copy of dbs grand rounds jan 2011
TRANSCRIPT
Assistant Professor of Surgery Director, Functional and Restorative Neurosurgery University of Connecticut
(Benabid et al., 1991; Blond et al., 1992)
DBS
SURGERY
Personnel
Equipment
Space
Interdisciplinary
Collabora>on
Movement Disorder Neurologist
Neurosurgeon
Psychiatrist Electrophysiologist
Neuropsychologist
Pa9ent
APRNs/ PAs
Anesthesia Team
OR Staff
Neuro-‐ICU Staff Pa9ent
DBS Lead Extension Implantable Pulse Generator (IPG)
Test Stimulator Clinician Programmer Pt Controller
Neurosurgeon
Neurologist Psychiatrist
STAGE PROCEDURE
BASELINE/PRE-‐OP
MRI (Stereotac>c) Pt Evaluated by Neurology Pt Evaluated by Neurosurgery Pt Evaluated by Neuropsychology Surgical Pre-‐op Hold Medica>ons Target Selec>on Trajectory Planning
STAGE 1 (2 DAYS)
CT Scan Stereotac>c frame placement Electrophysiology recording Electrode placement EPG tes>ng Post-‐Op CT Scan Post-‐Op X-‐Ray Neuro-‐ICU Observa>on Pt Discharged to home day 1 or 2
EPG =External Pulse Generator IPG =Implantable Pulse Generator
STAGE PROCEDURE
STAGE 2 (14 DAYS)
IPG Surgery Test impedance Post-‐Op X-‐Ray Ini>al IPG Programming Pt Discharged same day
STAGE 3 (12 WEEKS)
Wk 2: Post-‐Op visit with surgeon Wk 4: Post-‐Op with neurologist
Wk 12: Post-‐Op visits Neurologist and surgeon
STAGE 4 (>12 WEEKS) Post-‐Op visits with neurologist for op>miza>on of parameters
EPG =External Pulse Generator IPG =Implantable Pulse Generator
STAGE DEFINITION
1 Unilateral involvement only
1.5 Unilateral and axial involvement
2 Bilateral involvement w/o impairment of balance
2.5 Mild bilateral involvement with recovery on retropulsion test
3 Mild to moderate bilateral involvement, some postural instability, physically independent
4 Severe disability, able to stand and walk unassisted
5 Wheelchair-‐bound or bedridden except when assisted
UPDRS Item Assessment Scale Measurement
Range
Bradykinesia subscale
Score includes • body bradykinesia and hypokinesia • le_-‐ and right-‐hand finger taps, opening and closing of hands, prona>on/supina>on of hands, and heel taps
0 (not affected) to 36 (most severely
affected)
Tremor subscale
Score includes • ac>on tremor of right and le_ hands • res>ng tremor in the le_ and right hands and feet • res>ng tremor of the face, lips, and chin
0 (not affected) to 32 (most severely affected)
Rigidity subscale Score includes • rigidity in the neck • rigidity in the le_ and right upper and lower extremi>es
0 (not affected) to 20 (most severely affected)
PIGD (postural instability and gait
disorder)
Score includes • falling, freezing, ability to walk • gait, postural stability
0 (not affected) to 20 (most severely affected)
Representa>ve sample of key measurement items from the UPDRS scale Fahn et al., 1987
Unified Parkinson’s Disease Ra>ng Scale (UPDRS)
Cuny et al, 2002
Ulla et al, 2009
STN
SNr
Sagieal Sec>on through the Thalamus
Thalamus
Tremor-‐ Vim
Parkinson’s Disease-‐ STN
Dystonia-‐ Vim or GPi
Emerging targets: Subthalamic white maeer, Paralemniscal Radia>ons, and PPN
Krack et al., NEJM, 2003
“On 6me” more than doubled
54% 51%
71%
50%
0 10 20 30 40 50 60 70 80 90
100 % Improvement
DBS OFF DBS ON
• >800 published articles on DBS in MDJs • Safety and efficacy demonstrated • Long-term benefits
• The most common movement disorder
• Big impact on life: – Socially – Professionally – Emo>onally
hep://www.total-‐diet.com/170-‐stress-‐at-‐work/
• Begins in one upper limb
• 30% of cases include cranial musculature: head, voice, jaw & face
• Tremor may ini>ally be intermieent
hep://www.bartleby.com/107/illus1232.html
• 4th most disabling disease worldwide
• Psychiatric Disorders afflict 44 million in US at cost of > $300 billion
• >15% of disease burden in US (more than that of all cancers)
(Saxena et al., 2002)
LF Responders = pa>ents with at least a 25% reduc>on in YBOCS at last follow-‐up
• Forebrain projec>ons: Orbitofrontal & Prefrontal cortex via ventral internal capsule to DM thalamus & Amygdala, Hypothalamus
• Reciprocal posi>ve feedback loops Cor>co-‐striato-‐pallido-‐thalamo-‐cor>cal circuits
• Interac>ons with the Papez circuit via pregenual and rostral cingulate cortex
IC IC
Caudate Caudate
Putamen
Putamen
AcM
GP
Region where Subcaudate Tractotomy, Gamma Capsulotomy, and DBS Targets Overlap S. Haber
Medial
Orbital
Dorsolateral Premotor Motor
• 10 pa>ents -‐ Cleveland Clinic/Brown (2003-‐2006) • Only the most severe, debilitated, & highly treatment
resistant pa>ents were enrolled – Personal and professional disability – Suicide aeempts – At least five years of depression – At least five courses of medica>ons – Behavioral Therapy – Bilateral ECT
• Contraindica>ons – Substance abuse, personality disorder, psycho>c disorder
• At one year follow-‐up 2/3 of pa>ents had 50% improvement in depression scores
46 YOF, post-partum end-stage depression of over 10 years, medication-refractory with over 74
Electroconvulsive shock (ECT) treatments
(Mayberg et al., Neuron, 2005)
HAMD17 Scores Over Time
Scores*
Pt 1† Pt 2‡ Pt 3† Pt 4‡ Pt 5† Pt 6†
Preop baseline 29 22 29 24 26 25
1 week post-‐op (acute s>mula>on)
5 10 12 18 17 12
2 weeks post-‐op (DBS off) 9 13 23 18 22 n/a
3 months 2 15 14 25 7 14
6 months 5 15 9 23 6 12
*Clinical response: decrease in HAMD >50%. Clinical remission: absolute HAMD < 8. †Responders ‡Non-‐responders
(Adapted from Mayberg et al., Neuron, 2005
HDRS17
, Hamilton Depression Rating Scale ; GAF, Global Assessment of Functioning; BDI, Beck Depression Inventory; HDRS
24, Hamilton Depression Rating Scale; MADRS, Montgomery-Asberg Depression Rating Scale (Ward et al., 2010)
Study N Location of stimulation
Baseline Post-DBS
Lozano et al., 2008 20 Cg25 Baseline
HDRS17 24.4 ± 3.5 Mood 11.9 ± 1.5 Anxiety 3.8 ± 2.4
Sleep 3.6 ± 2.0 Somatic 4.9 ± 0.8
12 months 12.6 ± 6.3 5.9 ± 3.7* 1.6 ± 1.9* 2.0 ± 1.3* 3.0 ± 1.4*
Jiménez et al., 2007 1 Inferior thalamic peduncle
Baseline GAF 20 HDRS 33-42 BDI 38
1 week
3 16
1 month 90 8 11
Malone et al., 2009 15 VC/VS Baseline
HDRS24 33.1 MADRS 34.8
6 months 17.5 17.9
Schaepfer et al., 2008 3 NAcc Baseline
HDRS24 33.7 ± 3.8 MADRS 35.7 ± 2.9
1 week 19.7 ± 6.7 24.7 ± 6.7
(Mayberg et al., Neuron, 2005)
CBF decrease
CBF increase
x = -4 y = +28
Baseline CBF PET
All PT vs. NC
3 mo Post-DBS Surgery
6 mo Post-DBS Surgery
(Na6onal Survey on Drug use and Health, 2002) (The United Na6ons World Drug Report, 2007)
• Chronic relapsing disease • Psychological dependence • Physical dependence • Withdrawal syndrome • Tolerance • Con>nued use despite adverse
consequences • Impaired control
(Diagnos6c and Sta6s6cal Manual of Mental Disorders, 4th Ed) (Interna6onal Classifica6on of Diseases, 10th Ed)
(Stelten et al., 2008)
(Gao et al., 2003)
• Case report of a pa>ent with anxiety, depression, and alcohol dependence
• Bilateral s>mula>on • 12 month follow up • Therapeu>c effects were:
– Slight anxiety reduc>on – Allevia>on of co-‐morbid
alcohol dependence
(Kuhn et al., 2007) (Heinze et al., Front Hum Neuro, 2009)