Electroconvulsive Therapy in Patients With Deep Brain Stimulators

Vila‐Rodriguez, Fidel; McGirr, Alexander; Tham, Joseph; Hadjipavlou, George; Honey, Christopher R.

doi:10.1097/yct.0000000000000074

Cited by 23 publications

(24 citation statements)

References 1 publication

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“…As of July 2016, at least ten patients with DBS for treatment of PD, cervical dystonia, essential tremor, depression and obsessive compulsive disorder have been treated with ECT without AEs (Rosenthal et al, 2016). In most cases, the DBS system was turned off during ECT to prevent inadvertent DBS activation, but ECT has also been performed with the device on (Vila-Rodriguez et al, 2014). In some cases, the ECT protocols were modified to maximize the distance between the ECT electrodes and the DBS electrodes or the subcutaneous leads.…”

Section: The Application Of Low Intensity Tes In Human Studies: Aementioning

confidence: 99%

Low intensity transcranial electric stimulation: Safety, ethical, legal regulatory and application guidelines

Antal

Alekseichuk

Bikson

et al. 2017

Clinical Neurophysiology

875

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Low intensity transcranial electrical stimulation (TES) in humans, encompassing transcranial direct current (tDCS), transcutaneous spinal Direct Current Stimulation (tsDCS), transcranial alternating current (tACS), and transcranial random noise (tRNS) stimulation or their combinations, appears to be safe. No serious adverse events (SAEs) have been reported so far in over 18,000 sessions administered to healthy subjects, neurological and psychiatric patients, as summarized here. Moderate adverse events (AEs), as defined by the necessity to intervene, are rare, and include skin burns with tDCS due to suboptimal electrode-skin contact. Very rarely mania or hypomania was induced in patients with depression (11 documented cases), yet a causal relationship is difficult to prove because of the low incidence rate and limited numbers of subjects in controlled trials. Mild AEs (MAEs) include headache and fatigue following stimulation as well as prickling and burning sensations occurring during tDCS at peak-to-baseline intensities of 1–2 mA and during tACS at higher peak-to-peak intensities above 2 mA. The prevalence of published AEs is different in studies specifically assessing AEs vs. those not assessing them, being higher in the former. AEs are frequently reported by individuals receiving placebo stimulation. The profile of AEs in terms of frequency, magnitude and type is comparable in healthy and clinical populations, and this is also the case for more vulnerable populations, such as children, elderly persons, or pregnant women. Combined interventions (e.g., co-application of drugs, electrophysiological measurements, neuroimaging) were not associated with further safety issues. Safety is established for low-intensity ‘conventional’ TES defined as <4 mA, up to 60 min duration per day. Animal studies and modeling evidence indicate that brain injury could occur at predicted current densities in the brain of 6.3–13 A/m2 that are over an order of magnitude above those produced by tDCS in humans. Using AC stimulation fewer AEs were reported compared to DC. In specific paradigms with amplitudes of up to 10 mA, frequencies in the kHz range appear to be safe. In this paper we provide structured interviews and recommend their use in future controlled studies, in particular when trying to extend the parameters applied. We also discuss recent regulatory issues, reporting practices and ethical issues. These recommendations achieved consensus in a meeting, which took place in Göttingen, Germany, on September 6–7, 2016 and were refined thereafter by email correspondence.

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Section: The Application Of Low Intensity Tes In Human Studies: Aementioning

confidence: 99%

Low intensity transcranial electric stimulation: Safety, ethical, legal regulatory and application guidelines

Antal

Alekseichuk

Bikson

et al. 2017

Clinical Neurophysiology

875

728

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“…These potential limitations of DBS would need to be weighed against the unknown effects of frequent mECT starting at a young age. Of note, implanted DBS electrodes do not preclude ECT (Ducharme et al, 2011;Vila-Rodriguez et al, 2014), which is an important consideration given DBS candidate patients would likely be receiving mECT. Also, while brain and skull growth would preclude the accurate and consistent targeting of electrode leads in children and adolescents with ASD, severe cases of SIB typically persist into adulthood when DBS implantation surgery could become a viable alternative to mECT.…”

Section: Introductionmentioning

confidence: 99%

High-Frequency Stimulation at the Subthalamic Nucleus Suppresses Excessive Self-Grooming in Autism-Like Mouse Models

Chang

Berges

Chung

et al. 2015

Neuropsychopharmacol

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Approximately one quarter of individuals with an autism spectrum disorder (ASD) display self-injurious behavior (SIB) ranging from head banging to self-directed biting and punching. Sometimes, these behaviors are extreme and unresponsive to pharmacological and behavioral therapies. We have found electroconvulsive therapy (ECT) can produce life-changing results, with more than 90% suppression of SIB frequency. However, these patients typically require frequent maintenance ECT (mECT), as often as every 5 days, to sustain the improvement gained during the acute course. Long-term consequences of such frequent mECT started as early as childhood in some cases are unknown. Accordingly, there is a need for alternative forms of chronic stimulation for these patients. To explore the feasibility of deep brain stimulation (DBS) for intractable SIB seen in some patients with an ASD, we utilized two genetically distinct mouse models demonstrating excessive self-grooming, namely the Viaat-Mecp2 − /y and Shank3B −/− lines, and administered high-frequency stimulation (HFS) via implanted electrodes at the subthalamic nucleus (STN-HFS). We found that STN-HFS significantly suppressed excessive selfgrooming in both genetic lines. Suppression occurs both acutely when stimulation is switched on, and persists for several days after HFS is stopped. This effect was not explained by a change in locomotor activity, which was unaffected by STN-HFS. Likewise, social interaction deficits were not corrected by STN-HFS. Our data show STN-HFS suppresses excessive self-grooming in two autism-like mouse models, raising the possibility DBS might be used to treat intractable SIB associated with ASDs. Further studies are required to explore the circuitry engaged by STN-HFS, as well as other potential stimulation sites. Such studies might also yield clues about pathways, which could be modulated by non-invasive stimulatory techniques.

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“…In DBS for psychiatric indications, medication adjustment or initiation of new psychotropics is advised, as well as supportive psychotherapy and close monitoring of symptoms. Patients with severe depression are eligible candidates to receive electroconvulsive therapy [28], or intravenous ketamine infusions, and should be hospitalized if depression or suicidality becomes intense. If IPG failure is expected to happen, and replacement will not be available, there is no evidence supporting cycling or reduction of stimulation intensity.…”

Section: Recommendations If the Neurostimulator (Ipg) Cannot Be Replacedmentioning

confidence: 99%

Recommendations for Deep Brain Stimulation Device Management During a Pandemic

Miocinovic

Ostrem

Okun

et al. 2020

JPD

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U n c o r r e c t e d A u t h o r P r o o f Journal of Parkinson's Disease xx (20xx) x-xxAbstract. Most medical centers are postponing elective procedures and deferring non-urgent clinic visits to conserve hospital resources and prevent spread of COVID-19. The pandemic crisis presents some unique challenges for patients currently being treated with deep brain stimulation (DBS). Movement disorder (Parkinson's disease, essential tremor, dystonia), neuropsychiatric disorder (obsessive compulsive disorder, Tourette syndrome, depression), and epilepsy patients can develop varying degrees of symptom worsening from interruption of therapy due to neurostimulator battery reaching end of life, device malfunction or infection. Urgent intervention to maintain or restore stimulation may be required for patients with Parkinson's disease who can develop a rare but potentially life-threatening complication known as DBS-withdrawal syndrome. Similarly, patients with generalized dystonia can develop status dystonicus, patients with obsessive compulsive disorder can become suicidal, and epilepsy patients can experience potentially life-threatening worsening of seizures as a result of therapy cessation. DBS system infection can require urgent, and rarely emergent surgery. Elective interventions including new implantations and initial programming should be postponed. For patients with existing DBS systems, the battery status and electrical integrity interrogation can now be performed using patient programmers, and employed through telemedicine visits or by phone consultations. The decision for replacement of the implantable pulse generator to prevent interruption of DBS therapy should be made on a case-by-case basis taking into consideration battery status and a patient's tolerance to potential therapy disruption. Scheduling of the procedures, however, depends heavily on the hospital system regulations and on triage procedures with respect to safety and resource utilization during the health crisis. U n c o r r e c t e d A u t h o r P r o o f 32The novel coronavirus (COVID-19) pandemic is 33 rapidly changing how we live and practice medicine 34 globally. Patients treated with deep brain stimula-35 tion (DBS) for movement disorders, neuropsychiatric 36 disorders, and epilepsy face unique challenges. High-37 lighted in this article are practical management 38 recommendations for DBS providers during COVID-39 19 pandemic. Since public health guidelines vary 40 across countries, states and local municipalities and 41 rapidly change, each medical center needs to be 42 nimble and develop strategies to care for patients 43 within the home setting. DBS practices range from 44 large, tertiary centers to community clinics and vary 45 widely in terms of workflow, resource availability, 46 and level of expertise available on site. We provide 47 general recommendations and workflow algorithm 48 that centers can modify and adopt quickly while 49 exercising compliance at multiple levels. This cri-50 sis highlights the challenge of postponing electiv...

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Electroconvulsive Therapy in Patients With Deep Brain Stimulators

Cited by 23 publications

References 1 publication

Low intensity transcranial electric stimulation: Safety, ethical, legal regulatory and application guidelines

Low intensity transcranial electric stimulation: Safety, ethical, legal regulatory and application guidelines

High-Frequency Stimulation at the Subthalamic Nucleus Suppresses Excessive Self-Grooming in Autism-Like Mouse Models

Recommendations for Deep Brain Stimulation Device Management During a Pandemic

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