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PubMed2004

Tremor induced by thalamic deep brain stimulation in patients with complex regional facial pain.

We report on two patients who developed a new postural and action tremor after chronic stimulation of the contralateral thalamus (VPM nucleus) during treatment of a complex regional facial pain syndrome. The tremor was only present during deep brain stimulation (DBS) and was suppressed with adjustment of the stimulation parameters. Tremor was seen only with low frequency stimulation (50 Hz or lower) and disappeared with higher stimulation frequencies. In addition to being an unusual side effect of thalamic DBS, we believe that this phenomenon affords insight into one possible mechanism underlying essential tremor (ET). A central oscillatory mechanism involving the olivocerebellar complex and the thalamus, which is a part of the cerebro-cerebello-cerebral circuit, is thought to play an important role in the genesis of ET. Induction of a tremor resembling ET in our patients indicates an active role for low frequency stimulation. A plausible explanation for this is that low frequency stimulation in the thalamic area enhances the output of the tremor-producing network. This leads credence to the concept of central oscillations in a "tremor circuit," of which the thalamus is a part, as being important in ET.

Adult↗

PubMed2005

Bilateral deep brain stimulation of the pedunculopontine nucleus for Parkinson's disease.

Gait disturbance and postural instability are some the most disabling symptoms of idiopathic Parkinson's disease and in late stage disease can be resistant to both medical and surgical therapies. We implanted bilateral deep brain stimulation electrodes into the pedunculopontine nucleus in two patients with advanced Parkinson's disease. We demonstrate for the first time that low frequency (20-25 Hz) stimulation of this nucleus significantly improves gait dysfunction and postural instability in both the 'on' and 'off' medication states. Their combined total Unified Parkinson's Disease Rating Scale score improved by 53% and motor score by 57%. No procedure or stimulation-related complications were observed. If these findings are replicated in a larger number of patients, pedunculopontine nucleus stimulation may provide the means to alleviate these disabling and otherwise treatment-resistant symptoms of advanced Parkinson's disease.

Deep Brain Stimulation↗

PubMed2001

Long-term safety and efficacy of unilateral deep brain stimulation of the thalamus in essential tremor.

Our objective was to investigate the long-term safety and efficacy of unilateral deep brain stimulation (DBS) of the VIM nucleus of the thalamus in essential tremor. Forty-nine patients were evaluated for DBS between December 1993 and March 1998. Tremor was assessed by a clinical rating scale at 3 and 12 months and then yearly. Three patients were not implanted, seven were explanted prior to 24 months, 11 were lost to long-term follow-up, and three died from unrelated causes. Twenty-five patients were evaluated with follow-up greater than or equal to 2 years. The last postsurgical follow-up occurred on average 40.2 +/- 14.7 months after surgery. Tremor scores were significantly improved with stimulation on at the long-term follow-up as compared to baseline. There was no change in tremor scores from baseline to long-term follow-up with stimulation off. There was no significant change in any stimulus parameters from 3 months to the long-term follow-up. Three patients had asymptomatic intracerebral hemorrhages and one patient had postoperative seizures. Stimulus-related adverse reactions were mild and easily controlled with changes in stimulus parameters. Device-related complications were common and required repeated surgical procedures. Unilateral DBS of the thalamus has long-term efficacy in some patients for treatment of essential tremor. However, this therapy is compromised by loss of efficacy in some patients and device complications which increase the risk of additional surgical procedures.

Adult↗

PubMed2002

Effect of chronic pallidal deep brain stimulation on off period dystonia and sensory symptoms in advanced Parkinson's disease.

OBJECTIVE: To investigate the efficacy of chronic pallidal deep brain stimulation (DBS) on off period dystonia, cramps, and sensory symptoms in advanced Parkinson's disease (PD). METHODS: 16 patients (6 women, 10 men; mean age at surgery 65 years) suffering from advanced PD were followed up prospectively for one year after implantation of a monopolar electrode in the posteroventral lateral globus pallidus internus. Unilateral DBS was performed in 9 patients. 10 patients had bilateral procedures (contemporaneous bilateral surgery in 7 and staged bilateral surgery in 3 instances). The decision whether to perform unilateral or bilateral surgery depended on the clinical presentation of the patient. Patients were formally assessed preoperatively, at 3-5 days, 3 months, and 12 months after surgery. RESULTS: In patients who underwent unilateral surgery, pain was present in 7 (78%), off dystonia in 5 (56%), cramps in 6 (67%), and dysaesthesia in 4 (44%). In patients who underwent bilateral surgery, pain was present in 7 (70%), off dystonia in 6 (60%), cramps in 7 (70%), and dysaesthesia in 4 (40%). With unilateral DBS, contralateral off period dystonia was improved by 100% at 1 year postoperatively, pain by 74%, cramps by 88%, and dysaesthesia by 100%. There was less pronounced amelioration of ipsilateral off period dystonia and sensory symptoms. With bilateral DBS, total scores for dystonia were improved by 86%, for pain by 90%, for cramps by 90%, and for dysaesthesia by 88%. The benefit appeared early at the first evaluation 3-5 days after surgery and was stable throughout the follow up period. CONCLUSIONS: Pallidal DBS yields major improvement of off period dystonia, cramps, and sensory symptoms in patients with advanced PD.

Adult↗

PubMed2005

Tissue and electrode capacitance reduce neural activation volumes during deep brain stimulation.

OBJECTIVE: The growing clinical acceptance of neurostimulation technology has highlighted the need to accurately predict neural activation as a function of stimulation parameters and electrode design. In this study we evaluate the effects of the tissue and electrode capacitance on the volume of tissue activated (VTA) during deep brain stimulation (DBS). METHODS: We use a Fourier finite element method (Fourier FEM) to calculate the potential distribution in the tissue medium as a function of time and space simultaneously for a range of stimulus waveforms. The extracellular voltages are then applied to detailed multi-compartment cable models of myelinated axons to determine neural activation. Neural activation volumes are calculated as a function of the stimulation parameters and magnitude of the capacitive components of the electrode-tissue interface. RESULTS: Inclusion of either electrode or tissue capacitance reduces the VTA compared to electrostatic simulations in a manner dependent on the capacitance magnitude and the stimulation parameters (amplitude and pulse width). Electrostatic simulations with typical DBS parameter settings (-3 V or -3 mA, 90 micros, 130 Hz) overestimate the VTA by approximately 20% for voltage- or current-controlled stimulation. In addition, strength-duration time constants decrease and more closely match clinical measurements when explicitly accounting for the effects of voltage-controlled stimulation. CONCLUSIONS: Attempts to quantify the VTA from clinical neurostimulation devices should account for the effects of electrode and tissue capacitance. SIGNIFICANCE: DBS has rapidly emerged as an effective treatment for movement disorders; however, little is known about the VTA during therapeutic stimulation. In addition, the influence of tissue and electrode capacitance has been largely ignored in previous models of neural stimulation. The results and methodology of this study provide the foundation for the quantitative analysis of the VTA during clinical neurostimulation.

Algorithms↗

PubMed2001

Comparison of thalamotomy to deep brain stimulation of the thalamus in essential tremor.

OBJECTIVE: To compare outcome in Essential Tremor (ET) patients who have undergone either thalamotomy or Deep Brain Stimulation (DBS) of the thalamus. BACKGROUND: Although both thalamotomy and thalamic DBS are effective surgical treatments of tremor, it is not known if one procedure is superior to the other. DESIGN/METHODS: Thirty-five ET patients underwent thalamotomy between 1994-1998. Data on 18 patients were excluded. The remaining 17 patients were matched for age, sex, side of surgery, and tremor severity to 17 ET patients who underwent thalamic DBS. There were nine men and eight women in each group. The mean age of the thalamotomy group was 74.4 years and that of the thalamic DBS group was 73.1 years. RESULTS: There were no significant differences between any efficacy outcome variables comparing thalamotomy to DBS of the thalamus at baseline or follow-up visits. The surgical complications were higher for the thalamotomy group as compared to the DBS group. However, a larger number of DBS patients underwent repeat surgeries due to problems with the device and the leads. CONCLUSION: Although the efficacy is similar for thalamotomy and DBS of the thalamus for ET, thalamotomy is associated with a higher complication rate. DBS of the thalamus should be the procedure of choice for the surgical treatment of ET in most cases.

Aged↗

PubMed2003

Bilateral subthalamic nucleus deep brain stimulation for advanced PD: correlation of intraoperative MER and postoperative MRI with neuropathological findings.

This postmortem study correlated intraoperative subthalamic nucleus (STN) deep brain stimulation (DBS) placement and postoperative magnetic resonance imaging (MRI) with autopsy findings in a patient who died suddenly 4 days postoperatively from a pulmonary embolism. The study demonstrates that (1) MRI stereotactic localization combined with microelectrode recording (MER) is an accurate way to target STN; (2) multiple MER tracts do not cause significant injury to the brain; and (3) postoperative MRI accurately demonstrates location of the DBS electrodes.

Electric Stimulation Therapy↗

PubMed2003

Modulation of tremor amplitude during deep brain stimulation at different frequencies.

Rest tremor was quantified in the index finger tip of 16 patients with Parkinson's disease (PD) receiving deep brain stimulation (DBS) of the ventro-intermediate nucleus (Vim) of the thalamus, the subthalamic nucleus (STN), or the internal part of the globus pallidus (GPi) while being off L-dopa for 12h. Clinically, without DBS, tremor amplitude varied from absent to high. Tremor was recorded continuously for about 5 min under three conditions of DBS repeated twice, namely, effective frequency (E), ineffective frequency (I), and no DBS (O). No changes in tremor were observed across conditions in subjects with little or no tremor. However, in subjects with moderate to large amplitude tremor, DBS decreased tremor amplitude to near normal values within a few seconds. Generally, transitions were progressive and occurred with a varying time delay. Occasionally, tremor escaped from control regardless of the stimulation condition considered. In some cases tremor amplitude in one condition appeared to depend on the preceding condition. Finally, the results were reproducible on two consecutive days. We conclude that tremor control with DBS follows specific dynamical rules, which must be compatible with the hypotheses proposed regarding the underlying mechanisms of DBS.

Aged↗

PubMed2002

Impact of thalamic deep brain stimulation on disability and health-related quality of life in patients with essential tremor.

OBJECTIVES: To evaluate the impact of thalamic deep brain stimulation (DBS) on disability and health-related quality of life in patients with essential tremor. METHODS: Twenty seven consecutive patients were evaluated prospectively, before surgery and at a mean of 12 months (range 6-26) after thalamic DBS. Assessment tools included the Fahn-Tolosa-Marìn tremor rating scale (TRS), activities of daily living (ADL) taxonomy, Nottingham health profile (NHP) and the visual analogue scale (VAS) for measuring impact of disease on life. Additional information on the side effects of, and expectations from surgery was obtained by interview. RESULTS: Thalamic DBS improved the ability of the patients in eating, drinking, writing, home maintenance, hobbies, and participation in society. Activities of daily life requiring bimanual skills were less improved. The emotional condition of the patients was positively affected and the negative impact of the disease on life as a whole, and on social life was decreased. Seventy per cent of the patients considered that the surgical treatment met their expectations. CONCLUSIONS: After thalamic DBS, health-related quality of life including disability in ADL and social life were improved in patients with essential tremor.

Activities of Daily Living↗

PubMed1999

Do microelectrode techniques increase accuracy or decrease risks in pallidotomy and deep brain stimulation? A critical review of the literature.

Several recent publications have stated that the use of microelectrode recording (MER) during pallidotomy or deep brain stimulation (DBS) contributes to decreasing risks and side effects of surgery, and that such a technique is a prerequisite for minimizing lesion size and for accurate placement of the stereotactic lesion or the DBS electrode. To evaluate the consistency of these statements, we reviewed hundreds of papers and congress reports on MER- and non-MER-guided procedures published since 1992. This review showed that MER groups published more often than non-MER groups. While side effects of surgery were not uncommon in both groups, the rate of severe complications, such as hematoma, and mortality appeared to be higher when microelectrodes were used, both in ablative surgery and in DBS procedures. Besides, the nonaccurate placement of lesions or DBS electrodes, as assessed on published MRI figures, was not uncommon in MER publications. Lesion volume was, when reported, not different in both techniques. The electrical parameters of stimulation of implanted electrodes in the thalamic ventral intermediate (Vim) nucleus for treatment of tremor were higher in MER-guided surgery. The available literature suggests that MER techniques may increase the risks of surgery without enhancing its accuracy, compared to MRI-based macrostimulation techniques. To date, there is no randomized trial by one and the same group on the use of micro- versus macroelectrodes in surgery for movement disorders. A prerequisite for such a trial in the future must imply that the investigators have an equal nonprejudiced attitude towards, and equal confidence and experience in, either technique. Since such a prerequisite does not exist so far in the functional stereotactic community, a critical and comparative study of the available literature remains the only way to evaluate the pros and cons of either technique, in terms of targeting accuracy and surgical complications.

Bibliometrics↗

PubMed2002

[Deep brain stimulation of subthalamic nucleous in Parkinson's disease].

UNLABELLED: We present the preliminary results in patients well selected to be implanted by deep brain stimulation (DBS) for Parkinsons's disease (PD). METHODS: 8 PD patients with disabled tremor, akinetic/bradikinetic and rigidity, in spite of best therapeutic assay with poor response were referred to surgery. It was implanted DBS Itrell 2. Theses patients were evaluated by the following scales: UPDRS, Schwab and England. RESULTS: The preliminary results in 6 months showed significant improvement of motor performance and it is shown by the scores. There were no complications so far with these procedures. CONCLUSION: The preliminary results indicate that DBS is highly effective, with benefit to those patients and it is according to literature.

Aged↗

PubMed2000

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. Case report.

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.

Adult↗

PubMed2002

Changes in regional cerebral blood flow caused by deep-brain stimulation of the subthalamic nucleus in Parkinson's disease.

UNLABELLED: The aim of this study was to investigate the effect of deep-brain stimulation of the subthalamic nucleus (STN) on regional cerebral blood flow (rCBF) throughout the entire brain volume in patients with Parkinson's disease and to evaluate which of the brain areas showing an rCBF increase during STN stimulation related significantly to the improvement in motor function. METHODS: Ten consecutive Parkinson's disease patients (6 men, 4 women; mean age +/- SD, 59 +/- 8 y) with bilateral STN stimulators underwent 3 rCBF SPECT examinations at rest: the first preoperatively and the second and third postoperatively (follow-up, 4.8 +/- 1.4 mo) with STN stimulators on and off, respectively. The motor unified Parkinson's disease rating scale, the Hoehn and Yahr disability scale, and the Schwab and England activities-of-daily-living scale were used to evaluate the clinical state under each condition. Statistical parametric mapping was used to investigate rCBF during STN stimulation in comparison with rCBF preoperatively and with STN stimulators off. Also evaluated with statistical parametric mapping was the relationship between rCBF and individual motor scores used as covariates of interest. RESULTS: STN stimulation significantly changed rCBF in the right pre-supplementary motor area (pre-SMA), anterior cingulate cortex, and dorsolateral prefrontal cortex and in the medial Brodmann's area 8 (BA8) as defined in the atlas of Talairach and Tournoux (P < 0.05 corrected for multiple comparisons). The rCBF in these areas increased from the preoperative condition to the stimulators-on condition and decreased again after the stimulators were switched off. A significant correlation was detected between the improvement in motor scores and the rCBF increase only in the right pre-SMA and in the anterior cingulate motor area (P < 0.005, uncorrected). CONCLUSION: According to the topographic organization of the primate STN, our study shows that stimulation of the STN leads to rCBF increases in the motor (pre-SMA), associative, and limbic territories (anterior cingulate) in the frontal cortex. The significant correlation between motor improvement and rCBF increase in the pre-SMA and the anterior cingulate motor area reinforces the hypothesis that STN stimulation in parkinsonian patients can potentiate the cortical areas participating in higher-order aspects of motor control.

Brain↗

PubMed2003

[Neuropsychological changes and bilateral subthalamic deep brain stimulation in Parkinson's disease].

INTRODUCTION: To investigate neuropsychiatric changes in Parkinson's disease (PD) patients after 12 months of bilateral subthalamic deep brain stimulation (DBS-STN). SUBJECTS: Nine out of 23 patients with PD subjected to DBS-STN were included. The mean follow-up of this cohort was 12 months, mean disease duration 14.2 5.5 years and mean UPDRS motor score in < > 43.2 13.7. METHODS: Patients were selected on the basis of CAPSIT criteria. They underwent bilateral implant of stimulators in STN under stereotactic conditions. Quality of life scale (PDQ 39), depression scale (Brev-Cet), frontal function test (Stroop, Wisconsin, verbal fluency) and memory evaluation (Barcelona test) were monitored at baseline in < > medication and after 12 months in < > medication/< > stimulation. RESULTS: The patients' motor scores improved on an average of 40.2 % (p = 0.0002) in < > medication situation and 58 % in quality of life scores. We observed a benefit in depression scores (52 %, p = 0.003). Immediate verbal memory improved as well, 25 % (p = 0.04) in recall memory and 14 % (p = 0.02) in recognition memory. No changes were observed in visual memory, verbal fluency and/or global cognitive tests. CONCLUSION: DBS-STN in PD patients seems to be an effective tool for improving their quality of life, due to its benefits on motor function, verbal memory and mood. Bilateral DBS-STN did not affect either verbal fluency or executive functions in our patients. Neuropsychological assessment is a good tool for selection and study of the operated patients.

Activities of Daily Living↗

PubMed2006

Long-term benefit to pallidal deep brain stimulation in a case of dystonia secondary to pantothenate kinase-associated neurodegeneration.

Pantothenate kinase-associated neurodegeneration (PKAN) is a rare autosomal recessive disorder with onset in childhood and rapid progression. There is no causative and insufficient symptomatic drug therapy. Deep brain stimulation (DBS) of the internal pallidum (GPi) has been reported to improve motor function. Most case reports, however, are limited to short observational periods. The impact of DBS on the progression and life expectancy in PKAN is unknown. We present a 5-year outcome and video documentation of bilateral GPi-DBS of an adolescent patient suffering from genetically defined PKAN.

Adolescent↗

PubMed2004

Deep brain stimulation for intractable chronic cluster headache: proposals for patient selection.

Cluster headache is the most severe of the primary headaches. Positron emission tomography and functional MRI studies have shown that the ipsilateral posterior hypothalamus is activated during cluster headache attacks and is structurally asymmetric in these patients. These changes are highly specific for the condition and suggest that the cluster headache generator may be located in that brain area; they further suggest that electrical stimulation of that region might produce clinical improvement in chronic cluster headache sufferers refractory to medical therapy. In five patients with severe intractable chronic cluster headache, hypothalamic electrical stimulation produced complete and long-term pain relief with no relevant side-effects. We therefore consider it essential to propose criteria for selecting chronic cluster headache patients for hypothalamic deep brain stimulation before this procedure is undertaken at other academic medical centres.

Cluster Headache↗

PubMed2006

Variability in RF-induced heating of a deep brain stimulation implant across MR systems.

PURPOSE: To compare the MRI-related heating per unit of specific absorption rate (SAR) profile of a conductive implant between two 1.5-Tesla/64 MHz MR systems using a transmit/receive (t/r) head coil configuration. MATERIALS AND METHODS: Deep brain stimulation (DBS) leads were configured within a gel-filled phantom of the human head and torso. Temperature variation at each of four contacts of the bilaterally-placed leads was monitored using fluoroptic thermometry. MRI was performed using the t/r head coils of two different-generation 1.5-Tesla MR systems from the same manufacturer. Temperature changes were normalized to SAR values for the head (DeltaT/SAR-H), and the slope of this DeltaT/SAR-H by time relationship was compared between the two scanners. RESULTS: The DeltaT/SAR-H for the implant ranged from 3.5 to 5.5 times higher on one MR system as compared to the other (P < 0.01) depending on the measurement site. CONCLUSION: The findings support previous observations that console-reported SAR does not constitute a reliable index of heating for elongated, conductive implants, such as the DBS hardware system tested. In contrast to our previous findings using a t/r body coil, the data presented here reveal marked differences between two MR systems using t/r head coils (the coil configuration was consistent with the implant manufacturer's imaging guidelines). J. Magn. Reson. Imaging 2006. (c) 2006 Wiley-Liss, Inc.

Body Temperature↗

PubMed2003

Deep brain stimulation for Parkinson's disease dissociates mood and motor circuits: a functional MRI case study.

Behavioral disturbances have been reported with subthalamic (STN) deep brain stimulation (DBS) treatment in Parkinson's disease (PD). We report correlative functional imaging (fMRI) of mood and motor responses induced by successive right and left DBS. A 36-year-old woman with medically refractory PD and a history of clinically remitted depression underwent uncomplicated implantation of bilateral STN DBS. High-frequency stimulation of the left electrode improved motor symptoms. Unexpectedly, right DBS alone elicited several reproducible episodes of acute depressive dysphoria. Structural and functional magnetic resonance imaging (fMRI) imaging was carried out with sequential individual electrode stimulation. The electrode on the left was within the inferior STN, whereas the right electrode was marginally superior and lateral to the intended STN target within the Fields of Forel/zona incerta. fMRI image analysis (Analysis of Functional NeuroImages, AFNI) contrasting OFF versus ON stimulation identified significant lateralized blood oxygen level-dependent (BOLD) signal changes with DBS (P < 0.001). Left DBS primarily showed changes in motor regions: increases in premotor and motor cortex, ventrolateral thalamus, putamen, and cerebellum as well as decreases in sensorimotor/supplementary motor cortex. Right DBS showed similar but less extensive change in motor regions. More prominent were the unique increases in superior prefrontal cortex, anterior cingulate (Brodmann's area [BA] 24), anterior thalamus, caudate, and brainstem, and marked widespread decreases in medial prefrontal cortex (BA 9/10). The mood disturbance resolved spontaneously in 4 weeks despite identical stimulation parameters. Transient depressive mood induced by subcortical DBS stimulation was correlated with changes in mesolimbic cortical structures. This case provides new evidence supporting cortical segregation of motor and nonmotor cortico-basal ganglionic systems that may converge in close proximity at the level of the STN and the adjacent white matter tracts (Fields of Forel/zona incerta).

Adult↗