trajectories. RESULTS: As major trajectory obstacles, enlarged ventricles and an interfering superior thalamic vein were found. A standard frontal trajectory (angle > 40° relative to the anterior commissure-posterior commissure in sagittal images) for bilateral stimulation was safely applicable in 48% of patients, whereas a steeper frontal trajectory (angle <40 relative to the anterior commissure-posterior commissure in sagittal images) for bilateral stimulation was possible in 96%. Taken together, safe bilateral targeting of the LHb-c was possible in 98% of all patients. CONCLUSION: Targeting LHb-c is a feasible and safe technique in the majority of patients undergoing surgery for DBS. However, meticulous individual planning to avoid interference with ventricles and thalamus-related veins is mandatory because an alternative steep frontal entry point has to be considered in about half of the patients.

Bilateral stimulation of the subthalamic nucleus in patients with Parkinson disease: a study of efficacy and safety

2002 ◽  
Vol 96 (4) ◽  
pp. 666-672 ◽  
Author(s):  
Tanya Simuni ◽  
Jurg L. Jaggi ◽  
Heather Mulholland ◽  
Howard I. Hurtig ◽  
Amy Colcher ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Bilateral Stimulation ◽  
Content Type ◽  
Preoperative Status ◽  
Fine Print ◽  
Deep Brain ◽  
Stimulation Of

Object. Palliative neurosurgery has reemerged as a valid therapy for patients with advanced Parkinson disease (PD) that is complicated by severe motor fluctuations. Despite great enthusiasm for long-term deep brain stimulation (DBS) of the subthalamic nucleus (STN), existing reports on this treatment are limited. The present study was designed to investigate the safety and efficacy of bilateral stimulation of the STN for the treatment of PD. Methods. In 12 patients with severe PD, electrodes were stereotactically implanted into the STN with the assistance of electrophysiological conformation of the target location. All patients were evaluated preoperatively during both medication-off and -on conditions, as well as postoperatively at 3, 6, and 12 months during medication-on and -off states and stimulation-on and -off conditions. Tests included assessments based on the Unified Parkinson's Disease Rating Scale (UPDRS) and timed motor tests. The stimulation effect was significant in patients who were in the medication-off state, resulting in a 47% improvement in the UPDRS Part III (Motor Examination) score at 12 months, compared with preoperative status. The benefit was stable for the duration of the follow-up period. Stimulation produced no additional benefit during the medication-on state, however, when compared with patient preoperative status. Significant improvements were made in reducing dyskinesias, fluctuations, and duration of off periods. Conclusions. This study demonstrates that DBS of the STN is an effective treatment for patients with advanced, medication-refractory PD. Deep brain stimulation of the STN produced robust improvements in motor performance in these severely disabled patients while they were in the medication-off state. Serious adverse events were common in this cohort; however, only two patients suffered permanent sequelae.

Brain Shift and Pneumocephalus Assessment During Frame-Based Deep Brain Stimulation Implantation With Intraoperative Magnetic Resonance Imaging

2017 ◽  
Vol 14 (6) ◽  
pp. 668-674 ◽  
Author(s):  
Caio M Matias ◽  
Leonardo A Frizon ◽  
Fadi Asfahan ◽  
Juan D Uribe ◽  
Andre G Machado
Keyword(s):  
Magnetic Resonance Imaging ◽  
Deep Brain Stimulation ◽  
Magnetic Resonance ◽  
Brain Stimulation ◽  
Anterior Commissure ◽  
Brain Shift ◽  
Resonance Imaging ◽  
Posterior Commissure ◽  
Anatomic Landmarks ◽  
Deep Brain

Abstract BACKGROUND Brain shift and pneumocephalus are major concerns regarding deep brain stimulation (DBS). OBJECTIVE To report the extent of brain shift in deep structures and pneumocephalus in intraoperative magnetic resonance imaging (MRI). METHODS Twenty patients underwent bilateral DBS implantation in an MRI suite. Volume of pneumocephalus, duration of procedure, and 6 anatomic landmarks (anterior commissure, posterior commissure, right fornix [RF], left fornix [LF], right putaminal point, and left putaminal point) were measured. RESULTS Pneumocephalus varied from 0 to 32 mL (median = 0.6 mL). Duration of the procedure was on average 195.5 min (118-268 min) and was not correlated with the amount of pneumocephalus. There was a significant posterior displacement of the anterior commissure (mean = −1.1 mm, P < .001), RF (mean = −0.6 mm, P < .001), LF (mean = −0.7 mm, P < .001), right putaminal point (mean = −0.9 mm, P = .001), and left putaminal point (mean = −1.0 mm, P = .001), but not of the posterior commissure (mean = 0.0 mm, P = .85). Both RF (mean = −.7 mm, P < .001) and LF (mean = −0.5 mm, P < .001) were posteriorly displaced after a right-sided burr hole. There was a correlation between anatomic landmarks displacement and pneumocephalus after 2 burr holes (rho = 0.61, P = .007), but not after 1 burr hole (rho = 0.16, P = .60). CONCLUSION Better understanding of how pneumocephalus displaces subcortical structures can significantly enhance our intraoperative decision making and overall targeting strategy.

New method of deep brain stimulation therapy with two electrodes implanted in parallel and side by side

2001 ◽  
Vol 95 (6) ◽  
pp. 1075-1078 ◽  
Author(s):  
Takamitsu Yamamoto ◽  
Yoichi Katayama ◽  
Chikashi Fukaya ◽  
Hideki Oshima ◽  
Masahiko Kasai ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Adverse Effects ◽  
Brain Stimulation ◽  
Anterior Commissure ◽  
Posterior Commissure ◽  
Electrical Currents ◽  
Direction Parallel ◽  
Content Type ◽  
Contact Points ◽  
Deep Brain

✓ Reversibility and adaptability are preferred features of long-term therapeutic deep brain stimulation (DBS). In such therapy, a permanent stimulating electrode with four contact points is placed at the stimulation site and, generally speaking, bipolar stimulation is induced by various pairs of adjacent contact points on one electrode. The stimulation sites are thus all located along the trajectory of the implanted electrode. In a patient with unilateral severe essential tremor, the authors implanted two electrodes side by side and parallel to each other in the unilateral thalamic ventralis intermedius nucleus. Using these electrodes, the authors were able to deliver current flow not only along the electrode trajectory, but also between the two electrodes in a direction parallel to the anterior commissure—posterior commissure line. Although individual stimulations, delivered by each of the two electrodes using all parameters and all stimulation points, were unable to stop the patient's tremor completely without adverse effects, the new stimulation method, in which electrical currents passed between the two electrodes, effected complete abolition of the tremor without adverse effects. With the aid of this method, one can use two electrodes, implanted in parallel and side by side, to achieve maximum efficacy and to reduce adverse effects in some instances of DBS therapy.

A randomized double-blind crossover trial comparing subthalamic and pallidal deep brain stimulation for dystonia

2013 ◽  
Vol 119 (6) ◽  
pp. 1537-1545 ◽  
Author(s):  
Lisbeth Schjerling ◽  
Lena E. Hjermind ◽  
Bo Jespersen ◽  
Flemming F. Madsen ◽  
Jannick Brennum ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Deep Brain Stimulation ◽  
Brain Stimulation ◽  
Rating Scale ◽  
Bilateral Stimulation ◽  
Double Blind ◽  
Video Recordings ◽  
Deep Brain ◽  
Stimulation Of

Object The authors' aim was to compare the subthalamic nucleus (STN) with the globus pallidus internus (GPi) as a stimulation target for deep brain stimulation (DBS) for medically refractory dystonia. Methods In a prospective double-blind crossover study, electrodes were bilaterally implanted in the STN and GPi of 12 patients with focal, multifocal, or generalized dystonia. Each patient was randomly selected to undergo initial bilateral stimulation of either the STN or the GPi for 6 months, followed by bilateral stimulation of the other nucleus for another 6 months. Preoperative and postoperative ratings were assessed by using the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) and video recordings. Quality of life was evaluated by using questionnaires (36-item Short Form Health Survey). Supplemental Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) scores were assessed for patients with focal dystonia (torticollis) by examining the video recordings. Results On average for all patients, DBS improved the BFMDRS movement scores (p < 0.05) and quality of life physical scores (p < 0.01). After stimulation of the STN, the mean 6-month improvement in BFMDRS movement score was 13.8 points; after stimulation of the GPi, this improvement was 9.1 points (p = 0.08). Quality of life did not differ significantly regardless of which nucleus was stimulated. All 12 patients accepted 6 months of stimulation of the STN, but only 7 accepted 6 months of stimulation of the GPi. Among those who rejected stimulation of the GPi, 3 accepted concomitant stimulation of both the STN and GPi for 6 months, resulting in improved quality of life physical and mental scores and BFMDRS movement scores. Among the 4 patients who were rated according to TWSTRS, after 6 months of stimulation of both the STN and GPi, TWSTRS scores improved by 4.7% after stimulation of the GPi and 50.8% after stimulation of the STN (p = 0.08). Conclusions The STN seems to be a well-accepted, safe, and promising stimulation target in the treatment of dystonia, but further studies are necessary before the optimal target can be concluded. Simultaneous stimulation of the STN and GPi should be further investigated. Clinical trial registration no.: KF 01-110/01 (Committees on Biomedical Research Ethics of the Capital Region of Denmark).

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