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Deep brain stimulation

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Deep brain stimulation
DBS-probes shown in X-ray of the skull (white areas around maxilla and mandible represent metal dentures and are unrelated to DBS devices)
MeSHD046690
MedlinePlus007453

Deep brain stimulation (DBS) is a surgical treatment involving the implantation of a medical device called a brain pacemaker, which sends electrical impulses to specific parts of the brain. DBS in select brain regions has provided therapeutic benefits for otherwise treatment-resistant movement and affective disorders such as chronic pain, Parkinson's disease, tremor and dystonia.[1] Despite the long history of DBS,[2] its underlying principles and mechanisms are still not clear. DBS directly changes brain activity in a controlled manner, its effects are reversible (unlike those of lesioning techniques) and is one of only a few neurosurgical methods that allows blinded studies.

The Food and Drug Administration (FDA) approved DBS as a treatment for essential tremor in 1997, for Parkinson's disease in 2002,[3] and dystonia in 2003.[4] DBS is also routinely used to treat chronic pain and has been used to treat various affective disorders, including major depression. While DBS has proven helpful for some patients, there is potential for serious complications and side effects.

Components and placement

The deep brain stimulation system consists of three components: the implanted pulse generator (IPG), the lead, and the extension. The IPG is a battery-powered neurostimulator encased in a titanium housing, which sends electrical pulses to the brain to 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 of three areas of the brain. The lead is connected to the IPG by the extension, an insulated wire that runs 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.[5] The IPG can be calibrated by a neurologist, nurse or trained technician to optimize symptom suppression and control side effects.[6]

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 the ventrointermediate nucleus (VIM) of the thalamus. For dystonia and symptoms associated with Parkinson's disease (rigidity, bradykinesia/akinesia and tremor), the lead may be placed in either the globus pallidus or subthalamic nucleus.[7]

All three components are surgically implanted inside the body. Under local anesthesia, a hole about 14 mm in diameter is drilled in the skull and the electrode is inserted, with feedback from the patient for optimal placement. The installation of the IPG and lead occurs under general anesthesia.[8] The right side of the brain is stimulated to address symptoms on the left side of the body and vice versa.

Biochemistry

It has been shown in thalamic slices from mice[9] that DBS causes nearby astrocytes to release adenosine triphosphate (ATP), a precursor to adenosine (through a catabolic process). In turn, adenosine A1 receptor activation depresses excitatory transmission in the thalamus, thus causing an inhibitory effect that mimicks ablation or "lesioning".

Applications

Parkinson's disease

Insertion of electrode during surgery using a stereotactic frame

Parkinson's disease is a neurodegenerative disease whose primary symptoms are tremor, rigidity, bradykinesia and postural instability.[10] DBS does not cure Parkinson's, but it can help manage some of its symptoms and subsequently improve the patient’s quality of life.[11] At present, the procedure is used only for patients whose symptoms cannot be adequately controlled with medications, or whose medications have severe side effects.[5] 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[12] and/or directly diminish the side effects induced by Parkinsonian medications,[13] allowing a decrease in medications, or making a medication regimen more tolerable.

There are a few sites in the brain that can be targeted to achieve differing results, so each patient must be assessed individually, and a site will be chosen based on their needs. Traditionally, the two most common sites are the subthalamic nucleus (STN) and the globus pallidus interna (GPi), but other sites, such as the caudal zona incerta and the pallidofugal fibers medial to the STN, are being evaluated and showing promise.[14]

Research is being conducted as of 2007 to predict the onset of tremors before they occur by monitoring activity in the subthalamic nucleus. The goal is to provide stimulating pulses only when they are needed, to stop any tremors occurring before they start.[15]

DBS is approved in the United States by the Food and Drug Administration for the treatment of Parkinson's.[3] 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%).[16]

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 patients but results vary and appropriate patient selection is important. One study[17] of seventeen patients with intractable cancer pain found that thirteen 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.[18] DBS has also been applied for phantom limb pain.[19]

Major depression

Deep brain stimulation has been used in a small number of clinical trials to treat patients suffering from a severe form of treatment-resistant depression (TRD).[20] A number of neuroanatomical targets have been utilised for deep brain stimulation for TRD including the subgenual cingulate gyrus, nucleus accumbens, ventral capsule/ventral striatum, inferior thalamic peduncle and the lateral habenula.[20] The small patient numbers in the early trials of deep brain stimulation for TRD currently limit the selection of an optimum neuroanatomical target.[20] There is insufficient evidence to support DBS as a therapeutic modality for depression; however, the procedure may be an effective treatment modality in the future.[21]

Recently though, there have been more studies supporting the efficacy of DBS in treating depression. A study conducted at Emory University School of Medicine found that, "A significant decrease in depression and increase in function were associated with continuing stimulation. Remission and response rates were 18 percent and 41 percent after 24 weeks; 36 percent and 36 percent after one year and 58 percent and 92 percent after two years of active stimulation. Patients who achieved remission did not experience a spontaneous relapse. Efficacy was similar for Major Depressive Disorder and Bi-Polar patients, and no participant experienced a manic or hypomanic episode."[unreliable medical source?][22]

A systematic review of DBS for treatment resistant depression and obsessive–compulsive disorder identified 23 cases—nine for OCD, seven for treatment-resistant depression, and one for both. It found that "about half the patients did show dramatic improvement" and that adverse events were "generally trivial" given the younger psychiatric patient population than with movements disorders.[23]

DBS for treatment resistant depression can be as effective as antidepressants, with good response and remission rates, but adverse effects and safety need to be more fully evaluated. Common side effects include "wound infection, perioperative headache, and worsening/irritable mood ... and ... increased suicidality".[24]

DBS has not been approved as an evidence-based therapy for depression or OCD in North America.

Tourette syndrome

Deep brain stimulation has been used experimentally in treating a few patients with severe Tourette syndrome. Despite widely publicized early successes, DBS remains a highly experimental procedure for the treatment of Tourette's, and more study is needed to determine whether long-term benefits outweigh the risk.[25] 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".[26] As of 2006, there were five published reports of DBS in patients with TS; all experienced reduction in tics and the disappearance of obsessive-compulsive behaviors. "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."[26] There may be serious short- and long-term risks associated with DBS in persons with head and neck tics.

The procedure is invasive and expensive, and requires long-term expert care. Benefits for severe Tourette's are not conclusive, considering less robust effects of this surgery seen in the Netherlands. Tourette's is more common in pediatric populations, tending to remit in adulthood, so this would not generally be a recommended procedure for use on children. Because diagnosis of Tourette's is made based on a history of symptoms rather than analysis of neurological activity, it may not always be clear how to apply DBS for a particular patient. Due to concern over the use of DBS in the treatment of Tourette syndrome, the Tourette Syndrome Association convened a group of experts to develop recommendations guiding the use and potential clinical trials of DBS for TS.[27]

Other clinical applications

Alzheimer's: A 2010 study on the impact of DBS on Alzheimer's disease "suggested possible improvements and/or slowing in the rate of cognitive decline at 6 and 12 months in some patients."[28][29]

Trauma/coma: In August 2007, Nature reported that scientists in the US had stimulated a 38-year-old man who had been in a minimally conscious state for six years using DBS.[30] The patient initially had increased arousal and sustained eye-opening, as well as rapid bilateral head-turning to voice. After further stimulation, the previously non-verbal patient became capable of naming objects and using objects with his hands—for example, bringing a cup to his mouth. Moreover, he could swallow food and take meals by mouth, meaning he was no longer dependent on a gastrostomy tube.[31] This result follows research carried out over 40 years, which has analyzed the effects of deep brain stimulation in the thalamus (and elsewhere) in patients with post-traumatic coma.[32][33][34] While this research has shown some potential, deep brain stimulation is not yet a reliable cure for patients in post-traumatic coma.

OCD: DBS has been used in the treatment of obsessive-compulsive disorder[35] Although the clinical efficacy is not questioned, the mechanisms by which DBS works are still debated.[36] Long-term clinical observation has shown that the mechanism is not due to a progressive lesion, given that interruption of stimulation reverses its effects.[36]

Dystonia: Results of DBS in dystonia patients, where positive effects often appear gradually over a period of weeks to months, indicate a role of functional reorganization in at least some cases.[37]

Epilepsy: The procedure has been tested for effectiveness in patients with severe epilepsy.[38] A review of 189 studies covering DBS as well as vagus nerve stimulation and closed-loop stimulation (responsive neurostimulator [RNS]) indicate that neurostimulation provides "another tool with which to treat the complex disease of medically refractory epilepsy."[39]

Self-injury syndrome: DBS has produced encouraging results for patients with Lesch-Nyhan syndrome in Japan, Switzerland and France and USA[40]

Potential complications and side effects

While DBS is helpful for some patients, there is also the potential for neuropsychiatric side effects. Reports in the literature describe the possibility of apathy, hallucinations, compulsive gambling, hypersexuality, cognitive dysfunction, and depression. However, these may be temporary and related to correct placement and calibration of the stimulator and so are potentially reversible.[41] A 2006 study of 99 Parkinson's patients who had undergone DBS suggested a decline in executive functions relative to patients who had not undergone DBS, accompanied by problems with word generation, attention and learning. About 9% of patients had psychiatric events, which ranged in severity from a relapse in voyeurism to a suicide attempt. Most patients in this trial reported an improvement in their quality of life following DBS, and there was an improvement in their physical functioning.[42]

Because the brain can shift slightly during surgery, there is the possibility that the electrodes can become displaced or dislodged. This may cause more profound complications such as personality changes, but electrode misplacement is relatively easy to identify using CT. There may also be complications of surgery, such as bleeding within the brain.

After surgery, swelling of the brain tissue, mild disorientation and sleepiness are normal. After 2–4 weeks, there is a follow-up to remove sutures, turn on the neurostimulator and program it.

See also

References

  1. ^ Kringelbach ML, Jenkinson N, Owen SLF, Aziz TZ (2007). "Translational principles of deep brain stimulation". Nature Reviews Neuroscience. 8:623–635. PMID 17637800.
  2. ^ Gildenberg PL (2005). "Evolution of neuromodulation". Stereotact Funct Neurosurg, 83(2–3), 71–79. PMID 16006778.
  3. ^ a b U.S. Department of Health and Human Services.FDA approves implanted brain stimulator to control tremors. Retrieved October 18, 2006.
  4. ^ 'Brain pacemaker' treats dystonia. KNBC TV, April 22, 2003. Retrieved October 18, 2006.
  5. ^ a b National Institute of Neurological Disorders and Stroke. Deep brain stimulation for Parkinson's Disease information page. Retrieved November 23, 2006.
  6. ^ Volkmann J, Herzog J, Kopper F, Deuschl G. "Introduction to the programming of deep brain stimulators". Mov Disord. 2002 17, S181–187. PMID 11948775.
  7. ^ Deep brain stimulation. Surgery Encyclopedia. Retrieved January 25, 2007.
  8. ^ Deep Brain Stimulation, Department of Neurological Surgery, University of Pittsburgh. Retrieved May 13, 2008.
  9. ^ Bekar L, Libionka W, Tian G; et al. (2008). "Adenosine is crucial for deep brain stimulation–mediated attenuation of tremor". Nature Medicine. 14 (1): 75–80. doi:10.1038/nm1693. PMID 18157140. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  10. ^ Ropper (2005), p. 916
  11. ^ Kleiner-Fisman G, Herzog J, Fisman DN, et al. "Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes." Mov Disord. 2006 Jun;21 Suppl 14:S290–304 PMID 16892449
  12. ^ Moro E, Lang AE. "Criteria for deep-brain stimulation in Parkinson's disease: review and analysis". Expert Review of Neurotherapeutics. 2006 Nov;6(11):1695–705. PMID 17144783
  13. ^ Apetauerova D, Ryan RK, Ro SI, Arle J, et al. "End of day dyskinesia in advanced Parkinson's disease can be eliminated by bilateral subthalamic nucleus or globus pallidus deep brain stimulation". Movement Disorders. 2006 Aug;21(8):1277–9. PMID 16637040
  14. ^ Plaha P, Ben-Shlomo Y, Patel NK, Gill SS. "Stimulation of the caudal zona incerta is superior to stimulation of the subthalamic nucleus in improving contralateral parkinsonism". Brain (2006). 129, 1732–1747 PMID 16720681
  15. ^ The blade runner generation. The Sunday Times, July 22, 2007. Retrieved on March 20, 2008.
  16. ^ Doshi PK. "Long-term surgical and hardware-related complications of deep brain stimulation". Stereotact Funct Neurosurg (2011). 89:2, 89–95. PMID 21293168
  17. ^ Young RF & Brechner T. Electrical stimulation of the brain for relief of intractable pain due to cancer. Cancer. 1986;57:1266–72. PMID 3484665.
  18. ^ Johnson MI, Oxberry SG & Robb K. Stimulation-induced analgesia. In: Sykes N, Bennett MI & Yuan C-S. Clinical pain management: Cancer pain. 2nd ed. London: Hodder Arnold; 2008. ISBN 978-0-340-94007-5. p. 235–250.
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  20. ^ a b c Anderson, R. J., Frye, M. A., Abulseoud, O. A., Lee, K. H., McGillivray, J. A., Berk, M., & Tye, S. J. (2012). "Deep brain stimulation for treatment-resistant depression: Efficacy, safety and mechanisms of action". Neuroscience & Biobehavioral Reviews. 36(8), 1920–1933. PMID 22721950. http://dx.doi.org/10.1016/j.neubiorev.2012.06.001
  21. ^ Curr Opin Psychiatry. 2009 May;22(3):306–11
  22. ^ [unreliable medical source?]Medical Press. 2012 January 2; [1]
  23. ^ Lakhan SE, Callaway H. "Deep brain stimulation for obsessive-compulsive disorder and treatment-resistant depression: systematic review". BMC Research Notes. 2010 Mar 4;3(1):60. doi:10.1186/1756-0500-3-60 PMID 20202203
  24. ^ Moreines JL, McClintock SM, Holtzheimer PE. "Neuropsychologic effects of neuromodulation techniques for treatment-resistant depression: a review". Brain Stimul. 2011 Jan;4(1):17-27. PMID 21255751
  25. ^ Tourette Syndrome Association. Statement: Deep Brain Stimulation and Tourette Syndrome. Retrieved November 22, 2005.
  26. ^ a b Malone DA Jr, Pandya MM (2006). "Behavioral neurosurgery". Adv Neurol. 99:241–7. PMID 16536372
  27. ^ Mink JW, Walkup J, Frey KA, et al. (November 2006). "Patient selection and assessment recommendations for deep brain stimulation in Tourette syndrome". Mov Disord. 21(11):1831–8. PMID 16991144
  28. ^ Laxton AW, Tang-Wai DF, McAndrews MP, Zumsteg D, Wennberg R, Keren R, Wherrett J, Naglie G, Hamani C, Smith GS, Lozano AM (2010 Oct). "A phase I trial of deep brain stimulation of memory circuits in Alzheimer's disease". Ann Neurol. 68 (4): 521–34. PMID 20687206. {{cite journal}}: Check date values in: |date= (help)CS1 maint: multiple names: authors list (link)
  29. ^ Jessica Hamzelou (23 November 2011). "Alzheimer's damage reversed by deep brain stimulation". New Scientist.
  30. ^ Implant boosts activity in injured brain. Nature news (August 1, 2007). Retrieved on August 1, 2007
  31. ^ Schiff N. D. et al. "Behavioural improvements with thalamic stimulation after severe traumatic brain injury". Nature. 448, 600–3. (2007) PMID 17671503
  32. ^ Tsubokawa T, Yamamoto T, Katayama Y, Hirayama T, Maejima S, Moriya T. "Deep-brain stimulation in a persistent vegetative state: follow-up results and criteria for selection of candidates". Brain Inj. 1990 Oct–Dec;4(4):315–27. PMID 2252964
  33. ^ Sturm V, Kühner A, Schmitt HP, Assmus H, Stock G. "Chronic electrical stimulation of the thalamic unspecific activating system in a patient with coma due to midbrain and upper brain stem infarction". Acta Neurochir (Wien). 1979;47(3–4):235–44. PMID 314229
  34. ^ Hassler R, Dalle Ore G, Dieckmann G, Bricolo A, Dolce G. "Behavioural and EEG arousal induced by stimulation of unspecific projection systems in a patient with post-traumatic apallic syndrome". Electroencephalogr. Clin. Neurophysiol. 27, 306–310 (1969). PMID 4185661
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  36. ^ a b Benabid AL, Wallace B, Mitrofanis J, Xia R, Piallat B, Chabardes S, Berger F. (2005). "A putative generalized model of the effects and mechanism of action of high frequency electrical stimulation of the central nervous system". Acta Neurol Belg. 2005 Sep;105(3):149–57. PMID 16255153
  37. ^ Krauss JK (2002). "Deep brain stimulation for dystonia in adults. Overview and developments". Stereotactic and Functional Neurosurgery. 78 (3–4): 168–182. doi:10.1159/000068963. PMID 12652041.
  38. ^ Velasco F, Velasco M, Velasco AL, Jimenez F, Marquez I, Rise M (1995). "Electrical stimulation of the centromedian thalamic nucleus in control of seizures: long-term studies". Epilepsia 36: 63–71. PMID 8001511
  39. ^ Wu C, Sharan AD (2013 Jan-Feb). "Neurostimulation for the treatment of epilepsy: a review of current surgical interventions". Neuromodulation. 16 (1): 10–24. PMID 22947069. {{cite journal}}: Check date values in: |date= (help)
  40. ^ Deon LL, Kalichman MA, Booth CL, Slavin KV, Gaebler-Spira DJ (2012 Jan;). "Pallidal deep-brain stimulation associated with complete remission of self-injurious behaviors in a patient with Lesch-Nyhan syndrome: a case report". J Child Neurol. 27 (1): 117–20. PMID 21940691. {{cite journal}}: Check date values in: |date= (help)CS1 maint: extra punctuation (link) CS1 maint: multiple names: authors list (link)
  41. ^ Burn D, Troster A (2004). "Neuropsychiatric Complications of Medical and Surgical Therapies for Parkinson's Disease". Journal of Geriatric Psychiatry and Neurology. 17 (3): 172–180. doi:10.1177/0891988704267466. PMID 15312281.
  42. ^ Smeding H, Speelman J, Koning-Haanstra M; et al. (2006). "Neuropsychological effects of bilateral STN stimulation in Parkinson disease: A controlled study". Neurology. 66 (12): 1830–1836. doi:10.1212/01.wnl.0000234881.77830.66. PMID 16801645. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)

References

  • Appleby BS, Duggan PS, Regenberg A, Rabins PV (2007). "Psychiatric and neuropsychiatric adverse events associated with deep brain stimulation: A meta-analysis of ten years' experience". Movement Disorders 22:1722–1728 PMID 17721929
  • Bekar L, Libionka W, Tian G, Xu Q, Torres A, Wang X, Lovatt D, Williams E, Takano T, Schnermann J, Bakos R, Nedergaard M (2008). "Adenosine is crucial for deep brain stimulation–mediated attenuation of tremor". Nature Medicine, v.14, n.1, pp. 75–80.
  • Fins JJ. Deep Brain Stimulation (2004) In, Encyclopedia of Bioethics, 3rd Edition. Post, SG, Editor-in-Chief. New York: MacMillan Reference. Volume 2, pp. 629–634.
  • Gildenberg Philip L and Tasker, Ronald R (1998). Textbook of stereotactic and functional neurosurgery, McGraw-Hill Publishing.
  • Gildenberg Philip L (2005). "Evolution of neuromodulation". Stereotact Funct Neurosurg, 83(2–3), 71–79. PMID 16006778
  • Kringelbach ML, Jenkinson N, Owen SLF, Aziz TZ (2007). "Translational principles of deep brain stimulation". Nature Reviews Neuroscience. 8:623–635. PMID 17637800
  • McIntyre CC, Grill WM (2000). "Selective microstimulation of central nervous system neurons". Annals of Biomedical Engineering 38:219–233. PMID 10784087
  • McIntyre CC, Grill WM, Sherman DL, Thakor NV (2004). "Cellular effects of deep brain stimulation: model-based analysis of activation and inhibition". Journal of Neurophysiology 91:1457–1469. PMID 14668299
  • Ropper Allan H and Brown, Robert H. (2005) Adams and Victor's Principles of Neurology (8th Edition), McGraw-Hill Medical Publishing. ISBN 0-07-141620-X
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