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Results for “Deep Brain Stimulation”

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PubMed2005

Effects of different electrical parameter settings on the intelligibility of speech in patients with Parkinson's disease treated with subthalamic deep brain stimulation.

We evaluated the effects of different electrical parameter settings on the intelligibility of speech in patients with Parkinson's disease (PD) bilaterally treated with deep brain stimulation (DBS) in the subthalamic nucleus (STN). Ten patients treated with DBS for 15 +/- 5 months (mean, SD) with significant (P < 0.01) symptom reduction (Unified Parkinson's Disease Rating Scale III) were included. In the medication off condition, video laryngostroboscopy was performed and then, in random order, 11 DBS parameter settings were tested. Amplitude was increased and decreased by 25%, frequency was varied in the range 70 to 185 pps, and each of the contacts was tested separately as a cathode. The patients read a standard running text and five nonsense sentences per setting. A listener panel transcribed the nonsense sentences as perceived and valued the quality of speech on a visual analogue scale. With the patients' normally used settings, there was no significant (P = 0.058) group difference between DBS OFF and ON, but in four patients the intelligibility deteriorated with DBS ON. The higher frequencies or increased amplitude caused significant (P < 0.02) impairments of intelligibility, whereas changing the polarity between the separate contacts did not. The settings of amplitude and frequency have a major influence on the intelligibility of speech, emphasizing the importance of meticulous parameter adjustments when programming DBS to minimize side effects related to speech.

Aged↗

PubMed2005

Electroconvulsive therapy for depression in a Parkinson's disease patient with bilateral subthalamic nucleus deep brain stimulators.

We report a patient with advanced Parkinson's disease (PD) who developed a recurrence of major depression with psychotic features after bilateral subthalamic nucleus (STN) deep brain stimulation (DBS) surgery. Electroconvulsive therapy (ECT) dramatically improved the depression without shifting electrode position or damaging the DBS hardware. This case suggests that ECT can be a safe and effective option for severe depression in PD patients treated with STN DBS.

Antiparkinson Agents↗

PubMed2003

Deep brain stimulation: response to neuronal high frequency stimulation is mediated through GABA(A) receptor activation in rats.

High frequency stimulation (HFS) of deep brain regions such as globus pallidus internus or subthalamic nucleus can reverse Parkinson's symptoms probably through activation of gamma-aminobutyric acid (GABA)ergic neurotransmission. To prove the hypothesis, rat striatal slices were stimulated electrically (130 Hz) in vitro and dopamine (DA) outflow was measured using high performance liquid chromatography. HFS induced an attenuation in basal DA release in perfusate. Veratridine-induced DA outflow was blocked by the simultaneous application of HFS. Addition of bicuculline, a GABA(A) receptor antagonist, reversed the effect of HFS on DA outflow. In addition, destruction of striatal GABAergic neurons with kainic acid also reversed the effect of HFS. In conclusion, our present data provide strong evidence that HFS does not only need presynaptic GABA(A) receptors but also intact GABAergic nerve terminals coupled to GABA(A) receptors to exert an inhibitory effect and give a rationale of HFS effectiveness in the treatment of Parkinson's disease.

Animals↗

PubMed2006

Deep brain stimulation in the internal capsule and nucleus accumbens region: responses observed during active and sham programming.

BACKGROUND: Recently, anterior limb of the internal capsule and nucleus accumbens deep brain stimulation (DBS) has been used in the treatment of medication-refractory obsessive-compulsive disorder (OCD). This region has been previously explored with lesion therapy, but with the advent of DBS there exists the possibility of monitoring the acute and chronic effects of electrical stimulation. The stimulation-induced benefits and side effects can be reversibly and blindly applied to a variety of locations in this region. OBJECTIVE: To explore the acute effects of DBS in the anterior limb of the internal capsule and nucleus accumbens region. METHODS: Ten total DBS leads in five patients with chronic and severe treatment-refractory OCD were tested. Patients were examined 30 days after DBS placement and received either "sham" testing or actual testing of the acute effects of DBS (the alternative condition tested 30 days later). RESULTS: Pooled responses were reviewed for comparability of distribution using standard descriptive methods, and relationships between the variables of interest were sought using chi2 analysis. A total of 845 stimulation trials across the five patients were recorded and pooled. Of these 16% were elicited from sham stimulation and 17% from placebo (0 V stimulation). A comparison of active to sham trials showed that sham stimulation was not associated with significant side effects or responses from patients. Non-mood-related responses were found to be significantly associated with the ventral lead contacts (0 and 1) (p = 0.001). Responses such as taste, smell and smile were strongly associated with the most ventral lead positions. Similarly, physiological responses--for example, autonomic changes, increased breathing rate, sweating, nausea, cold sensation, heat sensation, fear, panic and panic episodes--were significantly associated with ventral stimulation (p = 0.001). Fear and panic responses appeared clustered around the most ventral electrode (0). Acute stimulation resulted in either improved or worsened mood responses in both the dorsal and ventral regions of the anterior limb of the internal capsule. CONCLUSION: The acute effects of DBS in the region of the anterior limb of the internal capsule and nucleus accumbens, particularly when obtained in a blinded fashion, provide a unique opportunity to localise brain regions and explore circuitry.

Adult↗

PubMed1999

The effect of deep brain stimulation on the frontal N30 component of somatosensory evoked potentials in advanced Parkinson's disease patients.

OBJECTIVES: In the present study we investigated whether in advanced Parkinson's disease (PD) patients the frontal component of short somatosensory evoked potentials (SEPs) to median nerve stimulation may be modified by basal ganglia deep brain stimulation (DBS). METHODS: We recorded the SEPs in 6 PD patients undergoing bilateral functional neurosurgery in the internal globus pallidus (GPi) (4 patients) and in the nucleus subthalamicus (STN) (two patients) during ineffective and effective bilateral BDS. Pre-operatively, the SEPs were also recorded in off therapy and during apomorphine infusion. RESULTS: From the evaluation of the latency and the amplitude characteristics of the major parietal (N20 and P25) and frontal (N30) components, we observed that whereas the parietal waves did not vary in any condition, the N30 potential showed a remarkable amplitude increase during apomorphine as well as during effective bilateral GPi or STN DBS. Furthermore, after the stimulators were turned off we noticed that the N30 amplitude potential progressively faded almost in parallel with the attenuation of DBS clinical effects. CONCLUSIONS: Our results lead to the conclusion that the bilateral DBS of both GPi and STN is really effective in producing a selective increase of frontal N30 amplitude probably improving the supplementary motor area functional activity, but these results do not clarify whether this amelioration is due to a central or a 'long loop' mechanism.

Antiparkinson Agents↗

PubMed2004

Suicide after successful deep brain stimulation for movement disorders.

The authors observed a high rate of suicide (6/140 patients, 4.3%) in a large cohort of patients with movement disorders treated with deep brain stimulation (DBS). Apparent risk factors included a previous history of severe depression and multiple successive DBS surgeries, whereas there was no relationship with the underlying condition, DBS target, electrical parameters, or modifications of treatment. Paradoxically, all patients experienced an excellent motor outcome following the procedure. The authors propose that patients at high risk for suicide should be excluded from DBS surgery.

Adult↗

PubMed2002

Neuropsychological assessment for management of patients with deep brain stimulation.

The inclusion of cognitive and behavioural criteria has been recommended for the management of patients with deep brain stimulation. A neuropsychological assessment may contribute to different issues: (1) selection of the best candidates for surgery, (2) evaluation of the consequences of surgery, (3) research of the best electrode implantation. Recent neuropsychological studies indicate that (1) with appropriate inclusion criteria, the effects of surgery on cognitive functions are limited; (2) an aggravation of behavioural disorders might be related to subthalamic nucleus (STN) stimulation and depend on electrode location; (3) subthalamic nucleus stimulation, but not the internal globus pallidus stimulation, improves psychomotor efficiency and working memory. These results would suggest that the implanted electrodes are not solely targeting the motor circuit and that the cognitive and motor circuits are not completely segregated.

Basal Ganglia↗

PubMed2003

Globus pallidus internus deep brain stimulation for dystonic conditions: a prospective audit.

In the current era of functional surgery for movement disorders, deep brain stimulation (DBS) of the globus pallidus internus (GPi) is emerging as the favoured target in the treatment of patients with dystonia. The results of 25 consecutive patients with medically intractable dystonia (12 with generalised dystonia, 7 with spasmodic torticollis, and 6 with other types of dystonia) treated with GPi stimulation are reported. Although comparisons were limited by differences in their respective neurological rating scales, chronic DBS benefited all groups, resulting in clear and progressive improvements in their condition. This study clearly demonstrates that DBS of the GPi provides amelioration of intractable dystonia.

Adolescent↗

PubMed2003

Body weight gain rate in patients with Parkinson's disease and deep brain stimulation.

We evaluated body weight changes in patients with Parkinson's disease (PD) after electrode implantation for deep brain stimulation (DBS) in the subthalamic nucleus (STN) in relation to clinical improvement. Thirty PD patients who received STN DBS were included (22 men, 8 women; mean age, 60.0 +/- 7.1 years; mean PD duration, 13.5 +/- 3.7 years; mean body mass index [BMI], 21.6 +/- 3.0 kg/m2). Body weight, physical activity, and Unified Parkinson's Disease Rating Scale (UPDRS) scores were noted before and 3 and 12 months after the procedure. Significant weight gain occurred in 29 patients; the mean increase was 14.8 +/- 9.8% of initial body weight in 1 year. Of the patients, 46.5% reported weight gain in the first 3 months, 21.4% gradual weight gain in the first 6 months, and 32.1% a slow increase for 1 year. Mean BMI increased up to 24.7 +/- 3.7 kg/m2. After 1 year, mean UPDRS motor score improved significantly in off and in on; and therapy complications improved by 91.0 +/- 17.0%. BMI changes at 3 and 12 months were significantly correlated to dyskinesia score changes, and levodopa dosage was not. In PD, STN DBS produces not only symptom control, but also weight gain. DBS candidates should be given nutritional counseling before the intervention to prevent rapid and/or excessive weight gain.

Body Mass Index↗

PubMed2004

Improvement of sleep quality in patients with advanced Parkinson's disease treated with deep brain stimulation of the subthalamic nucleus.

Most Parkinson's patients complain about sleep problems. The subjective effect of deep brain stimulation (DBS) of the subthalamic nucleus (STN) on nocturnal disabilities and sleep quality was elucidated by the recently established Parkinson's disease sleep scale (PDSS). The DBS-treated group obtained significant improvement of motor function assessed by the Unified Parkinson's Disease Rating Scale. The mean total PDSS improved significantly after surgery whereas no change was found for the control group. Significant improvements of individual questions were obtained for overall sleep quality and motor symptoms whereas nocturia and daytime sleepiness did not change despite significant reduction of parkinsonian medication.

Adult↗

PubMed2003

Thalamic deep brain stimulation for tremor-predominant Parkinson's disease.

OBJECTIVES: Determine the long-term efficacy of thalamic deep brain stimulation (DBS) for treatment of tremor among individuals with tremor-predominant Parkinson's disease (PD).Design. Longitudinal, unblinded assessment of tremor and activities of daily living (ADL) at baseline (pre-surgical), and post-operative intervals of 1, 3, and 12 months, and annually thereafter up to 3 years. METHODS: A clinical series of 19 individuals undergoing placement of a DBS system for treatment of PD-related tremor. A battery of subjective and objective measures of tremor was completed at planned pre- and post-operative intervals. RESULTS: Stimulation was associated with significant improvement on subjective and objective measures of ADL performance, midline tremor, and contralateral upper and lower extremity tremor, including parkinsonian resting and action tremors, over the follow-up period. Ipsilateral tremor showed little or no effect of stimulation after the first 3 months. Antiparkinsonian medication use and stimulation parameters showed little or no change over the course of follow-up. About half (53%) of all individuals reported at least one side effect, generally mild, during the follow-up period, with paresthesias and dysarthria being the most common. A total of two leads required replacement due to (1) infection, and (2) adverse side effects (i.e. burning and tingling with stimulation). CONCLUSION: DBS is associated with stable tremor control in PD. Side-effects are typically easily managed with stimulation adjustments, although in some cases lead replacement may be required.

Aged↗

PubMed2004

Thalamic deep brain stimulation for essential tremor: recommendations for long-term outcome analysis.

OBJECTIVES: Determine the efficacy of thalamic deep brain stimulation (DBS) for tremor control among individuals with essential tremor (ET). METHODS: A clinical series of 52 consecutive individuals undergoing placement of a DBS system for treatment of ET completed an unblinded battery of subjective and objective measures at postoperative intervals of one, three, and 12 months, and annually thereafter up to three years. The assessment battery included measures of tremor and activities of daily living. RESULTS: Both subjective and objective measures showed that stimulation was associated with significant improvement at nearly every postoperative interval as compared to pre-operative and stimulation 'off' ratings of activities of daily living functioning, midline tremor, contralateral upper extremity tremor, and contralateral lower extremity tremor. Ipsilateral tremor showed some improvement with stimulation, but only within the first three months. Trend analysis showed stable tremor control. Stimulation settings remained largely unchanged after the first three months. Dysarthria was more common among those with bilateral stimulation. A range of missing data estimation methods were performed, and subsequent analyses corroborated the main findings of the study. CONCLUSION: Thalamic DBS is generally a well-tolerated and effective treatment for ET. Methodological and analytical recommendations are provided for the evaluation of long-term outcome.

Aged↗

PubMedDate not supplied

Visual hallucinations induced by deep brain stimulation in Parkinson's disease.

We report a patient with idiopathic Parkinson's disease who underwent bilateral deep brain stimulation (DBS) of the nucleus subthalamicus (STN) and developed visual hallucinations (VH) while taking no medications only when the DBS was turned on. The hallucinations resolved when the stimulator was turned off. The phenomenology and the prompt response to clozapine suggest that DBS-induced VH mimic pharmacologically-induced VH.

Electric Stimulation Therapy↗

PubMed1998

Double-blind evaluation of subthalamic nucleus deep brain stimulation in advanced Parkinson's disease.

OBJECTIVE: To examine objectively the clinical effects of subthalamic nucleus (STN) deep brain stimulation (DBS) in advanced PD. METHODS: Our initial seven consecutive patients with medication-refractory motor fluctuations and levodopa-induced dyskinesias undergoing chronic STN DBS underwent a standardized preoperative evaluation followed by a 2-day double-blind evaluation of efficacy 6 to 12 months after electrode implantation. Diaries documenting motor fluctuations and dyskinesias were also completed preoperatively and postoperatively. RESULTS: In the medication-off state, turning the stimulators on resulted in improvement in mean total Unified Parkinson's Disease Rating Scale (UPDRS) motor score by 58% including the following improvements in composite scores: akinesia 57%, rigidity 52%, tremor 82%, and gait and postural stability 49%. Additionally, the medication-off state improved 17% without stimulation, possibly as a result of electrode insertion alone or carry-over of chronic stimulation. In the medication-on, stimulation-on state, all major features of parkinsonism improved and total UPDRS motor score improved 41% compared with before surgery. Activities of daily living were improved while off medication 30%, and levodopa-induced dyskinesias were reduced 83% while total drug dosage was decreased 40%. With chronic stimulation, patients reported that the percentage of time spent in the "on" state (without dyskinesias) increased from 26% to 52% and "off" time decreased from 30% to 6%. Operative complications including cognitive worsening were not uncommon. CONCLUSIONS: STN DBS is a promising new surgical option for the treatment of advanced PD. The marked clinical benefits obtained in these severely disabled patients outweighed the adverse effects.

Aged↗

PubMed2001

Deep brain stimulation in the treatment of Parkinson's disease: a cost-effectiveness analysis.

BACKGROUND: In treating PD, deep brain stimulation (DBS) has shown great promise in a series of uncontrolled studies. OBJECTIVE: To estimate the incremental cost effectiveness of DBS compared with the best medical management in late-stage PD. METHODS: The authors constructed a decision model to determine the lifetime incremental cost effectiveness between two options in patients with PD aged 50 years and older: 1) best medical management and 2) DBS. As the long-term efficacy of DBS (>3 years) is not known, key assumptions regarding the procedure's long-term durability were made. Costs were in US 2000 dollars, and quality-adjusted life year (QALY) was the effectiveness measure. Base assumptions were that quality of life (QOL) in patients with late-stage PD is 0.55 (0-to-1 scale, 1 is perfect health) and that DBS benefits are constant for 4 years, eroding gradually over the next 5 years until at parity with those produced by best medical management. Incremental cost-effectiveness and sensitivity analyses were performed. RESULTS: Under base-case assumptions, DBS provides an additional 0.72 QALY at an additional cost of $35,000 compared with best medical management that results in an incremental cost-effectiveness ratio (C/E) of $49,000. QOL increases of between 18 and 30% resulted in questionable cost effectiveness. QOL increases of between 6 and 18% resulted in incremental C/E ratios not usually considered cost effective (>100,000/QALY). CONCLUSIONS: The results suggest that DBS may be cost effective in treating PD if QOL improves 18% or more compared with those receiving best medical management. This underscores the need for randomized, controlled, prospective DBS experiments including QOL and economic components.

Aged↗

PubMed2002

Implantation of deep brain stimulators into the subthalamic nucleus: technical approach and magnetic resonance imaging-verified lead locations.

OBJECT: Chronic deep brain stimulation (DBS) of the subthalamic nucleus (STN) is a procedure that is rapidly gaining acceptance for the treatment of symptoms in patients with Parkinson disease (PD), but there are few detailed descriptions of the surgical procedure itself. The authors present the technical approach used to implant 76 stimulators into the STNs of patients with PD and the lead locations, which were verified on postoperative magnetic resonance (MR) images. METHODS: Implantation procedures were performed with the aid of stereotactic MR imaging, microelectrode recording (MER) in the region of the stereotactic target to define the motor area of the STN, and intraoperative test stimulation to assess the thresholds for stimulation-induced adverse effects. All patients underwent postoperative MR imaging, which was performed using volumetric gradient-echo and T2-weighted fast-spin echo techniques, computational reformatting of the MR image into standard anatomical planes, and quantitative measurements of lead location with respect to the midcommissural point and the red nucleus. Lead locations were statistically correlated with physiological data obtained during MER and intraoperative test stimulation. CONCLUSIONS: The authors' approach to implantation of DBS leads into the STN was associated with consistent lead placement in the dorsolateral STN, a low rate of morbidity, efficient use of operating room time, and robust improvement in motor function. The mean coordinates of the middle of the electrode array, measured on postoperative MR images, were 11.6 mm lateral, 2.9 mm posterior, and 4.7 mm inferior to the midcommissural point, and 6.5 mm lateral and 3.5 mm anterior to the center of the red nucleus. Voltage thresholds for several types of stimulation-induced adverse effects were predictive of lead location. Technical nuances of the surgery are described in detail.

Aged↗

PubMed2000

Identification of the target neuronal elements in electrical deep brain stimulation.

The aim of this study is to identify the primary neuronal target elements in electrical deep-brain stimulation, taking advantage of the difference in strength-duration time constant (tau(sd)) of large myelinated axons ( approximately 30-200 micros), small axons ( approximately 200-700 micros) and cell bodies and dendrites ( approximately 1-10 ms). Strength-duration data were measured in patients suffering from Parkinson's disease or essential tremor and treated by high-frequency stimulation in the ventral intermediate thalamic nucleus or the internal pallidum. Threshold voltages for the elimination of tremor were determined at various pulsewidths and a pulse rate of 130 pulses per second. The tau(sd) was calculated using Weiss's linear approximation. Its mean value was 64.6+/-25.4 micros (SD) for the thalamic nucleus and 75.3+/-25.5 micros for the internal pallidum. Corrections to the mean values were made because the tau(sd) values were based on voltage-duration measurements using polarizable electrodes. Apart from this systematic error, a resolution error, due to the relatively large increment steps of the pulse amplitude, was taken into account, resulting in mean tau(sd) estimates of 129 and 151 micros for the thalamic nucleus and the internal pallidum, respectively. It is concluded that the primary targets of stimulation in both nuclei are most probably large myelinated axons.

Axons↗

PubMed2000

Deep brain stimulation of the subthalamic nucleus for Parkinson's disease: methodologic aspects and clinical criteria.

The technique of deep brain stimulation (DBS) for the treatment of Parkinson's disease (PD) is evolving very rapidly. The subthalamic nucleus (STN) has become the preferred target in the past few years since our group demonstrated that high-frequency stimulation in this nucleus improves all cardinal features of PD, including resting tremor. This benefit in the parkinsonian symptoms allows a drastic reduction in daily levodopa requirements. Dyskinesias become drastically attenuated, possibly as a consequence of reduced dopaminergic medication but also because STN DBS may stabilize basal ganglia output activity, thus avoiding the problems associated with standard levodopa replacement therapy. DBS of the STN is associated with a marked improvement of motor function even in patients with advanced PD. Such a large degree of benefit in parkinsonian features relies on two crucial points that must be taken into consideration for achieving the best possible results with this technique: proper selection of patients and accuracy in targeting the STN. From a neurosurgical point of view, we believe that the most precise localization of the STN is obtained by using ventriculography to determine the stereotactic coordinates of the STN. This is complemented with intraoperative neuronal microrecording to define physiologically the sensorimotor region of the nucleus. Future advances in neuroimaging techniques may well lead to modifications of our current methodology.

Adult↗