Introduction to Deep Brain Stimulation

It is estimated that over 160,000 patients worldwide have received deep brain stimulation (DBS) to date predominantly for Parkinson's disease and other movement disorders. With the success of this therapy, a greater appreciation of the clinical benefits and adverse effects is being realized. Neurosurgeons are increasingly paying attention to the technical details of these procedures and optimizing targeting, surgical techniques, and programming to improve outcomes.In this issue, the nuances of surgical techniques for DBS are covered by Dr. House. Dr. Toda et al. and Mr. Chartrain et al. tackle the approach to treating tremors, either essential tremor or Holmes tremor, using either a single target or, in cases of difficult-to-treat tremors, using more than one target and interleaving the stimulation. These abstracts and videos will be appreciated by both those who are being initiated to DBS and the more seasoned practitioners who are looking for helpful hints to tackle challenging cases.

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Ultrahigh Frequency Deep Brain Stimulation at 10 000 Hz Improves Motor Function

Neurosurgery ◽

10.1093/neuros/nyz310_367 ◽

2019 ◽

Vol 66 (Supplement_1) ◽

Author(s):

Irene E Harmsen ◽

Darrin J Lee ◽

Robert F Dallapiazza ◽

Philippe De Vloo ◽

Robert Chen ◽

...

Keyword(s):

Spinal Cord ◽

Deep Brain Stimulation ◽

Adverse Effects ◽

Brain Stimulation ◽

Spinal Cord Stimulation ◽

Ultrahigh Frequency ◽

Clinical Effects ◽

Stimulation Parameters ◽

Clinical Benefits ◽

Deep Brain

Abstract INTRODUCTION Stimulation frequency has been considered a crucial determinant of efficacy in deep brain stimulation (DBS). DBS at frequencies over 250 Hz is not currently employed and consensus in the field suggests that higher frequencies are not clinically effective. With the recent demonstration of clinically effective ultrahigh frequency (UHF) spinal cord stimulation at 10 kHz we tested whether UHF stimulation could also be clinically useful in movement disorder patients with DBS. We evaluated the clinical effects and safety of UHF DBS in patients with subthalamic nucleus (STN) or ventral intermediate thalamic nucleus (VIM) DBS. METHODS We studied the effects of conventional (130 Hz) and UHF stimulation in 5 patients with Parkinson's disease (PD) with STN DBS and in one patient with essential tremor (ET) with VIM DBS. We compared the clinical benefit and adverse effects of stimulation at various amplitudes either intraoperatively or postoperatively with the electrodes externalized. RESULTS Motor performance improved in all 6 patients with UHF DBS. About 10 kHz stimulation at amplitudes = 3.0 mA appeared to be as effective as 130 Hz in improving motor symptoms (46.2% vs 53.5% motor score reduction, P = .110, N = 90 trials). Interestingly, 10 kHz stimulation resulted in fewer stimulation-induced paresthesiae and speech adverse effects than 130 Hz stimulation. CONCLUSION Our results indicate that DBS at 10 kHz produces clinical benefits in patients with movement disorders. Like 10 kHz spinal cord stimulation, 10 kHz DBS has the potential to produce clinical benefits while possibly reducing stimulation-induced adverse effects. Further studies will be required to optimize UHF DBS stimulation parameters and to determine its clinical utility.

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Multitarget deep brain stimulation for clinically complex movement disorders

Journal of Neurosurgery ◽

10.3171/2019.11.jns192224 ◽

2020 ◽

pp. 1-6 ◽

Cited By ~ 1

Author(s):

Tariq Parker ◽

Ashley L. B. Raghu ◽

James J. FitzGerald ◽

Alexander L. Green ◽

Tipu Z. Aziz

Keyword(s):

Deep Brain Stimulation ◽

Brain Stimulation ◽

Movement Disorders ◽

Electrode Placement ◽

Rational Approach ◽

Pallidal Stimulation ◽

Holmes Tremor ◽

Brainstem Stroke ◽

Complex Movement ◽

Deep Brain

Deep brain stimulation (DBS) of single-target nuclei has produced remarkable functional outcomes in a number of movement disorders such as Parkinson’s disease, essential tremor, and dystonia. While these benefits are well established, DBS efficacy and strategy for unusual, unclassified movement disorder syndromes is less clear. A strategy of dual pallidal and thalamic electrode placement is a rational approach in such cases where there is profound, medically refractory functional impairment. The authors report a series of such cases: midbrain cavernoma hemorrhage with olivary hypertrophy, spinocerebellar ataxia-like disorder of probable genetic origin, Holmes tremor secondary to brainstem stroke, and hemiballismus due to traumatic thalamic hemorrhage, all treated by dual pallidal and thalamic DBS. All patients demonstrated robust benefit from DBS, maintained in long-term follow-up. This series demonstrates the flexibility and efficacy, but also the limitations, of dual thalamo-pallidal stimulation for managing axial and limb symptoms of tremors, dystonia, chorea, and hemiballismus in patients with complex movement disorders.

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Recording Techniques Related to Deep Brain Stimulation for Movement Disorders and Responsive Stimulation for Epilepsy

10.1093/med/9780190228484.003.0038 ◽

2017 ◽

Author(s):

Jay L. Shils ◽

Sepehr Sani ◽

Ryan Kochanski ◽

Mena Kerolus ◽

Jeffrey E. Arle

Keyword(s):

Deep Brain Stimulation ◽

Brain Stimulation ◽

Movement Disorders ◽

Surgical Techniques ◽

Optimal Location ◽

Electrode Placement ◽

Functional Localization ◽

Preoperative Magnetic Resonance ◽

Intracranial Electroencephalography ◽

Deep Brain

Neuromodulation therapies are now common treatments for a variety of medically refractory disorders, including movement disorders and epilepsy. While surgical techniques for each disorder vary, electricity is used by both for relieving symptoms. During stereotactic placement of the stimulating electrode, either deep brain stimulation electrodes or cortical strip electrodes, intraoperative neurophysiology is used to localize the target structure. This physiology includes single-unit recordings, neurostimulation evoked response evaluation, and intracranial electroencephalography (EEG) to ensure the electrode leads are in the optimal location. Because the functional target for the responsive neurostimulator is more easily visualized on preoperative magnetic resonance imaging, intraoperative physiology is used more as a confirmatory tool, in contrast to the more functional localization-based use during electrode placement for movement disorders. This chapter discusses surgical placement of the electrodes for each procedure and the physiological guidance methodology used to place the leads in the optimal location.

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Speech and language adverse effects after thalamotomy and deep brain stimulation in patients with movement disorders: A meta-analysis

Movement Disorders ◽

10.1002/mds.26924 ◽

2017 ◽

Vol 32 (1) ◽

pp. 53-63 ◽

Cited By ~ 39

Author(s):

Soha Alomar ◽

Nicolas K.K. King ◽

Joseph Tam ◽

Ausaf A. Bari ◽

Clement Hamani ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Adverse Effects ◽

Brain Stimulation ◽

Movement Disorders ◽

Meta Analysis ◽

Speech And Language ◽

Deep Brain

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P.089 Ultra-high frequency deep brain stimulation at 10,000 Hz improves motor function

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2019.184 ◽

2019 ◽

Vol 46 (s1) ◽

pp. S37 ◽

Cited By ~ 1

Author(s):

IE Harmsen ◽

DJ Lee ◽

RF Dallapiazza ◽

P De Vloo ◽

R Chen ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Adverse Effects ◽

Brain Stimulation ◽

High Frequency ◽

Motor Score ◽

Ultra High Frequency ◽

Clinical Benefits ◽

Stn Dbs ◽

Recent Demonstration ◽

Deep Brain

Background: Stimulation frequency has been considered a crucial determinant of efficacy in deep brain stimulation (DBS). DBS at frequencies over 250Hz is not currently employed and consensus in the field suggests that higher frequencies are not clinically effective. With the recent demonstration of clinically effective ultra-high frequency (UHF) spinal cord stimulation at 10kHz we tested whether UHF stimulation could also be clinically useful in movement disorder patients with DBS. Methods: We studied the effects of conventional (130Hz) and UHF stimulation in five patients with Parkinson’s disease (PD) with STN DBS and in one patient with essential tremor (ET) with VIM DBS. We compared the clinical benefit and adverse effects of stimulation at various amplitudes either intraoperatively or postoperatively with the electrodes externalized. Results: Motor performance improved in all six patients with UHF DBS. 10kHz stimulation at amplitudes ≥3.0mA appeared to be as effective as 130Hz in improving motor symptoms (46.2% vs 53.5% motor score reduction, p=0.110, N=90 trials). Interestingly, 10kHz stimulation resulted in fewer stimulation-induced paresthesiae and speech adverse effects than 130Hz stimulation. Conclusions: Our results indicate that DBS at 10kHz produces clinical benefits while possibly reducing stimulation-induced adverse effects in patients with movement disorders.

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The Effect of Deep Brain Stimulation for Movement Disorders on Emotions

PsycEXTRA Dataset ◽

10.1037/e626972012-165 ◽

2008 ◽

Author(s):

Jonathan D. Richards ◽

Paul M. Wilson ◽

Pennie S. Seibert ◽

Carin M. Patterson ◽

Caitlin C. Otto ◽

...

Keyword(s):

Deep Brain Stimulation ◽

Brain Stimulation ◽

Movement Disorders ◽

Deep Brain

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Reoperation for device infection and erosion following deep brain stimulation implantable pulse generator placement

Journal of Neurosurgery ◽

10.3171/2019.3.jns183023 ◽

2020 ◽

Vol 133 (2) ◽

pp. 403-410 ◽

Cited By ~ 1

Author(s):

Travis J. Atchley ◽

Nicholas M. B. Laskay ◽

Brandon A. Sherrod ◽

A. K. M. Fazlur Rahman ◽

Harrison C. Walker ◽

...

Keyword(s):

Risk Factors ◽

Logistic Regression ◽

Deep Brain Stimulation ◽

Brain Stimulation ◽

Movement Disorders ◽

Pulse Generator ◽

Rank Test ◽

Implantable Pulse Generator ◽

Device Infection ◽

Deep Brain

OBJECTIVEInfection and erosion following implantable pulse generator (IPG) placement are associated with morbidity and cost for patients with deep brain stimulation (DBS) systems. Here, the authors provide a detailed characterization of infection and erosion events in a large cohort that underwent DBS surgery for movement disorders.METHODSThe authors retrospectively reviewed consecutive IPG placements and replacements in patients who had undergone DBS surgery for movement disorders at the University of Alabama at Birmingham between 2013 and 2016. IPG procedures occurring before 2013 in these patients were also captured. Descriptive statistics, survival analyses, and logistic regression were performed using generalized linear mixed effects models to examine risk factors for the primary outcomes of interest: infection within 1 year or erosion within 2 years of IPG placement.RESULTSIn the study period, 384 patients underwent a total of 995 IPG procedures (46.4% were initial placements) and had a median follow-up of 2.9 years. Reoperation for infection occurred after 27 procedures (2.7%) in 21 patients (5.5%). No difference in the infection rate was observed for initial placement versus replacement (p = 0.838). Reoperation for erosion occurred after 16 procedures (1.6%) in 15 patients (3.9%). Median time to reoperation for infection and erosion was 51 days (IQR 24–129 days) and 149 days (IQR 112–285 days), respectively. Four patients with infection (19.0%) developed a second infection requiring a same-side reoperation, two of whom developed a third infection. Intraoperative vancomycin powder was used in 158 cases (15.9%) and did not decrease the infection risk (infected: 3.2% with vancomycin vs 2.6% without, p = 0.922, log-rank test). On logistic regression, a previous infection increased the risk for infection (OR 35.0, 95% CI 7.9–156.2, p < 0.0001) and a lower patient BMI was a risk factor for erosion (BMI ≤ 24 kg/m2: OR 3.1, 95% CI 1.1–8.6, p = 0.03).CONCLUSIONSIPG-related infection and erosion following DBS surgery are uncommon but clinically significant events. Their respective timelines and risk factors suggest different etiologies and thus different potential corrective procedures.

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Predicting optimal deep brain stimulation parameters for Parkinson’s disease using functional MRI and machine learning

Nature Communications ◽

10.1038/s41467-021-23311-9 ◽

2021 ◽

Vol 12 (1) ◽

Author(s):

Alexandre Boutet ◽

Radhika Madhavan ◽

Gavin J. B. Elias ◽

Suresh E. Joel ◽

Robert Gramer ◽

...

Keyword(s):

Machine Learning ◽

Parkinson’S Disease ◽

Parkinson's Disease ◽

Deep Brain Stimulation ◽

Brain Stimulation ◽

A Priori ◽

Brain Response ◽

Brain Responses ◽

Clinical Benefits ◽

Deep Brain

AbstractCommonly used for Parkinson’s disease (PD), deep brain stimulation (DBS) produces marked clinical benefits when optimized. However, assessing the large number of possible stimulation settings (i.e., programming) requires numerous clinic visits. Here, we examine whether functional magnetic resonance imaging (fMRI) can be used to predict optimal stimulation settings for individual patients. We analyze 3 T fMRI data prospectively acquired as part of an observational trial in 67 PD patients using optimal and non-optimal stimulation settings. Clinically optimal stimulation produces a characteristic fMRI brain response pattern marked by preferential engagement of the motor circuit. Then, we build a machine learning model predicting optimal vs. non-optimal settings using the fMRI patterns of 39 PD patients with a priori clinically optimized DBS (88% accuracy). The model predicts optimal stimulation settings in unseen datasets: a priori clinically optimized and stimulation-naïve PD patients. We propose that fMRI brain responses to DBS stimulation in PD patients could represent an objective biomarker of clinical response. Upon further validation with additional studies, these findings may open the door to functional imaging-assisted DBS programming.

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