Abstract
Introduction
Directional deep brain stimulation (dDBS) has been suggested to have a similar therapeutic
effect when compared with the traditional omnidirectional DBS, but with an improved
therapeutic window that yields optimized clinical effect owing to the ability to better
direct, or “steer,” electric current. We present our single-center, retrospective
analysis of our experience in the use of dDBS in patients with movement disorders
and provide a review of the literature.
Materials and Methods
We identified all patients with Parkinson disease (PD) and essential tremor (ET) who
received a dDBS system between 2018 and 2022 and retrospectively examined characteristics
of their longitudinal treatment. A total of 70 leads were identified across 42 patients
(28 PD, 14 ET).
Results
Three types of systems were implemented (single-segment activation, 45.2% of patients;
multiple independent current control, 50.0%; and local field potential sensing-enabled,
4.7%). The subthalamic nucleus or globus pallidus internus was targeted in PD, and
the ventral intermediate nucleus of the thalamus in ET. Across the entire cohort (n = 70 leads), at initial programming, 54.2% of leads (n = 38) were programmed using directional stimulation. At the most recent reprogramming,
58.6% of leads (n = 41) implemented directionality. In patients with PD, the average decrease in levodopa-equivalent
daily dose at six months after implantation was 35.4% ± 39.2%. Despite the ability
to steer current to relieve stimulation-induced side effects, ten leads in six patients
required surgical revision owing to electrode malposition.
Conclusions
We show wide adaptability and implementation of directional stimulation, adding to
the growing compendium of real-world uses of dDBS therapy. We used directionality
to improve clinical response in both patients with PD and patients with ET and found
that its programming flexibility was used at high rates long after implantation and
initial programming. In patients with PD, dDBS led to a significant reduction in dopaminergic
medication, suggesting sustained clinical improvement. Nonetheless, accurate surgical
placement remains necessary to ensure optimal clinical outcomes.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe toAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Probing and regulating dysfunctional circuits using deep brain stimulation.Neuron. 2013; 77: 406-424https://doi.org/10.1016/j.neuron.2013.01.020
- Obesity and brain addiction circuitry: implications for deep brain stimulation.Neurosurgery. 2012; 71: 224-238https://doi.org/10.1227/NEU.0b013e31825972ab
- Thalamic deep brain stimulation in the treatment of essential tremor: a long-term follow-up.Br J Neurosurg. 2007; 21: 504-509https://doi.org/10.1080/02688690701552278
- Long-term results of thalamic deep brain stimulation for essential tremor.J Neurosurg. 2010; 112: 1271-1276https://doi.org/10.3171/2009.10.JNS09371
- Long-term follow-up of thalamic deep brain stimulation for essential and parkinsonian tremor.Neurology. 2003; 61: 1601-1604https://doi.org/10.1212/01.WNL.0000096012.07360.1C
- Long-term efficacy and mortality in Parkinson’s disease patients treated with subthalamic stimulation.Mov Disord. 2011; 26: 1931-1934https://doi.org/10.1002/mds.23817
- Long-term outcome of deep brain stimulation in generalised dystonia: a series of 60 cases.J Neurol Neurosurg Psychiatry. 2014; 85: 1371-1376https://doi.org/10.1136/jnnp-2013-306833
- Technology of deep brain stimulation: current status and future directions.Nat Rev Neurol. 2021; 17: 75-87https://doi.org/10.1038/s41582-020-00426-z
- Directional deep brain stimulation for Parkinson’s disease: results of an international crossover study with randomized, double-blind primary endpoint.Neuromodulation. 2022; 25: 817-828https://doi.org/10.1111/ner.13407
- Directional stimulation in Parkinson’s disease and essential tremor: the Cleveland Clinic experience.Neuromodulation. 2022; 25: 829-835https://doi.org/10.1111/ner.13374
- Thalamic directional deep brain stimulation for tremor: spend less, get more.Brain Stimul. 2018; 11: 600-606https://doi.org/10.1016/j.brs.2017.12.015
- Response to letter to the editor regarding: “bipolar directional deep brain stimulation in essential and parkinsonian tremor”-a technology underutilized.Neuromodulation. 2020; 23: 1229-1230https://doi.org/10.1111/ner.13311
- The actual use of directional steering and shorter pulse width in selected patients undergoing deep brain stimulation.Parkinsonism Relat Disord. 2021; 93: 58-61https://doi.org/10.1016/j.parkreldis.2021.11.009
- Role of directional configuration in deep brain stimulation for essential tremor: a single center experience.Tremor Other Hyperkinet Mov (N Y). 2021; 11: 47https://doi.org/10.5334/tohm.628
- Real-life experience on directional deep brain stimulation in patients with advanced Parkinson’s disease.J Pers Med. 2022; 12: 1224https://doi.org/10.3390/jpm12081224
- Long-term clinical experience with directional deep brain stimulation programming: a retrospective review.Neurol Ther. 2022; 11: 1309-1318https://doi.org/10.1007/s40120-022-00381-5
- Programming deep brain stimulation for Parkinson’s disease: the Toronto Western Hospital algorithms.Brain Stimul. 2016; 9: 425-437https://doi.org/10.1016/j.brs.2016.02.004
- Programming directional deep brain stimulation in Parkinson’s disease: a randomized prospective trial comparing early versus delayed stimulation steering.Stereotact Funct Neurosurg. 2021; 99: 484-490https://doi.org/10.1159/000517054
- Speech and language adverse effects after thalamotomy and deep brain stimulation in patients with movement disorders: a meta-analysis.Mov Disord. 2017; 32: 53-63https://doi.org/10.1002/mds.26924
- Segmented versus nonsegmented deep-brain stimulation for essential tremor differ in ataxic side effects.Tremor Other Hyperkinet Mov (N Y). 2019; 9: 621https://doi.org/10.5334/tohm.493
- Complications and side effects of deep brain stimulation in the posterior subthalamic area.Stereotact Funct Neurosurg. 2010; 88: 88-93https://doi.org/10.1159/000271824
- Microstimulation in the region of the human thalamic principal somatic sensory nucleus evokes sensations like those of mechanical stimulation and movement.J Neurophysiol. 2004; 91: 736-745https://doi.org/10.1152/jn.00648.2003
- Systematic review of levodopa dose equivalency reporting in Parkinson’s disease.Mov Disord. 2010; 25: 2649-2653https://doi.org/10.1002/mds.23429
- An updated calculator for determining levodopa-equivalent dose.Neurol Res Pract. 2021; 3: 58https://doi.org/10.1186/s42466-021-00157-6
- Steering the volume of tissue activated with a directional Deep Brain Stimulation lead in the globus pallidus pars interna: A modeling study with heterogeneous tissue properties.Front Comput Neurosci. 2020; 14https://doi.org/10.3389/fncom.2020.561180
- Pathophysiology of L-dopa-induced motor and non-motor complications in Parkinson’s disease.Prog Neurobiol. 2015; 132: 96-168https://doi.org/10.1016/j.pneurobio.2015.07.002
- Subthalamic nucleus deep brain stimulation: summary and meta-analysis of outcomes.Mov Disord. 2006; 21: S290-S304https://doi.org/10.1002/mds.20962
- Clinical outcome of deep brain stimulation for Parkinson’s disease.in: Handb Clin Neurol. 116. Elsevier, 2013: 107-128https://doi.org/10.1016/B978-0-444-53497-2.00010-3
- Five-year follow-up of bilateral stimulation of the subthalamic nucleus in advanced Parkinson’s disease.N Engl J Med. 2003; 349: 1925-1934https://doi.org/10.1056/NEJMoa035275
- Bilateral subthalamic stimulation monotherapy in advanced Parkinson’s disease: long-term follow-up of patients.Mov Disord. 2002; 17: 125-132https://doi.org/10.1002/mds.1278
- Comparing current steering technologies for directional deep brain stimulation using a computational model that incorporates heterogeneous tissue properties.Neuromodulation. 2020; 23: 469-477https://doi.org/10.1111/ner.13031
- Subthalamic nucleus deep brain stimulation with a multiple independent constant current-controlled device in Parkinson’s disease (INTREPID): a multicentre, double-blind, randomised, sham-controlled study.Lancet Neurol. 2020; 19 (Published correction appears in Lancet Neurol. 2020;19:e8): 491-501https://doi.org/10.1016/S1474-4422(20)30108-3
- Model-based comparison of deep brain stimulation array functionality with varying number of radial electrodes and machine learning feature sets.Front Comput Neurosci. 2016; 10: 58https://doi.org/10.3389/fncom.2016.00058
- In silico accuracy and energy efficiency of two steering paradigms in directional deep brain stimulation.Front Neurol. 2020; 11593798https://doi.org/10.3389/fneur.2020.593798
- Update on current technologies for deep brain stimulation in Parkinson’s disease.J Mov Disord. 2020; 13: 185-198https://doi.org/10.14802/jmd.20052
- Directional deep brain stimulation in the treatment of Parkinson’s disease.Neurology. 2022; 17: 64-67https://doi.org/10.17925/USN.2022.18.1.64
Article info
Publication history
Published online: January 17, 2023
Accepted:
December 12,
2022
Received in revised form:
November 22,
2022
Received:
September 1,
2022
Publication stage
In Press Corrected ProofFootnotes
Source(s) of financial support: Akash Mishra is partially supported by the Neurosurgery Research & Education Foundation (2022 Medical Student Summer Research Fellowship). The authors reported no other funding sources.
Conflict of Interest: The authors reported no conflict of interest.
Identification
Copyright
© 2022 International Neuromodulation Society. Published by Elsevier Inc. All rights reserved.
