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deep brain stimulation (DBS)

High-frequency continuous electrical stimulation to the subthalamic nucleus or nucleus accumbens through a surgically- implanted device. Indications: 1) Parkinson's disease* 2) dystonias 3) essential tremor 4) treatment-resistant unipolar & bipolar depression [2] 5) obsessive compulsive disorder [NGC] * characteristics of good candidates [6] - typical Parkinson's disease with tremor - good response to individual doses of Sinemet - dyskinesias - wearing-off motor fluctuations - good general health - strong family & social network - may be of benefit in 'off state' central pain [10] - may improve behavioral outcomes in younger patients with early motor complications [15] - worse quality-of-life score before DBS associated with greater improvement at 2 years [17] Advantages: 1) greater mobility 2) less dyskinesia (75%) [20] 3) less time in off state (59%) [20] 4) improved quality of life 5) may help driving ability [8] 6) benefits may last beyond 15 years [20] Contraindications: * characteristics of poor candidates [6] - atypical Parkinson's disease - poor response to Sinemet - dementia or apathy - depression or anxiety - serious comorbidity - poor social support - older age not necessarily a contraindication [9] Procedure: 1) dystonia a) placed into globus pallidus b) battery lasts only 2 years (2006) due to high level of stimulation required 2) Parkinson's disease a) placed into subthalamic nucleus of globus pallidus &/or into the globus pallidus internal segment [3,7] - dual-target continuous deep brain stimulation improves motor Parkinson's disease symptoms more than single-target continuous deep brain stimulation [21] b) bilateral stimulation generally required c) battery lasts only 5 years (2006) d) Brio Neurostimulation System - electrical pulse generator implanted subdermally in the upper chest constantly provides low-intensity electrical pulses to electrodes placed at target areas of the brain [12] e) investigational 8-contact constant-current lead design subthalamic nucleus implant (unitlateral or bilateral) allow delivering current independently at one or more contacts on the lead [13] f) constant-current Vercise System, implanted in the subthalamic nucleus [16] 3) essential tremor - placed into thalamus 4) depression - stimulation of subcallosal cingulate cortex [2] 5) obsessive compulsive disorder - bilateral stimulation of subthalamic nucleus &/or nucleus accumbens - insufficient evidence for use of unilateral deep brain stimulation Complications: 1) infection 2) cerebral hematoma 3) dislocation of the electrode 4) gait disorder; freezing of gait [4] 5) swimming skills impaired after deep brain stimulation (DBS) [18] 6) prevalence/incidence of dementia may not be higher with DBS [19] Management: - methylphenidate suggested for gait disorder - piribedil may be useful for treating apathy after bilateral subthalamic deep brain stimulation in patients with Parkinson's disease [5] Mechanism of action: - deep brain stimulation attenuates phase-amplitude coupling at rest & during preparation to move, movement toward a target, & touching the target [11] - phase-amplitude coupling returns to baseline only in patients with reduced rigidity with active deep brain stimulation [11] Notes: - Meditronics single source in 2006.

General

electrical stimulation

References

  1. Deuschl G et al, A randomized trial of deep-brain stimulation for Parkinson's disease. N Engl J Med 2006, 355:896 PMID: 16943492
  2. Holtzheimer PE et al. Subcallosal cingulate deep brain stimulation for treatment- resistant unipolar and bipolar depression. Arch Gen Psychiatry 2012 Feb; 69:150. PMID: 22213770
  3. Journal Watch, Massachusetts Medical Society, July 2, 2012 Weaver FM et al. Randomized trial of deep brain stimulation for Parkinson disease: Thirty-six-month outcomes. Neurology 2012 Jul 3; 79:55. PMID: 22722632 - Tagliati M. Turning tables: Should GPi become the preferred DBS target for Parkinson disease? Neurology 2012 Jul 3; 79:19 PMID: 22722627
  4. Moreau C et al. Methylphenidate for gait hypokinesia and freezing in patients with Parkinson's disease undergoing subthalamic stimulation: A multicentre, parallel, randomised, placebo-controlled trial. Lancet Neurol 2012 Jun 1 PMID: 22658702
  5. Thobois S et al. Parkinsonian apathy responds to dopaminergic stimulation of D2/D3 receptors with piribedil. Brain 2013 May; 136:1568 PMID: 23543483
  6. Medical Knowledge Self Assessment Program (MKSAP) 16 American College of Physicians, Philadelphia 2012
  7. Follett KA, Weaver FM, Stern M et al Pallidal versus subthalamic deep-brain stimulation for Parkinson's disease. N Engl J Med. 2010 Jun 3;362(22):2077-91 PMID: 20519680
  8. Buhmann C et al. Effect of subthalamic nucleus deep brain stimulation on driving in Parkinson disease. Neurology 2014 Jan 7; 82:32 PMID: 24353336
  9. DeLong MR et al. Effect of advancing age on outcomes of deep brain stimulation for Parkinson disease. JAMA Neurol 2014 Aug 25; PMID: 25155481 http://archneur.jamanetwork.com/article.aspx?articleid=1897094
  10. Jung YJ et al. An 8-year follow-up on the effect of subthalamic nucleus deep brain stimulation on pain in Parkinson disease. JAMA Neurol 2015 Mar 23 PMID: 25799451 http://archneur.jamanetwork.com/article.aspx?articleid=2210911
  11. de Hemptinne C et al. Therapeutic deep brain stimulation reduces cortical phase- amplitude coupling in Parkinson's disease. Nat Neurosci 2015 May; 18:779 PMID: 25867121 - Williams ZM. Good vibrations with deep brain stimulation. Nat Neurosci 2015 Apr 28; 18:618. PMID: 25919960
  12. FDA News Release. June 12, 2015 FDA approves brain implant to help reduce Parkinson's disease and essential tremor symptoms. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm451152.htm
  13. Timmermann L et al. Multiple-source current steering in subthalamic nucleus deep brain stimulation for Parkinson's disease (the VANTAGE study): A non-randomised, prospective, multicentre, open-label study. Lancet Neurol 2015 Jul; 14:693 PMID: 26027940
  14. Okun MS Deep-brain stimulation for Parkinson's disease. N Engl J Med. 2012 Oct 18;367(16):1529-38 PMID: 23075179
  15. Lhommee E, Wojtecki L, Czernecki V et al. Behavioural outcomes of subthalamic stimulation and medical therapy versus medical therapy alone for Parkinson's disease with early motor complications (EARLYSTIM trial): Secondary analysis of an open-label randomised trial. Lancet Neurol. 2018 Mar;17(3):223-231. PMID: 29452685
  16. Monaco K New DBS System Improves Parkinson's Symptoms. Sham-controlled INTREPID study assessed multiple-current Vercise System. MedPage Today. April 26, 2018 https://www.medpagetoday.com/meetingcoverage/aan/72557 - Vitek J, et al INTREPID: A prospective, double blinded, multicenter randomized controlled trial evaluating deep brain stimulation with a new multiple source, constant current rechargeable system in Parkinson's disease. American Academy of Neurology (AAN) 2018; Abstract ES Platform 001.
  17. Schuepach WMM, Tonder L, Schnitzler A et al. Quality of life predicts outcome of deep brain stimulation in early Parkinson disease. Neurology 2019 Mar 5; 92:e1109-e1120 PMID: 30737338
  18. George J Deep Brain Stimulation May Put Parkinson's Patients at Risk for Drowning. - Proficient swimmers discover swimming skills impaired after DBS. MedPage Today. Nov. 27, 2019 https://www.medpagetoday.com/geriatrics/parkinsonsdisease/83610 - Waldvogel D et al Beware of deep water after subthalamic deep brain stimulation. Neurology. Nov 27, 2019; https://n.neurology.org/content/early/2019/11/26/WNL.0000000000008664 - American Academny of Neurology Beware of Swimming if You Use Deep Brain Stimulation for Parkinson's. Case Studies Show Good Swimmers Lose Ability when Device Is On. Press Release. Nov 27, 2019 https://www.aan.com/PressRoom/Home/PressRelease/2758 - FDA Safety Communication. July 30, 2020 Risk of loss of coordination during water-related activities in Parkinson's Patients with Deep Brain Stimulators: FDA Safety Communication. https://www.fda.gov/medical-devices/safety-communications/risk-loss-coordination-during-water-related-activities-parkinsons-patients-deep-brain-stimulators
  19. George J Dementia and Deep-Brain Stimulation in Parkinson's - Prevalence, incidence may not be higher in DBS patients. MedPage Today July 2, 2020 https://www.medpagetoday.com/neurology/parkinsonsdisease/87402 - Bove F, Fraix V, Cavallieri F et al Dementia and subthalamic deep brain stimulation in Parkinson disease. A long-term overview. Neurology. July 1, 2020 PMID: 32611633 https://n.neurology.org/content/early/2020/07/01/WNL.0000000000009822
  20. George J How Long Do Deep Brain Stimulation Benefits Last? - Parkinson's patients saw continued improvement in motor symptoms, quality of life. MedPage Today June 2, 2021 https://www.medpagetoday.com/neurology/parkinsonsdisease/92888 - Bove F et al Long-term Outcomes (15 Years) After Subthalamic Nucleus Deep Brain Stimulation in Patients with Parkinson Disease. Neurology 2021. June 2 34078713 https://n.neurology.org/content/early/2021/06/02/WNL.0000000000012246 - Chou K, Charles D Subthalamic Nucleus Deep Brain Stimulation: Uncomplicating Motor Complications for the Long Haul. Neurology 2021. June 2 PMID: 34078714 https://n.neurology.org/content/early/2021/06/02/WNL.0000000000012245
  21. Schmidt SL et al. At home adaptive dual target deep brain stimulation in Parkinson disease with proportional control. Brain 2023 Dec 21; [e-pub]. PMID: 38128546 https://academic.oup.com/brain/advance-article-abstract/doi/10.1093/brain/awad429/7490826