Current Directions in Deep Brain Stimulation for Parkinson’s Disease—Directing Current to Maximize Clinical Benefit

Merola, Aristide; Romagnolo, Alberto; Krishna, Vibhor; Pallavaram, Srivatsan; Carcieri, Stephen; Goetz, Steven; Mandybur, George T.; Duker, Andrew P.; Dalm, Brian D.; Rolston, John D.; Fasano, Alfonso; Verhagen, Leo

doi:10.1007/s40120-020-00181-9

Cited by 37 publications

(24 citation statements)

References 57 publications

(61 reference statements)

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“…In parallel, the connectivity-based selection of stimulation parameters might also prove useful in evaluating the thalamocortical connectivity to optimize the post-surgical programming 38 . This approach is based on anatomically shaping the VTA model with directional DBS systems to optimized target coverage by preferentially steering the electrical field to obtain a better account for any shifts in VIM’s location and shape and improve the therapeutic window at a lower current 39, 40 .…”

Section: Discussionmentioning

confidence: 99%

Thalamic organization in essential tremor patients with neuropathy: implication for functional neurosurgery

Sammartino

Narayan

Changizi

et al. 2021

Preprint

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Background: Mechanisms underlying the suboptimal effect of ventral intermediate nucleus deep brain stimulation in patients with essential tremor and co-morbid peripheral neuropathy remain unclear. Objectives: We compared disease-related (location and extension of the ventral intermediate nucleus) and surgery-related (targeting, intraoperative testing) factors in essential tremor patients with and without peripheral polyneuropathy treated with deep brain stimulation of the ventral intermediate nucleus, testing whether the overlap between volume of tissue activated and ventral intermediate nucleus (target coverage) was associated with clinical outcomes. Methods: Preoperative diffusion magnetic resonance imaging was used for thalamic segmentation, based on preferential cortical connectivity. The target coverage was estimated using a finite element model. Tremor severity was scored at rest, posture, action, and handwriting at baseline, 6, and 12 months. Tremor improvement <50% at 12 months was deemed suboptimal. Vertex-wise shape analysis and edge analysis were performed to compare the ventral intermediate nucleus location and extension. Results: 9.7% (18/185) of essential tremor patients treated with deep brain stimulation had co-morbid polyneuropathy. These patients showed a more medial (p=0.03) and anterior (p=0.04) location of the ventral intermediate nucleus, lower target coverage (p=0.049), and worse clinical outcomes (p=0.006) compared to those without polyneuropathy. No differences were observed in the volume of tissue activated between the two groups. Optimal clinical outcomes were associated with greater target coverage (optimal coverage >48%). Conclusions: In essential tremor, co-morbid polyneuropathy may result in suboptimal deep brain stimulation outcomes and lower target coverage, likely related to a reorganization of the ventral thalamic nuclei.

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Section: Discussionmentioning

confidence: 99%

Thalamic organization in essential tremor patients with neuropathy: implication for functional neurosurgery

Sammartino

Narayan

Changizi

et al. 2021

Preprint

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“…The introduction of "directional leads" characterized by the middle two (of four) rings divided into three segments has allowed generating an axially asymmetric volume of tissue activation (VTA) tailored to the individual patient's anatomy (67,70). DBS bioelectrical parameters, such as therapeutic impedance and surface current density, are highly dependent on the electrode surface and inevitably change when switching from a circular ring contact to a single-segment activation.…”

Section: Hardware Innovationsmentioning

confidence: 99%

New Frontiers for Deep Brain Stimulation: Directionality, Sensing Technologies, Remote Programming, Robotic Stereotactic Assistance, Asleep Procedures, and Connectomics

et al. 2021

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Over the last few years, while expanding its clinical indications from movement disorders to epilepsy and psychiatry, the field of deep brain stimulation (DBS) has seen significant innovations. Hardware developments have introduced directional leads to stimulate specific brain targets and sensing electrodes to determine optimal settings via feedback from local field potentials. In addition, variable-frequency stimulation and asynchronous high-frequency pulse trains have introduced new programming paradigms to efficiently desynchronize pathological neural circuitry and regulate dysfunctional brain networks not responsive to conventional settings. Overall, these innovations have provided clinicians with more anatomically accurate programming and closed-looped feedback to identify optimal strategies for neuromodulation. Simultaneously, software developments have simplified programming algorithms, introduced platforms for DBS remote management via telemedicine, and tools for estimating the volume of tissue activated within and outside the DBS targets. Finally, the surgical accuracy has improved thanks to intraoperative magnetic resonance or computerized tomography guidance, network-based imaging for DBS planning and targeting, and robotic-assisted surgery for ultra-accurate, millimetric lead placement. These technological and imaging advances have collectively optimized DBS outcomes and allowed “asleep” DBS procedures. Still, the short- and long-term outcomes of different implantable devices, surgical techniques, and asleep vs. awake procedures remain to be clarified. This expert review summarizes and critically discusses these recent innovations and their potential impact on the DBS field.

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“…Directional DBS has been shown to optimize the volume of tissue activated (VTA) by increasing the therapeutic window (TW) through generating axially asymmetric fields of electrical stimulation (3) via single or multiple segmented leads. Earlier single-center studies (2) and initial results from a multicenter study (3) have also demonstrated the advantages of directional vs. conventional omnidirectional stimulation in increasing the side-effect threshold with a resultant increased TW and lower total electrical energy delivered (TEED). Despite the advantages in delivering better clinical outcomes with less side-effect, directional DBS is still underutilized.…”

Section: To the Editormentioning

confidence: 99%

Response to “Bipolar Directional Deep Brain Stimulation in Essential and Parkinsonian Tremor”—A Technology Underutilized

Tambirajoo

Ashkan

2020

Neuromodulation: Technology at the Neural Interface

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Current Directions in Deep Brain Stimulation for Parkinson’s Disease—Directing Current to Maximize Clinical Benefit

Cited by 37 publications

References 57 publications

Thalamic organization in essential tremor patients with neuropathy: implication for functional neurosurgery

Thalamic organization in essential tremor patients with neuropathy: implication for functional neurosurgery

New Frontiers for Deep Brain Stimulation: Directionality, Sensing Technologies, Remote Programming, Robotic Stereotactic Assistance, Asleep Procedures, and Connectomics

Response to “Bipolar Directional Deep Brain Stimulation in Essential and Parkinsonian Tremor”—A Technology Underutilized

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