Deep brain stimulation

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Deep brain stimulation
Tiefe Hirnstimulation - Sonden RoeSchaedel ap.jpg
DBS-probes shown in X-ray of the skull (white areas around maxilla and mandible represent metal dentures and are unrelated to DBS devices)
Specialty Neurosurgery
MeSH D046690
MedlinePlus 007453

Deep brain stimulation (DBS) is a surgical procedure that implants a neurostimulator and electrodes which sends electrical impulses to specified targets in the brain responsible for movement control. The treatment is designed for a range of movement disorders such as Parkinson's disease, essential tremor, and dystonia, as well as for certain neuropsychiatric conditions like obsessive-compulsive disorder (OCD) and epilepsy. [1] The exact mechanisms of DBS are complex and not entirely clear, but it is known to modify brain activity in a structured way. [2]

Contents

DBS has been approved by the Food and Drug Administration as a treatment for essential tremor and Parkinson's disease (PD) since 1997. [3] DBS was approved for dystonia in 2003, [4] obsessive–compulsive disorder (OCD) in 2009, and epilepsy in 2018. [5] [6] [7] DBS has been studied in clinical trials as a potential treatment for chronic pain for various affective disorders, including major depression. It is one of few neurosurgical procedures that allow blinded studies. [1] DBS is now being considered to be a possible treatment for drug addiction. The experiment has been done on animals but not yet human. [8]

Medical use

An adult male undergoing pre-op preparation for deep brain stimulation. Prep for Deep Brain Stimulation.png
An adult male undergoing pre-op preparation for deep brain stimulation.
Insertion of electrode during surgery using a stereotactic frame Parkinson surgery.jpg
Insertion of electrode during surgery using a stereotactic frame

Parkinson's disease

DBS is used to manage some of the symptoms of Parkinson's disease that cannot be adequately controlled with medications. [9] [10] PD is treated by applying high-frequency (> 100 Hz) stimulation to three target structures, namely to the ventrolateral thalamus, internal pallidum, and subthalamic nucleus (STN) to mimic the clinical effects of lesioning. [11] It is recommended for people who have PD with motor fluctuations and tremors inadequately controlled by medication, or to those who are intolerant to medication, as long as they do not have severe neuropsychiatric problems. [12] Four areas of the brain have been treated with neural stimulators in PD. These are the globus pallidus internus, thalamus, subthalamic nucleus and the pedunculopontine nucleus. However, most DBS surgeries in routine practice target either the globus pallidus internus or the Subthalamic nucleus.

Selection of the correct DBS target is a complicated process. Multiple clinical characteristics are used to select the target including – identifying the most troublesome symptoms, the dose of levodopa that the patient is currently taking, the effects and side-effects of current medications and concurrent problems. For example, subthalamic nucleus DBS may worsen depression and hence is not preferred in patients with uncontrolled depression.

Effectiveness

Generally, DBS is associated with a 30–60% improvement in motor score evaluations. [13] However, DBS is administered continuously and with fixed parameters and does not fully control motor fluctuations that characterize Parkinson's disease. Therefore, in recent years, the concept of Adaptive Deep Brain Stimulation (aDBS), a type of DBS that automatically adapts stimulation parameters to Parkinsonian symptoms, was developed. aDBS devices are currently under investigation to be adopted in clinical practice. [14]

Tourette syndrome

DBS has been used experimentally in treating adults with severe Tourette syndrome who do not respond to conventional treatment. Despite widely publicized early successes, DBS remains a highly experimental procedure for treating Tourette's, and more study is needed to determine whether long-term benefits outweigh the risks. [15] [16] [17] [18] The procedure is well tolerated, but complications include "short battery life, abrupt symptom worsening upon cessation of stimulation, hypomanic or manic conversion, and the significant time and effort involved in optimizing stimulation parameters". [19]

The procedure is invasive and expensive and requires long-term expert care. Benefits for severe Tourette's are inconclusive, considering the less robust effects of this surgery seen in the Netherlands. Tourette's is more common in pediatric populations, tending to remit in adulthood, so, in general, this would not be a recommended procedure for use on children. It may not always be obvious how to utilize DBS for a particular person because the diagnosis of Tourette's is based on a history of symptoms rather than an examination of neurological activity. Due to concern over the use of DBS in Tourette syndrome treatment, the Tourette Association of America convened a group of experts to develop recommendations guiding the use and potential clinical trials of DBS for TS. [20]

Robertson reported that DBS had been used on 55 adults by 2011, remained an experimental treatment at that time, and recommended that the procedure "should only be conducted by experienced functional neurosurgeons operating in centres which also have a dedicated Tourette syndrome clinic". [16] According to Malone et al. (2006), "Only patients with severe, debilitating, and treatment-refractory illness should be considered; while those with severe personality disorders and substance-abuse problems should be excluded." [19] Du et al. (2010) say, "As an invasive therapy, DBS is currently only advisable for severely affected, treatment-refractory TS adults". [17] Singer (2011) says, "pending determination of patient selection criteria and the outcome of carefully controlled clinical trials, a cautious approach is recommended". [15] Viswanathan et al. (2012) say DBS should be used for people with "severe functional impairment that cannot be managed medically". [21]

Epilepsy

As many as 36.3% of epilepsy patients are drug-resistant. [22] These patients are at risk for significant morbidity and mortality. [23] In cases where surgery is not an option, neurostimulation such as DBS, as well as vagus nerve stimulation and responsive neurostimulation can be considered.[ medical citation needed ] Targets other than the anterior nucleus of the thalamus have been studied for the treatment of epilepsy, such as the centromedian nucleus of the thalamus, the cerebellum and others. [24]

Adverse effects

Arteriogram of the arterial supply that can hemorrhage during DBS implantation. Mra1.jpg
Arteriogram of the arterial supply that can hemorrhage during DBS implantation.

DBS carries the risks of major surgery, with a complication rate related to the experience of the surgical team. The major complications include hemorrhage (1–2%) and infection (3–5%). [25]

The potential exists for neuropsychiatric side effects after DBS, including apathy, hallucinations, hypersexuality, cognitive dysfunction, depression, and euphoria. However, these effects may be temporary and related to (1) incorrect placement of electrodes, (2) open-loop VS closed-loop stimulation, meaning a constant stimulation or an A.I. monitoring delivery system [26] and (3) calibration of the stimulator, so these side effects are potentially reversible. [27]

Because the brain can shift slightly during surgery, the electrodes can become displaced or dislodged from the specific location. This may cause more profound complications such as personality changes, but electrode misplacement is relatively easy to identify using CT scan. Also, surgery complications may occur, such as bleeding within the brain. After surgery, swelling of the brain tissue, mild disorientation, and sleepiness are normal. After 2–4 weeks, a follow-up visit is used to remove sutures, turn on the neurostimulator, and program it.[ citation needed ]

Impaired swimming skills surfaced as an unexpected risk of the procedure; several Parkinson's disease patients lost their ability to swim after receiving deep brain stimulation. [28] [29]

Mechanisms

The exact mechanism of action of DBS is not known. [30] A variety of hypotheses try to explain the mechanisms of DBS: [31] [32]

  1. Depolarization blockade: Electrical currents block the neuronal output at or near the electrode site.
  2. Synaptic inhibition: This causes an indirect regulation of the neuronal output by activating axon terminals with synaptic connections to neurons near the stimulating electrode.
  3. Desynchronization of abnormal oscillatory activity of neurons
  4. Antidromic activation either activating/blockading distant neurons or blockading slow axons [2]

DBS represents an advance on previous treatments which involved pallidotomy (i.e., surgical ablation of the globus pallidus) or thalamotomy (i.e., surgical ablation of the thalamus). [33] Instead, a thin lead with multiple electrodes is implanted in the globus pallidus, nucleus ventralis intermedius thalami, or subthalamic nucleus, and electric pulses are used therapeutically. The lead from the implant is extended to the neurostimulator under the skin in the chest area.[ citation needed ]

Its direct effect on the physiology of brain cells and neurotransmitters is currently debated, but by sending high-frequency electrical impulses into specific areas of the brain, it can mitigate symptoms [34] and directly diminish the side effects induced by PD medications, [35] allowing a decrease in medications, or making a medication regimen more tolerable.[ citation needed ]

Components and placement

The DBS system consists of three components: the implanted pulse generator (IPG), the lead, and an extension. The IPG is a battery-powered neurostimulator encased in a titanium housing, which sends electrical pulses to the brain that interfere with neural activity at the target site. The lead is a coiled wire insulated in polyurethane with four platinum-iridium electrodes and is placed in one or two different nuclei of the brain. The lead is connected to the IPG by an extension, an insulated wire that runs below the skin, from the head, down the side of the neck, behind the ear, to the IPG, which is placed subcutaneously below the clavicle, or in some cases, the abdomen. [9] The IPG can be calibrated by a neurologist, nurse, or trained technician to optimize symptom suppression and control side effects. [36]

DBS leads are placed in the brain according to the type of symptoms to be addressed. For non-Parkinsonian essential tremor, the lead is placed in either the ventrointermediate nucleus of the thalamus or the zona incerta; [37] for dystonia and symptoms associated with PD (rigidity, bradykinesia/akinesia, and tremor), the lead may be placed in either the globus pallidus internus or the subthalamic nucleus; for OCD and depression to the nucleus accumbens; for incessant pain to the posterior thalamic region or periaqueductal gray; and for epilepsy treatment to the anterior thalamic nucleus.[ citation needed ]

All three components are surgically implanted inside the body. Lead implantation may take place under local anesthesia or under general anesthesia ("asleep DBS"), such as for dystonia. A hole about 14 mm in diameter is drilled in the skull and the probe electrode is inserted stereotactically, using either frame-based or frameless stereotaxis. [38] During the awake procedure with local anesthesia, feedback from the person is used to determine the optimal placement of the permanent electrode. During the asleep procedure, intraoperative MRI guidance is used for direct visualization of brain tissue and device. [39] The installation of the IPG and extension leads occurs under general anesthesia. [40] The right side of the brain is stimulated to address symptoms on the left side of the body and vice versa.[ citation needed ]

Research

Chronic pain

Stimulation of the periaqueductal gray and periventricular gray for nociceptive pain, and the internal capsule, ventral posterolateral nucleus, and ventral posteromedial nucleus for neuropathic pain has produced impressive results with some people, but results vary. One study [41] of 17 people with intractable cancer pain found that 13 were virtually pain-free and only four required opioid analgesics on release from hospital after the intervention. Most ultimately did resort to opioids, usually in the last few weeks of life. [42] DBS has also been applied for phantom limb pain. [43]

Major depression and obsessive-compulsive disorder

Lateral X-ray of the head: Deep brain stimulation in Obsessive-compulsive disorder (OCD). 42-year-old man, surgery in 2013. X-ray of deep brain stimulation in OCD, L.png
Lateral X-ray of the head: Deep brain stimulation in Obsessive–compulsive disorder (OCD). 42-year-old man, surgery in 2013.

DBS has been used in a small number of clinical trials to treat people with severe treatment-resistant depression (TRD). [44] A number of neuroanatomical targets have been used for DBS for TRD including the subgenual cingulate gyrus, posterior gyrus rectus, [45] nucleus accumbens, [46] ventral capsule/ventral striatum, inferior thalamic peduncle, and the lateral habenula. [44] A recently proposed target of DBS intervention in depression is the superolateral branch of the medial forebrain bundle; its stimulation lead to surprisingly rapid antidepressant effects. [47]

The small numbers in the early trials of DBS for TRD currently limit the selection of an optimal neuroanatomical target. [44] Evidence is insufficient to support DBS as a therapeutic modality for depression; however, the procedure may be an effective treatment modality in the future. [48] In fact, beneficial results have been documented in the neurosurgical literature, including a few instances in which people who were deeply depressed were provided with portable stimulators for self-treatment. [49] [50] [51]

A systematic review of DBS for TRD and OCD identified 23 cases, nine for OCD, seven for TRD, and one for both. "[A]bout half the patients did show dramatic improvement" and adverse events were "generally trivial" given the younger age of the psychiatric population relative to the age of people with movement disorders. [52] The first randomized, controlled study of DBS for the treatment of TRD targeting the ventral capsule/ventral striatum area did not demonstrate a significant difference in response rates between the active and sham groups at the end of a 16-week study. [53] However, a second randomized controlled study of ventral capsule DBS for TRD did demonstrate a significant difference in response rates between active DBS (44% responders) and sham DBS (0% responders). [54] Efficacy of DBS is established for OCD, with on average 60% responders in severely ill and treatment-resistant patients. [55] Based on these results the Food and Drug Administration (FDA) has approved DBS for treatment-resistant OCD under a Humanitarian Device Exemption (HDE), requiring that the procedure be performed only in a hospital with specialist qualifications to do so.

DBS for TRD can be as effective as antidepressants and have good response and remission rates, but adverse effects and safety must be more fully evaluated. Common side effects include "wound infection, perioperative headache, and worsening/irritable mood [and] increased suicidality". [56]

Other clinical applications

Results of DBS in people with dystonia, where positive effects often appear gradually over a period of weeks to months, indicate a role of functional reorganization in at least some cases. [57] The procedure has been tested for effectiveness in people with epilepsy that is resistant to medication. [58] DBS may reduce or eliminate epileptic seizures with programmed or responsive stimulation.[ citation needed ]

DBS of the septal areas of persons with schizophrenia has resulted in enhanced alertness, cooperation, and euphoria. [59] Persons with narcolepsy and complex-partial seizures also reported euphoria and sexual thoughts from self-elicited DBS of the septal nuclei. [50]

Orgasmic ecstasy was reported with the electrical stimulation of the brain with depth electrodes in the left hippocampus at 3mA, and the right hippocampus at 1 mA. [60]

In 2015, a group of Brazilian researchers led by neurosurgeon Erich Fonoff  [ pt ] described a new technique that allows for simultaneous implants of electrodes called bilateral stereotactic procedure for DBS. The main benefits are less time spent on the procedure and greater accuracy. [61]

In 2016, DBS was found to improve learning and memory in a mouse model of Rett syndrome. [62] More recent (2018) work showed, that forniceal DBS upregulates genes involved in synaptic function, cell survival, and neurogenesis, [63] making some first steps at explaining the restoration of hippocampal circuit function.

Epilepsy target

According to one long-term follow-up study, DBS targeting the anterior nucleus of the thalamus may be somewhat more effective for temporal lobe epilepsy, and efficacy may increase over time. [64] [65]

See also

Related Research Articles

<span class="mw-page-title-main">Substantia nigra</span> Structure in the basal ganglia of the brain

The substantia nigra (SN) is a basal ganglia structure located in the midbrain that plays an important role in reward and movement. Substantia nigra is Latin for "black substance", reflecting the fact that parts of the substantia nigra appear darker than neighboring areas due to high levels of neuromelanin in dopaminergic neurons. Parkinson's disease is characterized by the loss of dopaminergic neurons in the substantia nigra pars compacta.

<span class="mw-page-title-main">Basal ganglia</span> Group of subcortical nuclei involved in the motor and reward systems

The basal ganglia (BG) or basal nuclei are a group of subcortical nuclei found in the brains of vertebrates. In humans and other primates, differences exist, primarily in the division of the globus pallidus into external and internal regions, and in the division of the striatum. Positioned at the base of the forebrain and the top of the midbrain, they have strong connections with the cerebral cortex, thalamus, brainstem and other brain areas. The basal ganglia are associated with a variety of functions, including regulating voluntary motor movements, procedural learning, habit formation, conditional learning, eye movements, cognition, and emotion.

In the anatomy of the brain, the centromedian nucleus, also known as the centrum medianum, is a part of the intralaminar thalamic nuclei (ITN) in the thalamus. There are two centromedian nuclei arranged bilaterally.

<span class="mw-page-title-main">Subthalamic nucleus</span> Small lens-shaped nucleus in the brain

The subthalamic nucleus (STN) is a small lens-shaped nucleus in the brain where it is, from a functional point of view, part of the basal ganglia system. In terms of anatomy, it is the major part of the subthalamus. As suggested by its name, the subthalamic nucleus is located ventral to the thalamus. It is also dorsal to the substantia nigra and medial to the internal capsule. It was first described by Jules Bernard Luys in 1865, and the term corpus Luysi or Luys' body is still sometimes used.

<span class="mw-page-title-main">Hyperkinesia</span> Excessive movements due to basal ganglia dysfunction

Hyperkinesia refers to an increase in muscular activity that can result in excessive abnormal movements, excessive normal movements, or a combination of both. Hyperkinesia is a state of excessive restlessness which is featured in a large variety of disorders that affect the ability to control motor movement, such as Huntington's disease. It is the opposite of hypokinesia, which refers to decreased bodily movement, as commonly manifested in Parkinson's disease.

<span class="mw-page-title-main">Thalamotomy</span> Surgical procedure

Thalamotomy is a surgical procedure in which a functional lesion is made into the thalamus to improve the overall brain function in patients. First introduced in the 1950s, it is primarily effective for tremors such as those associated with Parkinson's disease, where a selected portion of the thalamus is surgically destroyed (ablated). Neurosurgeons use specialized equipment to precisely locate an area of the thalamus, usually choosing to work on only one side. Bilateral procedures are poorly tolerated because of increased complications and risk, including vision and speech problems. The positive effects on tremors are immediate. Other less destructive procedures are sometimes preferred, such as subthalamic deep brain stimulation, since this procedure can also improve tremors and other symptoms of PD.

Hemiballismus or hemiballism is a basal ganglia syndrome resulting from damage to the subthalamic nucleus in the basal ganglia. Hemiballismus is a rare hyperkinetic movement disorder, that is characterized by violent involuntary limb movements, on one side of the body, and can cause significant disability. Ballismus affects both sides of the body and is much rarer. Symptoms can decrease during sleep.

<span class="mw-page-title-main">Hypokinesia</span> Decreased movement due to basal ganglia dysfunction

Hypokinesia is one of the classifications of movement disorders, and refers to decreased bodily movement. Hypokinesia is characterized by a partial or complete loss of muscle movement due to a disruption in the basal ganglia. Hypokinesia is a symptom of Parkinson's disease shown as muscle rigidity and an inability to produce movement. It is also associated with mental health disorders and prolonged inactivity due to illness, amongst other diseases.

The pedunculopontine nucleus (PPN) or pedunculopontine tegmental nucleus is a collection of neurons located in the upper pons in the brainstem. It is involved in voluntary movements, arousal, and provides sensory feedback to the cerebral cortex and one of the main components of the reticular activating system. It is a potential target for deep brain stimulation treatment for Parkinson's disease. It was first described in 1909 by Louis Jacobsohn-Lask, a German neuroanatomist.

<span class="mw-page-title-main">Spasmodic torticollis</span> Medical condition

Spasmodic torticollis is an extremely painful chronic neurological movement disorder causing the neck to involuntarily turn to the left, right, upwards, and/or downwards. The condition is also referred to as "cervical dystonia". Both agonist and antagonist muscles contract simultaneously during dystonic movement. Causes of the disorder are predominantly idiopathic. A small number of patients develop the disorder as a result of another disorder or disease. Most patients first experience symptoms midlife. The most common treatment for spasmodic torticollis is the use of botulinum toxin type A.

<span class="mw-page-title-main">Pallidotomy</span> Surgical procedure to damage the globus pallidus

Pallidotomy is a neurosurgical procedure. It is used to treat Parkinson's disease and some other conditions, often as an alternative to deep brain stimulation. It involves placing a tiny electrical probe in the globus pallidus, one of the basal ganglia of the brain, to damage it. Unilateral pallidotomy can cause side effects including problems with language learning, visuospatial constructional ability, and executive functions. Bilateral pallidotomy is not effective, with many severe side effects.

In the management of Parkinson's disease, due to the chronic nature of Parkinson's disease (PD), a broad-based program is needed that includes patient and family education, support-group services, general wellness maintenance, exercise, and nutrition. At present, no cure for the disease is known, but medications or surgery can provide relief from the symptoms.

<span class="mw-page-title-main">Responsive neurostimulation device</span> Category of medical devices that respond to signals in a patients body to treat disease

Responsive neurostimulation device is a medical device that senses changes in a person's body and uses neurostimulation to respond in the treatment of disease. The FDA has approved devices for use in the United States in the treatment of epileptic seizures and chronic pain conditions. Devices are being studied for use in the treatment of essential tremor, Parkinson's disease, Tourette's syndrome, depression, obesity, and post-traumatic stress disorder.

<span class="mw-page-title-main">Internal globus pallidus</span>

The internal globus pallidus and the external globus pallidus (GPe) make up the globus pallidus. The GPi is one of the output nuclei of the basal ganglia. The GABAergic neurons of the GPi send their axons to the ventral anterior nucleus (VA) and the ventral lateral nucleus (VL) in the dorsal thalamus, to the centromedian complex, and to the pedunculopontine complex.

Ablative brain surgery is the surgical ablation by various methods of brain tissue to treat neurological or psychological disorders. The word "Ablation" stems from the Latin word Ablatus meaning "carried away". In most cases, however, ablative brain surgery does not involve removing brain tissue, but rather destroying tissue and leaving it in place. The lesions it causes are irreversible. There are some target nuclei for ablative surgery and deep brain stimulation. Those nuclei are the motor thalamus, the globus pallidus, and the subthalamic nucleus.

<span class="mw-page-title-main">Basal ganglia disease</span> Group of physical problems resulting from basal ganglia dysfunction

Basal ganglia disease is a group of physical problems that occur when the group of nuclei in the brain known as the basal ganglia fail to properly suppress unwanted movements or to properly prime upper motor neuron circuits to initiate motor function. Research indicates that increased output of the basal ganglia inhibits thalamocortical projection neurons. Proper activation or deactivation of these neurons is an integral component for proper movement. If something causes too much basal ganglia output, then the ventral anterior (VA) and ventral lateral (VL) thalamocortical projection neurons become too inhibited, and one cannot initiate voluntary movement. These disorders are known as hypokinetic disorders. However, a disorder leading to abnormally low output of the basal ganglia leads to reduced inhibition, and thus excitation, of the thalamocortical projection neurons which synapse onto the cortex. This situation leads to an inability to suppress unwanted movements. These disorders are known as hyperkinetic disorders.

Neurostimulation is the purposeful modulation of the nervous system's activity using invasive or non-invasive means. Neurostimulation usually refers to the electromagnetic approaches to neuromodulation.

Neuromodulation is "the alteration of nerve activity through targeted delivery of a stimulus, such as electrical stimulation or chemical agents, to specific neurological sites in the body". It is carried out to normalize – or modulate – nervous tissue function. Neuromodulation is an evolving therapy that can involve a range of electromagnetic stimuli such as a magnetic field (rTMS), an electric current, or a drug instilled directly in the subdural space. Emerging applications involve targeted introduction of genes or gene regulators and light (optogenetics), and by 2014, these had been at minimum demonstrated in mammalian models, or first-in-human data had been acquired. The most clinical experience has been with electrical stimulation.

<span class="mw-page-title-main">Alim Louis Benabid</span>

Alim Louis Benabid is a French-Algerian emeritus professor, neurosurgeon and member of the French Academy of Sciences, who has had a global impact in the development of deep brain stimulation (DBS) for Parkinson's disease and other movement disorders. He became emeritus professor of biophysics at the Joseph Fourier University in Grenoble in September 2007, and chairman of the board of the Edmond J. Safra Biomedical Research Center in 2009 at Clinatec, a multidisciplinary institute he co-founded in Grenoble that applies nanotechnologies to neurosciences.

<span class="mw-page-title-main">Adaptive Deep Brain Stimulation</span> Neurosurgical treatment involving implantation of an adaptive neurostimularot

Adaptive Deep Brain Stimulation (aDBS), also known as Closed Loop Deep Brain stimulation (clDBS), is a neuro-modulatory technique currently under investigation for the treatment of neurodegenerative diseases.

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