Deep brain stimulation for the treatment of parkinsonian, essential, and poststroke tremor: a suitable stimulation method and changes in effective stimulation intensity

2004 ◽  
Vol 101 (2) ◽  
pp. 201-209 ◽  
Author(s):  
Takamitsu Yamamoto ◽  
Yoichi Katayama ◽  
Toshikazu Kano ◽  
Kazutaka Kobayashi ◽  
Hideki Oshima ◽  
...  
Keyword(s):  
Essential Tremor ◽  
Content Type ◽  
Parkinsonian Tremor ◽  
Stimulation Intensity ◽  
Tremor Suppression ◽  
Cathodal Stimulation ◽  
Fine Print ◽  
Deep Brain ◽  
Stimulation Of

Object. The tremor-suppression effect resulting from long-term stimulation of the thalamic nucleus ventralis intermedius (Vim) and the nucleus ventralis oralis posterior (Vop) was examined in the treatment of parkinsonian, essential, and poststroke tremor. Methods. After identifying the accurate anterior border of the nucleus ventrocaudalis (Vc), deep brain stimulation (DBS) electrodes with four contacts were inserted into the Vim—Vop region at an angle of between 40 and 50° from the horizontal plane of the anterior commissure—posterior commissure line. Two distal contacts were placed on the Vim side and two proximal contacts on the Vop side. The best sites of stimulation and parameters of bipolar stimulation were selected in each case and follow-up examinations were conducted for at least 2 years. In all 15 cases of parkinsonian tremor (18 sides) and in 14 of 15 cases of essential tremor (24 of 25 sides), cathodal stimulation of the Vim side with anodal stimulation of the Vop side was determined to be the best choice to suppress the tremor. In poststroke tremor, however, six of 12 cases (six of 12 sides) were selected for cathodal stimulation of the Vop side with anodal stimulation of the Vim side. The average stimulation intensity 1 month after initiation of DBS was 1.61 V in cases of parkinsonian tremor, 1.99 V in cases of essential tremor, and 2.39 V in cases of poststroke tremor. A comparison of stimulation intensities required at 1 and 24 months after initiation of DBS revealed that the lowest effective stimulation intensity increased 24.2% in cases of parkinsonian tremor, 21% in cases of poststroke tremor, and 46.9% in cases of essential tremor. Suppression of tremor was achieved in all cases (42 cases, 55 sides) during a period of 2 years. Nevertheless, two cases of poststroke tremor required dual-lead stimulation at the unilateral Vim—Vop region from the start of DBS, and two cases of essential tremor and one case of poststroke tremor required a stimulation intensity that was high enough to evoke unpleasant paresthesia and slight motor contraction during the follow-up period. Conclusions. Effective stimulation sites and stimulation intensities differ in different kinds of tremor; Vim and Vop stimulation is necessary in many cases. Interactions of the Vim and Vop under the control of interconnected areas of the motor circuitry may play an important role in both the development and DBS-induced suppression of tremor.

Stimulation of the subthalamic region for essential tremor

2004 ◽  
Vol 101 (1) ◽  
pp. 48-54 ◽  
Author(s):  
Puneet Plaha ◽  
Nikunj K. Patel ◽  
Steven S. Gill
Keyword(s):  
Essential Tremor ◽  
Upper Limb ◽  
Functional Disability ◽  
Rating Scale ◽  
Related Complication ◽  
Content Type ◽  
The Mean ◽  
Fine Print ◽  
Deep Brain

Object. The goal of this study was to determine the safety and efficacy of bilateral subthalamic region stimulation in the treatment of essential tremor (ET). Methods. Following induction of general anesthesia, four patients with disabling tremor that had proved to be refractory to pharmacotherapy underwent magnetic resonance imaging—guided deep brain stimulation (DBS) of the bilateral subthalamic region. Tremor was assessed by applying the Fahn-Tolosa-Marín Tremor Rating Scale at baseline and again at the 12-month follow-up examination. Following surgery the total tremor score improved by 80.1% (from a baseline mean score of 63 ± 15.1 to a score of 11.8 ± 3.9 at 12 months postoperatively). There was a significant improvement (p < 0.0001) in the mean tremor score of the upper limb (postural and action component) from a baseline score of 3 ± 0.9 to a score of 0.5 ± 0.5 at 12 months postoperatively. In two patients with Score 4 head tremor complete arrest of the tremor was observed at 12 months. Motor function scores of the upper limb for drawing spirals, pouring water, and drawing lines improved significantly (p < 0.05) by 66.7, 76.9, and 58.3%, respectively. Handwriting improved by 68%, but this gain was not significant. The mean activities of daily living score at baseline was 20 ± 3.2; there was an 88.8% improvement in this score to 2.3 ± 1.5 at the 12-month evaluation. The voltage required for effective tremor control was low (mean 1.8 ± 0.2 V) and, along with the other parameters of DBS (frequency and pulse width), did not change significantly over the 12-month period. Tolerance to the action component of tremor was not seen. There was no procedural or stimulation-related complication. Conclusions. Bilateral subthalamic region stimulation is effective in arresting tremor and head titubation, as well as functional disability in ET. Complications like dysarthria and disequilibrium were not seen. These patients required low voltages of stimulation and did not develop a tolerance to the treatment.

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.

Long-term deep brain stimulation in elderly patients with cardiac pacemakers

2005 ◽  
Vol 102 (1) ◽  
pp. 53-59 ◽  
Author(s):  
Hans-Holger Capelle ◽  
Richard K. Simpson ◽  
Martin Kronenbuerger ◽  
Jochen Michaelsen ◽  
Volker Tronnier ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Elderly Patients ◽  
Brain Stimulation ◽  
Movement Disorders ◽  
Cardiac Pacemakers ◽  
Content Type ◽  
Two Systems ◽  
Fine Print ◽  
Deep Brain ◽  
Stimulation Of

Object. Deep brain stimulation (DBS) has become an accepted therapy for movement disorders such as Parkinson disease (PD) and essential tremor (ET), when these conditions are refractory to medical treatment. The presence of a cardiac pacemaker is still considered a contraindication for DBS in functional neurosurgery. The goal of this study was to evaluate the technical and clinical management of DBS for the treatment of movement disorders in elderly patients with cardiac pacemakers. Methods. Six patients with cardiac pacemakers underwent clinical and cardiac examinations to analyze the safety of DBS in the treatment of movement disorders. Four patients suffered from advanced PD and two patients had ET. The mean age of these patients at surgery was 69.5 years (range 63–79 years). The settings of the pacemakers were programmed in a manner considered to minimize the chance of interference between the two systems. There were no adverse events during surgery. Four patients underwent stimulation of the thalamic ventralis intermedius nucleus (VIM), and two patients stimulation of the subthalamic nucleus. In general, bipolar sensing was chosen for the cardiac pacemakers. In all but one patient the quadripolar DBS electrodes were programmed for bipolar stimulation. Several control electrocardiography studies, including 24-hour monitoring, did not show any interference between the two systems. At the time this paper was written the patients had been followed up for a mean of 25.3 months (range 4–48 months). Conclusions. In certain conditions it is safe for patients with cardiac pacemakers to receive DBS for treatment of concomitant movement disorders. Cardiac pacemakers should not be viewed as a general contraindication for DBS in patients with movement disorders.

Factors involved in long-term efficacy of deep brain stimulation of the thalamus for essential tremor

2008 ◽  
Vol 109 (4) ◽  
pp. 640-646 ◽  
Author(s):  
Julie G. Pilitsis ◽  
Leo Verhagen Metman ◽  
John R. Toleikis ◽  
Lindsay E. Hughes ◽  
Sepehr B. Sani ◽  
...  
Keyword(s):  
Essential Tremor ◽  
Disease Progression ◽  
Rating Scale ◽  
Long Term Outcomes ◽  
Intraoperative Fluoroscopy ◽  
Duration Of Disease ◽  
Deep Brain ◽  
Stimulation Of

Object Although nucleus ventralis intermedius stimulation has been shown to be safe and efficacious in the treatment of essential tremor, there is a subset of patients who eventually lose benefit from their stimulation. Proposed causes for this phenomenon include tolerance, disease progression, and suboptimal location. The goal of this study was to assess the factors that may lead to both stimulation failure, defined as loss of meaningful tremor relief, and less satisfactory outcomes, defined as leads requiring voltages > 3.6 V for effective tremor control. Methods The authors present their clinical outcomes from 31 leads in 27 patients who had effective tremor control for > 1 year following nucleus ventralis intermedius stimulation. All patients postoperatively had a mean decrease in both the writing and drawing subscales of the Fahn-Tolosa-Marin Tremor Rating Scale (p < 0.001). Results After a mean follow-up of 40 months, 22 patients continued to have tremor control with stimulation. Four patients eventually lost efficacy of their stimulation at a mean of 39 months. There was no difference in age, duration of disease, or disease severity between the groups. Examination of perioperative factors revealed that suboptimal anteroposterior positioning as evidenced on intraoperative fluoroscopy occurred significantly more frequently in patients with stimulation failure (p = 0.018). In patients with less satisfactory outcomes, no difference was seen between group demographics. Fluoroscopy again revealed suboptimal positioning more frequently in these patients (p = 0.005). Conclusions This study provides further evidence that suboptimal lead position in combination with disease progression or tolerance may result in less satisfactory long-term outcomes.

Efficacy of unilateral deep brain stimulation of the thalamic ventralis intermedius nucleus in a patient with bipolar disorder associated with Klinefelter syndrome and essential tremor

2000 ◽  
Vol 93 (1) ◽  
pp. 127-128 ◽  
Author(s):  
Albert E. Telfeian ◽  
John A. Boockvar ◽  
Tanya Simuni ◽  
Jurg Jaggi ◽  
Brett Skolnick ◽  
...  
Keyword(s):  
Bipolar Disorder ◽  
Deep Brain Stimulation ◽  
Essential Tremor ◽  
Brain Stimulation ◽  
Genetic Basis ◽  
Klinefelter Syndrome ◽  
Content Type ◽  
History Of ◽  
Deep Brain ◽  
Stimulation Of

✓ Deep brain stimulation (DBS) of the ventralis intermedius nucleus (Vim) is a safe and effective treatment for essential tremor. Bipolar disorder and essential tremor had each been reported to occur in association with Klinefelter syndrome but the three diseases have been reported to occur together in only one patient. The genetic basis and natural history of these disorders are not completely understood and may be related rather than coincidental. The authors report on a 23-year-old man with Klinefelter syndrome (47,XXY) and bipolar disorder who was treated successfully with unilateral DBS of the thalamic Vim for essential tremor.

Electrical stimulation of the brain in treatment of chronic pain

1985 ◽  
Vol 62 (3) ◽  
pp. 389-396 ◽  
Author(s):  
Ronald F. Young ◽  
Richard Kroening ◽  
Wayne Fulton ◽  
Robert A. Feldman ◽  
Israel Chambi
Keyword(s):  
Chronic Pain ◽  
Electrical Stimulation ◽  
Gray Matter ◽  
Pain Treatment ◽  
Psychiatric Evaluation ◽  
Content Type ◽  
The Brain ◽  
Fine Print ◽  
Stimulation Of

✓ Forty-eight patients underwent electrical stimulation of the brain for treatment of chronic pain between 1978 and 1983. Average pain duration prior to treatment was 4.5 years. Before selection for this procedure patients underwent pain treatment in a multidisciplinary pain center, intensive psychological and psychiatric evaluation, and assessment of pain responsiveness to intravenous administration of placebo, morphine, and naloxone. A total of 71 electrodes were placed in the 48 patients at a variety of stimulating targets, including the periaqueductal gray matter, periventricular gray matter, thalamus, and internal capsule. Seventy-two percent of patients experienced complete or partial pain relief. In addition, 59% of patients were able to discontinue narcotic usage. Twenty-five percent of patients returned to normal physical activities and another 33% showed marked improvement in functional capacity. Follow-up periods ranged from 2 to 60 months; with a mean follow-up period of 20 months. A variety of relatively minor complications occurred, but no mortality or permanent sequelae were experienced. No patient's pain was made worse as a result of electrical stimulation. Electrical stimulation of the brain offers a safe and relatively effective method for the treatment of chronic pain in appropriately selected patients, who are unresponsive to other forms of therapy.

Long-term follow up of bilateral deep brain stimulation of the subthalamic nucleus in patients with advanced Parkinson disease

2003 ◽  
Vol 99 (3) ◽  
pp. 489-495 ◽  
Author(s):  
Galit Kleiner-Fisman ◽  
David N. Fisman ◽  
Elspeth Sime ◽  
Jean A. Saint-Cyr ◽  
Andres M. Lozano ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Parkinson Disease ◽  
Subthalamic Nucleus ◽  
Brain Stimulation ◽  
Content Type ◽  
Over Time ◽  
Fine Print ◽  
Deep Brain

Object. The use of deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been associated with a marked initial improvement in individuals with advanced Parkinson disease (PD). Few data are available on the long-term outcomes of this procedure, however, or whether the initial benefits are sustained over time. The authors present the long-term results of a cohort of 25 individuals who underwent bilateral DBS of the STN between 1996 and 2001 and were followed up for 1 year or longer after implantation of the stimulator. Methods. Patients were evaluated at baseline and repeatedly after surgery by using the Unified Parkinson's Disease Rating Scale (UPDRS); the scale was applied to patients during periods in which antiparkinsonian medications were effective and periods when their effects had worn off. Postoperative UPDRS total scores and subscores, dyskinesia scores, and drug dosages were compared with baseline values, and changes in the patients' postoperative scores were evaluated to assess the possibility that the effect of DBS diminished over time. In this cohort the median duration of follow-up review was 24 months (range 12–52 months). The combined (ADL and motor) total UPDRS score during the medication-off period improved after 1 year, decreasing by 42% relative to baseline (95% confidence interval [CI 35–50%], p < 0.001) and the motor score decreased by 48% (95% CI 42–55%, p < 0.001). These gains did diminish over time, although a sustained clinical benefit remained at the time of the last evaluation (41% improvement over baseline, 95% CI 31–50%; p < 0.001). Axial subscores at the time of the last evaluation showed only a trend toward improvement (p = 0.08), in contrast to scores for total tremor (p < 0.001), rigidity (p < 0.001), and bradykinesia (p = 0.003), for which highly significant differences from baseline were still present at the time of the last evaluation. Medication requirements diminished substantially, with total medication doses reduced by 38% (95% CI 27–48%, p < 0.001) at 1 year and 36% (95% CI 25–48%, p < 0.001) at the time of the last evaluation; this decrease may have accounted, at least in part, for the significant decrease of 46.4% (95% CI 20.2–72.5%, p = 0.007) in dyskinesia scores obtained by patients during the medication-on period. No preoperative demographic variable, such as the patient's age at the time of disease onset, age at surgery, sex, duration of disease before surgery, preoperative drug dosage, or preoperative severity of dyskinesia, was predictive of long-term outcome. The only predictor of a better outcome was the patient's preoperative response to levodopa. Conclusions. In this group of patients with advanced PD who underwent bilateral DBS of the STN, sustained improvement in motor function was present a mean of 2 years after the procedure, and sustained reductions in drug requirements were also achieved. Improvements in tremor, rigidity, and bradykinesia were more marked and better sustained over time than improvements in axial symptoms. A good preoperative response to levodopa predicted a good response to surgery.

Electrical stimulation of the globus pallidus internus in patients with primary generalized dystonia: long-term results

2004 ◽  
Vol 101 (2) ◽  
pp. 189-194 ◽  
Author(s):  
Philippe Coubes ◽  
Laura Cif ◽  
Hassan El Fertit ◽  
Simone Hemm ◽  
Nathalie Vayssiere ◽  
...  
Keyword(s):  
Electrical Stimulation ◽  
Globus Pallidus ◽  
Globus Pallidus Internus ◽  
Long Term Results ◽  
Content Type ◽  
Generalized Dystonia ◽  
Fine Print ◽  
Stimulation Of

Object. Primary generalized dystonia (PGD) is a medically refractory disease of the brain causing twisting or spasmodic movements and abnormal postures. In more than 30% of cases it is associated with the autosomal DYT1 mutation. Continuous electrical stimulation of the globus pallidus internus (GPi) has been used successfully in the treatment of PGD. The aim of this study was to examine the long-term efficacy and safety of deep brain stimulation (DBS) in the treatment of PGD in children and adults with and without the DYT1 mutation. Methods. Thirty-one patients with PGD were selected for surgery. Electrodes were bilaterally implanted under stereotactic guidance and connected to neurostimulators that were inserted subcutaneously. Efficacy was evaluated by comparing scores on the clinical and functional Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) before and after implantation. The efficacy of stimulation improved with time. After 2 years, compared with preoperative values, the mean (± standard deviation) clinical and functional BFMDRS scores had improved by 79 ± 19% and 65 ± 33%, respectively. At the 2-year follow-up examination the improvement was comparable in patients with and without the DYT1 mutation in both the functional (p = 0.12) and clinical (p = 0.33) scores. Children displayed greater improvements in the clinical score than adult patients (p = 0.04) at 2 years of follow up. In contrast, there was no significant difference in functional scores between children and adults (p = 0.95). Conclusions. Electrical stimulation of the GPi is an effective, reversible, and adaptable treatment for PGD and should be considered for conditions refractory to pharmaceutical therapies.

Bilateral thalamic deep brain stimulation for the treatment of head tremor

2002 ◽  
Vol 96 (3) ◽  
pp. 615-618 ◽  
Author(s):  
Caglar Berk ◽  
Christopher R. Honey
Keyword(s):  
Deep Brain Stimulation ◽  
Essential Tremor ◽  
Brain Stimulation ◽  
Rating Scale ◽  
Content Type ◽  
Head Tremor ◽  
Fine Print ◽  
Clinical Rating Scale ◽  
Deep Brain

✓ Isolated head tremor is rare, but can be disabling. The authors' experience with the treatment of limb tremor due to essential tremor led them to consider using bilateral thalamic deep brain stimulation (DBS) in two patients presenting only with disabling head tremor. One patient exhibited no peripheral tremor and the other displayed only a slight upper-limb tremor. Both patients underwent placement of units that apply simultaneous bilateral thalamic DBS. Surgical targets were verified by using intraoperative macrostimulation, and the stimulators were implanted during the same surgery. Patients were videotaped preoperatively and at 2, 4, 6, and 9 months postoperatively during periods in which the stimulators were turned on and off. Videotapes were randomized and rated for resting, postural, and action tremors according to the Fahn clinical rating scale for tremor. Because this scale is not designed for head tremor, the patients were also evaluated on the basis of a functional scale that reflected their quality of life and the amount of disability caused by head tremor. Both patients experienced no tremor after their stimulators were turned on and properly adjusted at the 6th postoperative week. The patients were followed for a total of 9 months and results remained stable throughout this period. No complications were encountered. Bilateral thalamic DBS appears to be an effective and safe treatment for isolated head tremor in patients with essential tremor. The authors present a scale for the functional assessment of head tremor.

Long-term deep brain stimulation in a patient with essential tremor: clinical response and postmortem correlation with stimulator termination sites in ventral thalamus

2000 ◽  
Vol 93 (1) ◽  
pp. 140-144 ◽  
Author(s):  
John A. Boockvar ◽  
Albert Telfeian ◽  
Gordon H. Baltuch ◽  
Brett Skolnick ◽  
Tanya Simuni ◽  
...  
Keyword(s):  
Deep Brain Stimulation ◽  
Essential Tremor ◽  
Brain Stimulation ◽  
Content Type ◽  
Tremor Suppression ◽  
Ventral Thalamus ◽  
Postmortem Studies ◽  
Motor Thalamus ◽  
Deep Brain

✓ Essential tremor can be suppressed with chronic, bilateral deep brain stimulation (DBS) of the ventralis intermedius nucleus (Vim), the cerebellar receiving area of the motor thalamus. The goal in this study was to correlate the location of the electrodes with the clinical efficacy of DBS in a patient with essential tremor. The authors report on a woman with essential tremor in whom chronic bilateral DBS directed to the ventral thalamus produced adequate tremor suppression until her death from unrelated causes 16 months after placement of the electrodes. Neuropathological postmortem studies of the brain in this patient demonstrated that both stimulators terminated in the Vim region of the thalamus, and that chronic DBS elicited minor reactive changes confined to the immediate vicinity of the electrode tracks. Although the authors could not identify neuropathological abnormalities specific to essential tremor, they believe that suppression of essential tremor by chronic DBS correlates with bilateral termination of the stimulators in the Vim region of the thalamus.

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