Directional deep brain stimulation: an intraoperative double-blind pilot study.
Identifieur interne : 000721 ( PubMed/Curation ); précédent : 000720; suivant : 000722Directional deep brain stimulation: an intraoperative double-blind pilot study.
Auteurs : Claudio Pollo [Suisse] ; Alain Kaelin-Lang [Suisse] ; Markus F. Oertel [Suisse] ; Lennart Stieglitz [Suisse] ; Ethan Taub [Suisse] ; Peter Fuhr [Suisse] ; Andres M. Lozano [Canada] ; Andreas Raabe [Suisse] ; Michael Schüpbach [Suisse]Source :
- Brain : a journal of neurology [ 1460-2156 ] ; 2014.
English descriptors
- KwdEn :
- MESH :
- methods : Deep Brain Stimulation.
- therapy : Parkinson Disease.
- Adult, Aged, Double-Blind Method, Female, Humans, Intraoperative Care, Male, Middle Aged, Young Adult.
Abstract
Deep brain stimulation of different targets has been shown to drastically improve symptoms of a variety of neurological conditions. However, the occurrence of disabling side effects may limit the ability to deliver adequate amounts of current necessary to reach the maximal benefit. Computed models have suggested that reduction in electrode size and the ability to provide directional stimulation could increase the efficacy of such therapies. This has never been demonstrated in humans. In the present study, we assess the effect of directional stimulation compared to omnidirectional stimulation. Three different directions of stimulation as well as omnidirectional stimulation were tested intraoperatively in the subthalamic nucleus of 11 patients with Parkinson's disease and in the nucleus ventralis intermedius of two other subjects with essential tremor. At the trajectory chosen for implantation of the definitive electrode, we assessed the current threshold window between positive and side effects, defined as the therapeutic window. A computed finite element model was used to compare the volume of tissue activated when one directional electrode was stimulated, or in case of omnidirectional stimulation. All but one patient showed a benefit of directional stimulation compared to omnidirectional. A best direction of stimulation was observed in all the patients. The therapeutic window in the best direction was wider than the second best direction (P = 0.003) and wider than the third best direction (P = 0.002). Compared to omnidirectional direction, the therapeutic window in the best direction was 41.3% wider (P = 0.037). The current threshold producing meaningful therapeutic effect in the best direction was 0.67 mA (0.3-1.0 mA) and was 43% lower than in omnidirectional stimulation (P = 0.002). No complication as a result of insertion of the directional electrode or during testing was encountered. The computed model revealed a volume of tissue activated of 10.5 mm(3) in omnidirectional mode, compared with 4.2 mm(3) when only one electrode was used. Directional deep brain stimulation with a reduced electrode size applied intraoperatively in the subthalamic nucleus as well as in the nucleus ventralis intermedius of the thalamus significantly widened the therapeutic window and lowered the current needed for beneficial effects, compared to omnidirectional stimulation. The observed side effects related to direction of stimulation were consistent with the anatomical location of surrounding structures. This new approach opens the door to an improved deep brain stimulation therapy. Chronic implantation is further needed to confirm these findings.
DOI: 10.1093/brain/awu102
PubMed: 24844728
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Oertel</name><affiliation wicri:level="1"><nlm:affiliation>1 Department of Neurosurgery, Bern University Hospital, Inselspital, Bern, Switzerland.</nlm:affiliation><country xml:lang="fr">Suisse</country><wicri:regionArea>1 Department of Neurosurgery, Bern University Hospital, Inselspital, Bern</wicri:regionArea></affiliation></author><author><name sortKey="Stieglitz, Lennart" sort="Stieglitz, Lennart" uniqKey="Stieglitz L" first="Lennart" last="Stieglitz">Lennart Stieglitz</name><affiliation wicri:level="1"><nlm:affiliation>1 Department of Neurosurgery, Bern University Hospital, Inselspital, Bern, Switzerland.</nlm:affiliation><country xml:lang="fr">Suisse</country><wicri:regionArea>1 Department of Neurosurgery, Bern University Hospital, Inselspital, Bern</wicri:regionArea></affiliation></author><author><name sortKey="Taub, Ethan" sort="Taub, Ethan" uniqKey="Taub E" first="Ethan" last="Taub">Ethan Taub</name><affiliation wicri:level="1"><nlm:affiliation>3 Department of Neurosurgery, Basel University Hospital, Basel, Switzerland.</nlm:affiliation><country xml:lang="fr">Suisse</country><wicri:regionArea>3 Department of Neurosurgery, Basel University Hospital, Basel</wicri:regionArea></affiliation></author><author><name sortKey="Fuhr, Peter" sort="Fuhr, Peter" uniqKey="Fuhr P" first="Peter" last="Fuhr">Peter Fuhr</name><affiliation wicri:level="1"><nlm:affiliation>4 Department of Neurology, Basel University Hospital, Basel, Switzerland.</nlm:affiliation><country xml:lang="fr">Suisse</country><wicri:regionArea>4 Department of Neurology, Basel University Hospital, Basel</wicri:regionArea></affiliation></author><author><name sortKey="Lozano, Andres M" sort="Lozano, Andres M" uniqKey="Lozano A" first="Andres M" last="Lozano">Andres M. Lozano</name><affiliation wicri:level="1"><nlm:affiliation>5 Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada.</nlm:affiliation><country xml:lang="fr">Canada</country><wicri:regionArea>5 Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto</wicri:regionArea></affiliation></author><author><name sortKey="Raabe, Andreas" sort="Raabe, Andreas" uniqKey="Raabe A" first="Andreas" last="Raabe">Andreas Raabe</name><affiliation wicri:level="1"><nlm:affiliation>1 Department of Neurosurgery, Bern University Hospital, Inselspital, Bern, Switzerland.</nlm:affiliation><country xml:lang="fr">Suisse</country><wicri:regionArea>1 Department of Neurosurgery, Bern University Hospital, Inselspital, Bern</wicri:regionArea></affiliation></author><author><name sortKey="Schupbach, Michael" sort="Schupbach, Michael" uniqKey="Schupbach M" first="Michael" last="Schüpbach">Michael Schüpbach</name><affiliation wicri:level="1"><nlm:affiliation>2 Department of Neurology, Bern University Hospital, Inselspital, Bern, Switzerland.</nlm:affiliation><country xml:lang="fr">Suisse</country><wicri:regionArea>2 Department of Neurology, Bern University Hospital, Inselspital, Bern</wicri:regionArea></affiliation></author></analytic><series><title level="j">Brain : a journal of neurology</title><idno type="eISSN">1460-2156</idno><imprint><date when="2014" type="published">2014</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass><keywords scheme="KwdEn" xml:lang="en"><term>Adult</term><term>Aged</term><term>Deep Brain Stimulation (methods)</term><term>Double-Blind Method</term><term>Female</term><term>Humans</term><term>Intraoperative Care</term><term>Male</term><term>Middle Aged</term><term>Parkinson Disease (therapy)</term><term>Young Adult</term></keywords><keywords scheme="MESH" qualifier="methods" xml:lang="en"><term>Deep Brain Stimulation</term></keywords><keywords scheme="MESH" qualifier="therapy" xml:lang="en"><term>Parkinson Disease</term></keywords><keywords scheme="MESH" xml:lang="en"><term>Adult</term><term>Aged</term><term>Double-Blind Method</term><term>Female</term><term>Humans</term><term>Intraoperative Care</term><term>Male</term><term>Middle Aged</term><term>Young Adult</term></keywords></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Deep brain stimulation of different targets has been shown to drastically improve symptoms of a variety of neurological conditions. However, the occurrence of disabling side effects may limit the ability to deliver adequate amounts of current necessary to reach the maximal benefit. Computed models have suggested that reduction in electrode size and the ability to provide directional stimulation could increase the efficacy of such therapies. This has never been demonstrated in humans. In the present study, we assess the effect of directional stimulation compared to omnidirectional stimulation. Three different directions of stimulation as well as omnidirectional stimulation were tested intraoperatively in the subthalamic nucleus of 11 patients with Parkinson's disease and in the nucleus ventralis intermedius of two other subjects with essential tremor. At the trajectory chosen for implantation of the definitive electrode, we assessed the current threshold window between positive and side effects, defined as the therapeutic window. A computed finite element model was used to compare the volume of tissue activated when one directional electrode was stimulated, or in case of omnidirectional stimulation. All but one patient showed a benefit of directional stimulation compared to omnidirectional. A best direction of stimulation was observed in all the patients. The therapeutic window in the best direction was wider than the second best direction (P = 0.003) and wider than the third best direction (P = 0.002). Compared to omnidirectional direction, the therapeutic window in the best direction was 41.3% wider (P = 0.037). The current threshold producing meaningful therapeutic effect in the best direction was 0.67 mA (0.3-1.0 mA) and was 43% lower than in omnidirectional stimulation (P = 0.002). No complication as a result of insertion of the directional electrode or during testing was encountered. The computed model revealed a volume of tissue activated of 10.5 mm(3) in omnidirectional mode, compared with 4.2 mm(3) when only one electrode was used. Directional deep brain stimulation with a reduced electrode size applied intraoperatively in the subthalamic nucleus as well as in the nucleus ventralis intermedius of the thalamus significantly widened the therapeutic window and lowered the current needed for beneficial effects, compared to omnidirectional stimulation. The observed side effects related to direction of stimulation were consistent with the anatomical location of surrounding structures. This new approach opens the door to an improved deep brain stimulation therapy. Chronic implantation is further needed to confirm these findings.</div></front></TEI><pubmed><MedlineCitation Status="MEDLINE" Owner="NLM"><PMID Version="1">24844728</PMID><DateCreated><Year>2014</Year><Month>06</Month><Day>21</Day></DateCreated><DateCompleted><Year>2014</Year><Month>08</Month><Day>25</Day></DateCompleted><DateRevised><Year>2014</Year><Month>06</Month><Day>21</Day></DateRevised><Article PubModel="Print-Electronic"><Journal><ISSN IssnType="Electronic">1460-2156</ISSN><JournalIssue CitedMedium="Internet"><Volume>137</Volume><Issue>Pt 7</Issue><PubDate><Year>2014</Year><Month>Jul</Month></PubDate></JournalIssue><Title>Brain : a journal of neurology</Title><ISOAbbreviation>Brain</ISOAbbreviation></Journal><ArticleTitle>Directional deep brain stimulation: an intraoperative double-blind pilot study.</ArticleTitle><Pagination><MedlinePgn>2015-26</MedlinePgn></Pagination><ELocationID EIdType="doi" ValidYN="Y">10.1093/brain/awu102</ELocationID><Abstract><AbstractText>Deep brain stimulation of different targets has been shown to drastically improve symptoms of a variety of neurological conditions. However, the occurrence of disabling side effects may limit the ability to deliver adequate amounts of current necessary to reach the maximal benefit. Computed models have suggested that reduction in electrode size and the ability to provide directional stimulation could increase the efficacy of such therapies. This has never been demonstrated in humans. In the present study, we assess the effect of directional stimulation compared to omnidirectional stimulation. Three different directions of stimulation as well as omnidirectional stimulation were tested intraoperatively in the subthalamic nucleus of 11 patients with Parkinson's disease and in the nucleus ventralis intermedius of two other subjects with essential tremor. At the trajectory chosen for implantation of the definitive electrode, we assessed the current threshold window between positive and side effects, defined as the therapeutic window. A computed finite element model was used to compare the volume of tissue activated when one directional electrode was stimulated, or in case of omnidirectional stimulation. All but one patient showed a benefit of directional stimulation compared to omnidirectional. A best direction of stimulation was observed in all the patients. The therapeutic window in the best direction was wider than the second best direction (P = 0.003) and wider than the third best direction (P = 0.002). Compared to omnidirectional direction, the therapeutic window in the best direction was 41.3% wider (P = 0.037). The current threshold producing meaningful therapeutic effect in the best direction was 0.67 mA (0.3-1.0 mA) and was 43% lower than in omnidirectional stimulation (P = 0.002). No complication as a result of insertion of the directional electrode or during testing was encountered. The computed model revealed a volume of tissue activated of 10.5 mm(3) in omnidirectional mode, compared with 4.2 mm(3) when only one electrode was used. Directional deep brain stimulation with a reduced electrode size applied intraoperatively in the subthalamic nucleus as well as in the nucleus ventralis intermedius of the thalamus significantly widened the therapeutic window and lowered the current needed for beneficial effects, compared to omnidirectional stimulation. The observed side effects related to direction of stimulation were consistent with the anatomical location of surrounding structures. This new approach opens the door to an improved deep brain stimulation therapy. Chronic implantation is further needed to confirm these findings.</AbstractText><CopyrightInformation>© The Author (2014). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved. For Permissions, please email: journals.permissions@oup.com.</CopyrightInformation></Abstract><AuthorList CompleteYN="Y"><Author ValidYN="Y"><LastName>Pollo</LastName><ForeName>Claudio</ForeName><Initials>C</Initials><AffiliationInfo><Affiliation>1 Department of Neurosurgery, Bern University Hospital, Inselspital, Bern, Switzerland claudio.pollo@insel.ch.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Kaelin-Lang</LastName><ForeName>Alain</ForeName><Initials>A</Initials><AffiliationInfo><Affiliation>2 Department of Neurology, Bern University Hospital, Inselspital, Bern, Switzerland.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Oertel</LastName><ForeName>Markus F</ForeName><Initials>MF</Initials><AffiliationInfo><Affiliation>1 Department of Neurosurgery, Bern University Hospital, Inselspital, Bern, Switzerland.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Stieglitz</LastName><ForeName>Lennart</ForeName><Initials>L</Initials><AffiliationInfo><Affiliation>1 Department of Neurosurgery, Bern University Hospital, Inselspital, Bern, Switzerland.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Taub</LastName><ForeName>Ethan</ForeName><Initials>E</Initials><AffiliationInfo><Affiliation>3 Department of Neurosurgery, Basel University Hospital, Basel, Switzerland.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Fuhr</LastName><ForeName>Peter</ForeName><Initials>P</Initials><AffiliationInfo><Affiliation>4 Department of Neurology, Basel University Hospital, Basel, Switzerland.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Lozano</LastName><ForeName>Andres M</ForeName><Initials>AM</Initials><AffiliationInfo><Affiliation>5 Department of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Raabe</LastName><ForeName>Andreas</ForeName><Initials>A</Initials><AffiliationInfo><Affiliation>1 Department of Neurosurgery, Bern University Hospital, Inselspital, Bern, Switzerland.</Affiliation></AffiliationInfo></Author><Author ValidYN="Y"><LastName>Schüpbach</LastName><ForeName>Michael</ForeName><Initials>M</Initials><AffiliationInfo><Affiliation>2 Department of Neurology, Bern University Hospital, Inselspital, Bern, Switzerland.</Affiliation></AffiliationInfo></Author></AuthorList><Language>eng</Language><PublicationTypeList><PublicationType UI="D016428">Journal Article</PublicationType><PublicationType UI="D016449">Randomized Controlled Trial</PublicationType><PublicationType UI="D013485">Research Support, Non-U.S. Gov't</PublicationType></PublicationTypeList><ArticleDate DateType="Electronic"><Year>2014</Year><Month>05</Month><Day>19</Day></ArticleDate></Article><MedlineJournalInfo><Country>England</Country><MedlineTA>Brain</MedlineTA><NlmUniqueID>0372537</NlmUniqueID><ISSNLinking>0006-8950</ISSNLinking></MedlineJournalInfo><CitationSubset>AIM</CitationSubset><CitationSubset>IM</CitationSubset><CommentsCorrectionsList><CommentsCorrections RefType="CommentIn"><RefSource>Nat Rev Neurol. 2014 Jul;10(7):364</RefSource><PMID Version="1">24934141</PMID></CommentsCorrections><CommentsCorrections RefType="CommentIn"><RefSource>Brain. 2014 Jul;137(Pt 7):1854-6</RefSource><PMID Version="1">24838765</PMID></CommentsCorrections></CommentsCorrectionsList><MeshHeadingList><MeshHeading><DescriptorName UI="D000328" MajorTopicYN="N">Adult</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D000368" MajorTopicYN="N">Aged</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D046690" MajorTopicYN="N">Deep Brain Stimulation</DescriptorName><QualifierName UI="Q000379" MajorTopicYN="Y">methods</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D004311" MajorTopicYN="N">Double-Blind Method</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D005260" MajorTopicYN="N">Female</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D007430" MajorTopicYN="Y">Intraoperative Care</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008297" MajorTopicYN="N">Male</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D008875" MajorTopicYN="N">Middle Aged</DescriptorName></MeshHeading><MeshHeading><DescriptorName UI="D010300" MajorTopicYN="N">Parkinson Disease</DescriptorName><QualifierName UI="Q000628" MajorTopicYN="Y">therapy</QualifierName></MeshHeading><MeshHeading><DescriptorName UI="D055815" MajorTopicYN="N">Young Adult</DescriptorName></MeshHeading></MeshHeadingList><KeywordList Owner="NOTNLM"><Keyword MajorTopicYN="N">Parkinson’s disease</Keyword><Keyword MajorTopicYN="N">deep brain stimulation</Keyword><Keyword MajorTopicYN="N">directional electrode</Keyword><Keyword MajorTopicYN="N">essential tremor</Keyword><Keyword MajorTopicYN="N">volume of tissue activated</Keyword></KeywordList></MedlineCitation><PubmedData><History><PubMedPubDate PubStatus="entrez"><Year>2014</Year><Month>5</Month><Day>22</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate><PubMedPubDate PubStatus="pubmed"><Year>2014</Year><Month>5</Month><Day>23</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate><PubMedPubDate PubStatus="medline"><Year>2014</Year><Month>8</Month><Day>26</Day><Hour>6</Hour><Minute>0</Minute></PubMedPubDate></History><PublicationStatus>ppublish</PublicationStatus><ArticleIdList><ArticleId IdType="pubmed">24844728</ArticleId><ArticleId IdType="pii">awu102</ArticleId><ArticleId 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